Diaphragmatic resection and liver mobilization during surgery for advanced ovarian cancer

Advanced ovarian cancer is a challenging disease that spreads principally to the peritoneal tissues. It is reported that diaphragmatic involvement occurred in 40% of patients with tumors localized in the pelvic cavity and 70% of cases with extrapelvic metastasis. Many gynecology oncology surgeons believe that invasive diaphragmatic disease is the most challenging disease localization to be wholly eradicated, second only to portal triad disease. The knowledge of diaphragm anatomy, the relevant hepatic attachments, and the central vasculature is substantial for the performance of radical surgery during debulking of upper abdominal quadrants in advanced ovarian cancer patients. Some surgical techniques are available to provide a proper cytoreductive effect for diaphragm involvement in ovarian cancer, including ablation using the Argon Beam Coagulator (ABC), aspiration using Cavitron Ultrasonic Surgical Aspirator (CUSA), peritonectomy (stripping), or full-thickness diaphragmatic resection. A multidisciplinary approach with the involvement of a thoracic surgeon could be beneficial for the correct assessment of the disease, the choice of the best treatment, and the success of the surgical procedure. To evaluate reconstructive surgery with meshes implantation during complex diaphragmatic procedures, care must be taken. No large study evaluated the perioperative outcomes related to diaphragmatic peritoneal stripping or diaphragmatic full-thickness resection; however, pleural effusion occurred in 43% of cases after peritoneal stripping and 51% after diaphragmatic full-thickness resections needing thoracentesis or chest tube placement in 4% and 9%, respectively. Moreover, the rate of postoperative pneumothorax (4% vs. 9%) and subdiaphragmatic abscess (3% vs. 3%) are similar after either of the two techniques. The current evidence from the literature suggests that the decision to drain postoperative effusion and the drainage method should be made in all cases at the discretion of the attending surgical team. Intraoperative pleural evacuation of fluid and air and closure of the diaphragm with eversion of the edges into the peritoneal cavity reduces postoperative effusions and pneumothorax. Typically, a chest tube is planned for patients with preoperative or postoperative large effusions, clinical signs of respiratory impairment, and radiological signs of pulmonary compromise. New minimally surgical approaches, technologies, energies, and postoperative care protocols are emerging to reduce the morbidity of this oncologic population.