Pediatric Surgery NaT
Oophorectomy for Tumor
Steps of the Procedure
What are the important surgical aspects of ovarian tumor resection?
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 unless preoperative risk stratification is suggestive of malignancy. Preservation of reproductive potential is a high priority during surgery for ovarian lesions in children. Large, invasive 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.
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.
Ovarian masses that are localized, with negative markers and reassuring characteristics on imaging 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 a return to the operating room for completion oophorectomy, and families should be counseled about this possibility prior to the initial procedure. Random biopsies in the absence of an obvious lesion (e.g. removing a normal-appearing omentum) do not confer improved survival[1][2].
Surgical staging is imperative for treatment, assigning extent of disease, prognosis and treatment. The revised surgical guidelines of the Children’s Oncology Group include:[1]
· 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 when malignancy is suspected.
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