Modified posterior pelvic exenteration for ovarian cancer in 8 steps

Posterior pelvic exenteration is frequently required during cytoreductive surgery for advanced ovarian cancer with extensive pelvic involvement. Despite its oncologic importance, the procedure remains technically demanding, with substantial variability in surgical planes, sequence, and complexity. A standardized and streamlined approach is lacking.

We present a surgical film demonstrating a modified posterior pelvic exenteration performed for advanced ovarian cancer with rectal involvement. Following comprehensive preoperative evaluation, tumor debulking surgery was undertaken. Intraoperative findings revealed complete obliteration of the pouch of Douglas, necessitating posterior pelvic exenteration. The procedure is organized into eight standardized steps (1) retroperitoneal access and vascular control, (2) bladder peritoneum incision and vesicovaginal space development, (3) pararectal and paravesical space dissection, (4) vaginal and ligamentous dissection, (5) sigmoid and rectal mobilization, (6) distal rectal transection, (7) proximal rectal transection, and (8) colorectal anastomosis. Unlike traditional techniques, this modification avoids routine dissection of the lateral paravesical and Latzk's spaces and limits excessive ureteric manipulation.

This modified posterior pelvic exenteration technique simplifies surgical workflow while preserving oncologic radicality. By reducing unnecessary dissections, the approach may decrease operative complexity, minimize the risk of bleeding and ureteric ischemia, and shorten operative time. The standardized eight-step framework also facilitates anatomical understanding and may reduce the learning curve for surgeons performing complex pelvic cytoreductive procedures.