Peritoneal Survey Technique During Debulking Surgery
A systematic peritoneal survey during debulking surgery must begin immediately upon entering the abdomen with aspiration of ascites or peritoneal lavage for cytologic examination, followed by methodical visualization and selective biopsy of all peritoneal surfaces in 22 anatomical regions, with documentation of disease extent and residual tumor in the operative note. 1
Initial Entry and Cytologic Assessment
Upon entering the abdomen, immediately aspirate any ascites present or perform peritoneal lavage for cytologic examination. 1 This should be done before any manipulation of tissues to avoid contamination.
For obvious disease beyond the ovaries, cytologic assessment will not alter stage or management, but should still be performed for documentation. 1
Systematic Peritoneal Exploration
All peritoneal surfaces must be systematically visualized and palpated in a standardized sequence: 1
Examine the pelvis: including the cul-de-sac, bladder peritoneum, and pelvic sidewalls 1
Inspect both paracolic gutters bilaterally from pelvis to diaphragm 1
Visualize the undersurfaces of both hemidiaphragms completely 1
Examine all peritoneal surfaces of the small and large bowel, including the mesentery 1
Inspect the omentum (infracolic and supracolic portions) 1
Examine the liver surface, gallbladder, stomach, and spleen 1
Biopsy Protocol
Any peritoneal surface or adhesion suspicious for harboring metastasis must be selectively excised or biopsied. 1 This is critical because visual assessment alone has limitations, particularly after neoadjuvant chemotherapy where sensitivity drops from 98% to 86% and microscopically carcinomatous areas may appear benign. 2
In the absence of suspicious areas, random peritoneal biopsies are mandatory from: 1
- The pelvis (cul-de-sac and bladder peritoneum) 1
- Both paracolic gutters 1
- Undersurfaces of both diaphragms (diaphragm scraping for Papanicolaou stain is an acceptable alternative) 1
Documentation Requirements
The operative report must include: 1
- A detailed description of all lesions prior to excision
- Precise description of the surgery undertaken
- Quantification of the extent of initial disease using standardized terminology 1
- Precise description of the size and localization of any residual tumor left in place 1
The peritoneal cavity should be conceptualized as 22 anatomical regions for systematic documentation. 2
Critical Pitfalls to Avoid
After neoadjuvant chemotherapy, visual assessment is significantly less reliable (86% sensitivity vs 98% at primary surgery), leading to potential incomplete resection of microscopically involved areas that appear benign. 2 Therefore, liberal use of biopsies in areas of previous disease or suspicious scarring is essential during interval debulking surgery. 1
For mucinous tumors, appendectomy is absolutely mandatory as part of the peritoneal survey, since primary appendiceal adenocarcinoma frequently mimics ovarian cancer and the appendix may be the only site of extra-ovarian spread. 1, 3 The upper and lower gastrointestinal tract should be carefully evaluated to rule out an occult gastrointestinal primary. 1
Failure to perform systematic lymph node assessment is a common error. For patients with tumor nodules ≤2 cm outside the pelvis (presumed stage IIIB), bilateral pelvic and para-aortic lymph node dissection should be performed, as metastatic nodes can persist despite chemotherapy. 1
Surgical Goal
The primary goal is maximal cytoreduction with removal of all gross disease. 1 Residual disease <1 cm defines optimal cytoreduction, but complete resection of all visible disease should be the target, as this is associated with 54% 5-year survival compared to 16% with incomplete resection. 4