# Help Needed!!



## ellie.phelps@gmail.com (May 13, 2010)

POSTOPERATIVE DIAGNOSIS:
1. Stage III ovarian carcinoma.
2. Family history of BRCA deleterious gene mutation.

PROCEDURE
1.	Exploratory laparotomy with cytoreductive surgery including extrafascial total abdominal hysterectomy with bilateral salpingo-oophorectomy
2.	Radical Omentectomy
3.	Appendectomy
4.	Near total peritoneal resection including stripping of diaphragms and resection of large peritoneal implants along the retroperitoneum, liver, posterior cul-de-sak, pericolic gutters and anterior abdominal wall bilaterally.
5.	Resection of small bowel implants
6.	Bilateral utererolysis


Through a generous midline incision, the abdomen was entered and immediately extensive
Carcinomatosis was identified, consistent with the preoperative imaging. A large amount of
ascites was encountered and this was evacuated. A small sample was obtained for cytology.
With the abdomen decompressed and the ascites evacuated, a thorough examination was performed and there was multiple implants along the right sub diaphragmatic surface. There were implants along the posterior peritoneal reflection of the liver on the right side. There were implants just on top of the vena cava and right adrenal glands which were large in size. There were additional implants along the pericolic gutters and to the small bowel and essentially replaced the entire omentum and the omentum was approximately 6 centimeters thick and completely replaced with cancer. There were implants along the peritoneal surface along the retroperitoneum directly overlying the kidneys and this continued down into the pelvis. The uterus was essentially not recognizable and the ovarian masses were significant in size. 

The omentum was taken off the transverse colon and resected up to the greater curve of the stomach. The disease replaces the omentum and the gastroepiploic vessels needed to be sacrificed.  There was extensive disease abutting the spleen and this was peeled off of the spleen and this all was omental extension and this required additional mobilization of the splenic flexure and mobilization of the retroperitoneum to completely resect the splenic attachments of the omentum which were very significant and heavily involved with disease. The dissection continued along the hepatic flexure and the omentum was resected off of it and it was resected along its attachments in the hepatic flexure and the omentum was passed off the field. The omentum was approximately 6 cm thick and completely replaced with cancer. There was no evidence of bowel obstruction. 
Our focus then shifted toward resecting implants along the left suhdiaphragmatic pleural surface and this was performed. Extensive peritoneal resection was performed and continued en bloc down along the left pericolic gutter and retroperitoneal surface directly overlying the left kidney. The sigmoid colon was adherent to the abdominal wall and this was freed in order 10 expose the peritoneum which was continued to be resected.  The left ovarian vessels and the ureter were identified and preserved. The left ovarian vessels were secured transected and over sewn. The anatomy in the pelvis was essentially not recognizable and we continued with a subfascial dissection and the round ligament was encountered and this was transected. The ureter was dissected along its retroperitoneal course and the uterine vessel was transected near its origin and the entire specimen was dissected medially and the posterior cul-de-sac was dissected off of the rectum and the same type of approach was repeated on the right side. The vagina was entered anteriorly below the cervix and the cervix was rotated cephalad and the posterior vaginal wall was transected and meticulous dissection was needed in order to harpy dissect the cul-de-sak area while preserving the rectum. The large pelvic mass did include the uterus, cervix, bilateral fallopian tubes and ovaries and this was passed off the field.

Peritoneal dissection continued along the right pericolic gutter and the appendix was significantly involved and removed. The peritoneal implants along the retroperitoneum directly overlying the right kidney were resected as well as multiple implants in the right pericolic gutter which were completely stripped and resected as the entire peritoneum was resected on the right side. The peritoneal dissection continued and the right diaphragm was completely stripped and all of the disease was removed from the right diaphragm. The liver was completely mobilized on the right. The peritoneal reflection near the vena cava on the tight was heavily involved with implants and this required sharp dissection along the vena cava and complete mobilization of the liver in order to free this area to resect these implants. There was a large implant directly overlying the vena cava and right adrenal gland which required sharp dissection and this was completely resected. The small bowel was run in duplicate and there were multiple small bowel implants which were all resected. The lesser sac was explored and there were small implants which were also resected. 

I have come up with 58952 and 50715 and help with this one would be greatly appreciated.


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## Kimmers (May 13, 2010)

58952, 50715-50 is what I come up with.


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