Steps of the Procedure

The goal of surgery is to

• completely and accurately stage the disease
• safely and completely resect the tumor
• spare all uninvolved reproductive organs

The bias should be toward preserving fertility in the vast majority of cases. Preservation of reproductive potential is a high priority during surgery for ovarian lesions in children. Large, invasive germ cell tumors should be biopsied with definitive resection planned following neoadjuvant chemotherapy. In the very rare cases of adenocarcinoma, an aggressive surgical approach may be warranted.

Laparoscopic procedures are being increasingly performed for evaluation of pelvic masses and there is now data to demonstrate that the benefits of a faster recovery time and shorter hospital stay seen in adults are also applicable to children [1][2].

If a suspected ovarian malignancy is detected at the time of laparoscopy, complete surgical staging and resection is recommended with consideration for conversion to an open procedure if needed to assure proper staging and tumor removal without spillage. The technical approach to removal of the ovary should be accomplished with an attempt to preserve normal anatomy when possible.

Prior to excision, the contralateral ovary should be examined externally and biopsies obtained of any surface abnormalities.

The ovary is usually quite mobile. The tissue along the broad ligament and between the ovary and fallopian tube is divided with either an energy device or clamps and ties. The broad ligament is similarly divided with care to avoid the ipsilateral ureter. If a salpingo-oophorectomy is to be performed, the fallopian tube is then divided at the uterus and incorporated with the specimen.

How is a partial or subtotal oophorectomy performed?

Ovarian masses that are localized, with negative markers and a benign appearance on imaging and at operation can be treated with an ovarian sparing technique. The mass typically has a well defined margin and can be shelled out of the ovarian parenchyma which might be quite thin but consists of viable tissue. It is not necessary to reconstruct or close the ovarian remnant after partial excision.

Pedunculated tumors can be treated with partial oophorectomy by dividing the ovarian parenchyma with electrocautery leaving a rim of normal tissue on the mass.

Findings of malignancy on pathology usually require return to the operating room for completion oophorectomy.

What are the steps of a complete open or laparoscopic staging procedure?

The staging procedures for ovarian malignancy differ somewhat for the different cell types. This can result in inadequate staging of unsuspected epithelial tumors.

Surgical staging is imperative for treatment, assigning extent of disease, prognosis and treatment. The revised surgical guidelines of the Children’s Oncology Group [3] include

• Collection of ascites or washing for cytology upon entering the abdominal cavity. This proves important because a significant number of tumors apparently confined to the gonad prove to have positive cytologic results, upstaging the disease and changing treatment.
• Inspection and palpation of the omentum with omentectomy for any irregularities.
• Examination of peritoneal surfaces with sampling of any abnormalities with particular attention to the pelvis. Inspection of the diaphragm is no longer required if the pelvis is fully inspected.
• Examination of retroperitoneal nodes with biopsy of grossly abnormal nodes.
• Careful inspection of the contralateral ovary with biopsy of any suspicious areas.
• Oophorectomy of the tumorous ovary.

Epithelial tumors are staged by the FIGO system which requires peritoneal biopsies, peritoneal washings/aspiration, omentectomy, removal of the primary tumor and an ipsilateral lymph node dissection. The need for a lymph node dissection is not based on the gross appearance of the nodes since up to 30% of clinically normal nodes can be positive for metastatic disease.

see Ovarian Tumors Staging