What is the role of supracolic omentectomy and peritonectomy in treating metastatic ovarian cancer with peritoneal and omental invasion?

Supracolic Omentectomy and Peritonectomy in Metastatic Ovarian Cancer

Supracolic omentectomy and peritonectomy are critical surgical procedures that significantly improve survival in metastatic ovarian cancer by removing all visible disease, which is essential for optimal cytoreduction and improved mortality outcomes.

Understanding These Procedures

Supracolic Omentectomy

Supracolic omentectomy refers to the complete surgical removal of the omentum, a fatty apron-like structure that hangs from the stomach and covers the abdominal organs. In ovarian cancer:

• The omentum is frequently a site of metastasis and may be studded with small tumor deposits or entirely replaced by tumor (forming an "omental cake") 1
• Two common surgical approaches include:
  1. Dissecting the omentum off the transverse colon in the avascular plane
  2. Opening the lesser sac off the greater curvature of the stomach 1
• Complete removal is mandatory for optimal cytoreduction, as the omentum is a common site for metastatic spread

Peritonectomy

Peritonectomy involves surgical removal of portions of the peritoneum (the membrane lining the abdominal cavity) that contain visible cancer deposits. This includes:

• Pelvic peritonectomy: Removal of peritoneum from the pelvis
• Diaphragmatic peritonectomy: Stripping of peritoneum from the undersurface of the diaphragm
• Paracolic gutter peritonectomy: Removal of peritoneum along the lateral gutters of the abdomen 1, 2

Role in Treatment of Metastatic Ovarian Cancer

These procedures are integral components of cytoreductive surgery for advanced ovarian cancer with the following goals:

1. Maximal Cytoreduction: The objective is to remove all visible disease or reduce residual tumor to less than 1 cm in diameter (optimal cytoreduction) 1

2. Improved Survival: Each 10% increase in maximal cytoreduction is associated with a 5.5% increase in median survival time 1

3. Disease Staging: These procedures help accurately determine the extent of disease spread

Surgical Approach

For patients with metastatic ovarian cancer involving the peritoneum and omentum, the surgical approach typically includes:

• Total hysterectomy and bilateral salpingo-oophorectomy (removal of uterus, fallopian tubes, and ovaries)
• Complete omentectomy (removal of all involved omentum)
• Peritonectomy of involved surfaces
• Lymph node assessment and possible dissection
• Additional procedures as needed to achieve optimal cytoreduction, which may include:
  • Bowel resection
  • Splenectomy
  • Diaphragm stripping 1

Clinical Significance

The extent of surgical cytoreduction is one of the most powerful determinants of survival in advanced ovarian cancer:

• Patients with no visible residual disease after surgery have the best prognosis
• Median survival typically doubles (from approximately 17 months to 39 months) with aggressive surgery that achieves optimal cytoreduction 1
• These procedures are essential components of the standard of care for advanced ovarian cancer with peritoneal spread 1

Potential Complications

Important considerations include:

• Risk of bleeding, particularly during splenectomy or when removing tumor from vascular areas
• Potential for injury to adjacent structures (ureters, bowel, pancreas)
• Need for specialized surgical expertise (gynecologic oncologist) 1
• If splenectomy is performed, post-operative immunization against encapsulated organisms (Streptococcus pneumoniae, meningococcus, and Haemophilus influenzae) is necessary 1

These surgical procedures are critical components in the comprehensive management of metastatic ovarian cancer and should be performed by experienced gynecologic oncologists to maximize the chance of optimal cytoreduction and improved survival.