What is epithelial ovarian cancer and why is it so challenging to treat?

Epithelial ovarian cancer (EOC) is a type of cancer that starts in the cells on the surface of the ovary. It is a leading cause of gynecological cancer deaths. Because it is often diagnosed at a late stage, management requires a multi-faceted approach with surgery being key to diagnose the extent of the disease and remove cancerous tissue. Cytoreductive surgery, neoadjuvant chemotherapy and HIPEC are methods used to treat it.

What is primary cytoreductive surgery and what does it involve?

Primary cytoreductive surgery (CRS) is an aggressive surgical approach to remove all visible tumor from the abdominal and pelvic cavities. This maximizes the effectiveness of subsequent chemotherapy. It often involves radical pelvic surgery, bowel surgery, diaphragm resection, and multi-visceral resections. The goal of CRS is to remove as much of the cancer as possible to improve the chances of successful treatment.

What is extra-peritoneal hysteroannessiectomy and how does it help in treating epithelial ovarian cancer?

Extra-peritoneal hysteroannessiectomy (EH) is a surgical procedure often combined with en bloc rectal resection and cytoreductive surgery to manage epithelial ovarian cancer (EOC). It involves meticulously removing the pelvic peritoneum and associated tissues. By removing the pelvic peritoneum and associated tissues, surgeons can achieve optimal cytoreduction and improve treatment outcomes.

What is neoadjuvant chemotherapy and why is it used before surgery in some cases of ovarian cancer?

Neoadjuvant chemotherapy (NACT) is a treatment approach where chemotherapy is administered before surgery. This is done particularly when primary complete cytoreductive surgery (CRS) is not feasible due to the patient's health or the extent of the disease. NACT aims to shrink the tumor, making subsequent interval debulking surgery more effective. The goal is to reduce the tumor burden before attempting surgical removal.

Microscopic view of ovarian cancer cells being surgically removed.

Ovarian Cancer Surgery: A Comprehensive Guide to Extra-Peritoneal Hysteroannessiectomy

Q: What is intraoperative hyperthermic intraperitoneal chemotherapy and how does it work?

Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) is a technique used to target microscopic residual disease after cytoreductive surgery (CRS). HIPEC involves delivering heated chemotherapy directly into the abdominal cavity during surgery. This helps to eliminate any remaining cancer cells that may not be visible to the naked eye, potentially improving survival rates. It is used in combination with other treatments to target any remaining microscopic disease.

Avery Sinclair in Health & Wellness December 2025 • 4 min read.

"Expert insights into advanced surgical techniques for epithelial ovarian cancer, including en bloc rectal resection and cytoreductive surgery."

Epithelial ovarian cancer (EOC) is a formidable challenge in women's health, ranking as a leading cause of gynecological cancer deaths worldwide. The complexity of this disease lies in its often silent progression, leading to advanced-stage diagnoses where the cancer has already spread extensively within the peritoneal cavity. Effective management of EOC requires a multi-faceted approach, with surgery playing a pivotal role in both diagnosing the extent of the disease and removing as much cancerous tissue as possible.

The surgical approach to EOC has evolved considerably over the years. Initially, primary complete cytoreductive surgery (CRS) was the standard of care, aiming to remove all visible signs of the tumor. However, this approach is not always feasible, particularly in patients with poor overall health or widespread disease. In such cases, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery has emerged as a viable alternative. More recently, intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) has been introduced as a promising technique to target microscopic residual disease and improve survival rates.

This article delves into the technical details of extra-peritoneal hysteroannessiectomy (EH), a surgical procedure often combined with en bloc rectal resection and cytoreductive surgery in the management of EOC and other peritoneal surface malignancies. Drawing upon a retrospective observational study involving 419 patients, we aim to provide a comprehensive overview of the surgical approaches, techniques, and considerations involved in this complex procedure. Our goal is to equip surgeons and gynecologic oncologists with the knowledge and insights necessary to optimize surgical outcomes and improve the lives of women battling this challenging disease.

Understanding the Surgical Landscape: Primary Cytoreductive Surgery and Beyond

Microscopic view of ovarian cancer cells being surgically removed.

The cornerstone of EOC treatment has traditionally been primary cytoreductive surgery (CRS). This aggressive surgical approach aims to remove all visible tumor from the abdominal and pelvic cavities, maximizing the effectiveness of subsequent chemotherapy. Several specialized procedures are often employed to achieve this goal, including:

Radical Pelvic Surgery: This may involve extensive dissection and removal of affected tissues within the pelvis.

Bowel Surgery: Resection of segments of the bowel may be necessary to remove tumor implants.
Diaphragm Resection: The diaphragm, the muscle separating the chest and abdominal cavities, may need to be resected if it contains cancerous lesions.
Multi-Visceral Resections: In some cases, multiple organs may need to be removed to achieve complete cytoreduction.

EOC's unique pattern of metastasis, spreading non-contiguously along peritoneal surfaces, necessitates a meticulous and thorough surgical approach. While the disease typically remains confined to the peritoneal cavity until late stages, it can form large-volume masses in various locations, including the omentum, sigmoid colon serosa, and pericolic gutters. Lymph node involvement, particularly in the pelvic and periaortic regions, is also common, especially in advanced-stage disease.

Conclusion: Optimizing Surgical Strategies for Improved Outcomes

Extra-peritoneal hysteroannessiectomy, often in conjunction with en bloc rectal resection, stands as a critical component of peritonectomy procedures, particularly in cases of primary EOC with peritoneal spread. By meticulously removing the pelvic peritoneum and associated tissues, surgeons can achieve optimal cytoreduction, improve treatment outcomes, and ultimately enhance the quality of life for women facing this challenging disease. Further research, including large-scale randomized trials, is essential to refine surgical techniques, optimize patient selection, and solidify the role of combined approaches like EH and HIPEC in the comprehensive management of advanced EOC.