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Surgical management in the pelvis for patients with advanced ovarian cancer

In 12 to 21% of women, the diagnosis of epithelial ovarian cancer is at the advanced stage, and patient survival is negatively correlated with residual disease diameter in many series and meta-analyses. This evidence emphasizes the role of maximal cytoreduction in this particular oncologic population. In patients with disrupted pelvic anatomical conditions such as the so-called “frozen pelvis”, the surgeons are called to a significant effort to achieve the maximal cytoreduction. Unlike colorectal cancer, malignant ovarian cells tend to invade superficial abdominal surfaces disseminating within the peritoneal cavity, thus involving the peritoneum layer and the omentum in most cases. This different etiopathogenesis determines the possibility of resecting most superficial lesions by mesorectal or total peritoneal stripping, thus achieving optimal surgical outcomes. Radical surgeries to debulk high-stage ovarian cancer have been described since 1965, additionally; in the 1970s, Hudson published the rationale and the description of retrograde hysterectomy during a radical oophorectomy. During the last two decades, the technique of radical oophorectomy with en-bloc resection of rectosigmoid for the frozen pelvis has gained popularity, and different surgical steps have been standardized to ease replication and used for teaching purposes. Moreover, the reduction of bleeding and the oncologic effectiveness of this cytoreductive procedure fit well together with the concept of the complete multiorgan debulking required in advanced ovarian cancer. In this view, the use of this standardized radical surgery allows the safe and comprehensive removal of all pelvic cancer in patients with advanced ovarian disease. This manuscript is an extensive updated technical overview from the pioneering series of our retired mentors to the current evolving surgical breakthroughs. Nowadays, this complex exenterative surgery paradigm for the frozen pelvis in advanced ovarian cancer is still changing because the innovative biological, genetic knowledge is continuously growing and evolving parallel to the advanced perioperative, anesthesiologic, and radiologic care.