Staging ovarian masses intra op... what are we responsible for as pediatric surgeons?

Managing ovarian masses in children can be quite challenging. This is more of a decision making challenge than a technical one.

The fact that we usually have little information preop that is useful in helping to risk stratify a lesion and answer the question 'is this malignant or not' makes many of the decisions we make difficult: Laparoscopic or open resection? shall we try to save any remnant ovarian tissue or do a complete oopherectomy?...

Occasionally some intraoperative findings guide that decision, but more frequently we are faced with an ovarian mass, normal preop AFP/BHCG (whatever the diagnostic implications of those are), and no evidence of local or distant spread.

Regardless of different approaches to that scenario, one thing we are responsible to do as surgeons is clearly document intraoperative findings (including pertinent negatives) so that the information is available if the mass does turn out to be malignant.

Per COG recommendations, intraoperative documentation of the following should be made (including pertinent negatives)

1. Collection of ascites or washings on entering the peritoneum

2. Examination of peritoneal surface with biopsy of any nodules

3. Examination and palpation of retroperitoneal LN's and biopsy of firm or enlarged ones

4. Inspection and palpation of the omentum with excision of any abnormal or adherent areas

5. Inspection and palpation of the contralateral ovary and biopsy any abnormal areas

6. Complete resection of the tumor and ovary with sparing of the fallopian tubes if not involved.

Clearly, if a totally laparoscopic approach is used, palpation of the peritoneal lining and omental lesions is not possible, which makes it impossible to perform the complete staging mentioned. In some situations, however, the contralateral ovary and retroperitoneal lymph nodes may still be palpated if a small Pfannenstiel incision is used to extract the ovarian mass.

Reference:
Oltmann S et al. Pediatric ovarian malignancies: how efficacious are current staging practices? JPS(2010)45,1096-1102