Nerve sparing excision of gastrohepatic ligament lesion as part of cytoreductive surgical management of advanced ovarian malignancy.

Abstract

Metastases to the lesser sac (also known as the omental bursa) and its contents are frequently seen in advanced ovarian cancer. This would require a thorough and meticulous intra-operative surgical exploration and mapping for patients requiring radical supracolic omentectomy requiring sacrifice of the gastro-epiploic arcade. We describe an educational surgical technique with maximum effort to preserve the right and left gastric arteries, when the right and left gastro-epiploic arteries and short gastric arteries are divided. These steps are demonstrated with attention to anatomical landmarks of the lesser sac to minimise intraoperative and postoperative morbidity. This surgical approach will not only spare the gastric branches of the vagus nerve (rami gastrici) but also prevent gastric ischaemic changes. We describe the case of a 77-year-old female patient diagnosed with stage 3C high grade serous ovarian/tubal cancer on the neoadjuvant chemotherapy pathway, undergoing delayed debulking surgery. The gynaecological oncology surgeon should confidently hold detailed knowledge of upper abdominal anatomy in their armamentarium, to maximise the safety and efficacy of ultra-radical surgery to achieve R0 (no residual disease); which is a single independent risk factor for survival. This video demonstrates a challenging case with an undesirable location of metastatic disease requiring advanced upper abdomen surgical skills and knowledge, with specific consideration of intraoperative multidisciplinary decision-making.