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Surgery for an ovarian mass is performed because it may contain cancer tissue. While
the patient is under general anaesthetic, a frozen section examination will be performed
by the pathologist to investigate whether the tumour is malignant or benign. If
the tumour appears to be malignant, the pathologist will also try to specifiy what
type of cancer it is.
If the tumour is benign no further surgical procedures are necessary. Depending
on the patients age, removal of the other ovary and/or a hysterectomy can be done.
If the tumour is a Germ cell tumour usually these patients are young and still
wish to have children - the affected ovary should be removed and biopsies from the
inside of the abdomen and sometimes from the lymph nodes are taken depending on
the tumour type. This staging procedure will confirm that the tumour has not spread
and it will reveal tumour dissemination. In more than 90% the tumour will be confined
to the one ovary.
Some patients with germ cell tumours require chemotherapy. The chances are very high
that the ovarian function deteriorates during chemotherapy but will resumes its
function once chemotherapy finishes. During chemotherapy an oral contraceptive pill
or another suppressor of the ovarian function should be used to rest the ovary.
If patients have completed their family planning they will be offered a total hysterectomy
with or without a staging procedure (depending on the frozen section result).
If the tumour is an epithelial ovarian cancer and it is apparently confined to
one ovary, a full hysterectomy, bilateral removal of tubes and ovaries, removal
of the omentum and pelvic washings, biopsies from the inner surface of the abdomen
and from the lymph nodes should be done (surgical staging). This staging procedure
will determine if the tumour has spread within the abdomen. In more than 70% of
patients the tumour will not have spread and will be confined to the one ovary.
In the other 30% of patients it is essential to know that there was tumour spread
because these patients can then be treated with chemotherapy. The success rate in
these patients is very encouraging.
If tumour has apparently spread to other organs it is important to remove as much
tumour as medically and technically possible. The less the amount of postoperative
residual tumour, the higher the chance of response to chemotherapy and the higher
are the chances of cure. In order to remove significant portions of the tumour (debulking)
some patients require surgery to the diaphragm, to the spleen, the pancreas and
to the bowel. However, tumour in the porta of the liver, in lymph nodes above the
renal vessels or tumour in the mesentery of the bowel cannot be removed.
Before the operation imaging (X-ray and CT scan) and blood tests are routine measures
and give useful information prior to surgery. Usually the bowel needs to be prepared
and cleared in case of bowel surgery. Please fast at least 6 hours prior to surgery.
Please stop smoking before the operation as it makes your postoperative management
much easier.
The procedure requires general anaesthesia. I encourage patients to have an epidural
catheter inserted because it allows for appropriate pain control after the operation.
The procedure usually takes 2 to 4 hours and is carried out by a midline incision
through the abdominal wall.
When you wake up from anaesthesia there will be lines running in and out of you.
A drip will give you the necessary fluids, a catheter will drain the urine from
your bladder and the epidural catheter will allow for adequate pain control. An
oxygen mask will supply oxygen to the respiratory system. A drain may collect body
fluid from the inside of the abdomen. These lines will be removed once I am happy
that your body functions return to normal, which is usually after 24 to 48 hours.
The final histopathological report of all the biopsies taken during surgery may take
up to one week. It forms the basis for the decision if any and what kind of further
treatment is required.
Surgery always carries risks. Before surgery, we do everything to minimise these
risks. I give antibiotics before I do the skin incision in order to avoid skin and
other infections. Commencing prior to surgery I give Heparin or cals compression
stockings in order to prevent the formation of blood clots in the legs. At surgery
sterile handling of instruments further reduces the risk of infectious complications.
However, there are some immanent risks of surgery for ovarian cancer:
Medical and anaesthetic risks associated with general anaesthetic, with epidural analgesia or with postoperative pain control do exist. In patients with pre-existing medical conditions these risks are obviously higher.
There is a risk of injury to pelvic organs, such as the bowel, the bladder, the ureters, blood vessels and nerves. These injuries usually get repaired during surgery. However, in a small proportion of patients these injuries are not recognised during surgery or injuries may even develop after surgery. Then another operation is required to repair those defects. Injury to big blood vessels may result in need of blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. Many patients will experience some numbness of the skin around the upper thigh.
Bladder dysfunction: Due to the dissection of the tissue around the bladder and the ureter the bladder sensation is disturbed. As a consequence most patients experience difficulties emptying their urinary bladder. Therefore a urinary catheter will stay in the bladder for up to 5 days. If the bladder dysfunction is still present after a week, the patient will be trained to perform self-catheterisation of the bladder. Bladder dysfunction beyond 4 weeks is extremely rare.
Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymph oedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection.
If the ovaries were preserved, there is a risk in the range of 10 to 20% to develop ovarian cysts, which subsequently may require surgery.
Other possible complications include ...
Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia
Thromboembolic complications (formation of blood clots)
Numbness and swelling to the skin around the incision
Psychosexual changes
As a consequence of surgery for epithelial ovarian cancer, your ovaries will almost
certainly be removed. If you are less than 50 years of age (sometimes even less
than 60 years) you will become instantly menopausal and you may wish to consider
Hormonal replacement Therapy (HRT). I am very happy to discuss the issues of HRT
with you.
Most patients with ovarian cancer will require chemotherapy. Patients usually tolerate
chemotherapy very well. If chemotherapy is required I will bring you in contact
with one of the medical oncologists.
You need to stay in hospital for around one week to 10 days. I recommend to give
yourself a break for the next few weeks. Especially I recommend to avoid intercourse,
vaginal tampons and full baths for the next 6 weeks.
Please notify me immediately if your condition becomes worse after you have been
discharged from hospital.
After surgery, you should be seen regularly for follow-up for at least 5 years. These
examinations will include PAP smears, pelvic examinations and sometimes imaging
methods.
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