title: The sandwich technique of diaphragmatic stripping or full-thickness resection for advanced ovarian cancer: how to keep it short and simple.
abstract: OBJECTIVE
  Residual tumor is an important prognostic factor in advanced ovarian cancer patients. A recent analysis from a large Gynecologic Oncology Group trial identified the diaphragm as the most common localization for residual tumor after surgery in advanced ovarian cancer. This stresses the need for more knowledge and training in diaphragmatic surgery in patients with advanced ovarian cancer.
  
  
  METHODS
  We aimed to describe a safe structured technique to perform transection of the peritoneal diaphragm or full-thickness resection of the diaphragm.
  
  
  RESULTS
  The structured technique consists of 5 steps as follows: (1) knowledge of anatomical landmarks, (2) adequate exposure of the surgical field, (3) mobilization of the liver, (4) demarcation of the resection lines of the peritoneum, and (5) mobilization of the diaphragmatic peritoneum by using the sandwich technique or performance of a full-thickness resection with subsequent suture.
  
  
  CONCLUSIONS
  Diaphragmatic surgery is an important part of upper abdominal surgery in advanced ovarian cancer patients. It is a safe structured procedure, which should be routinely performed to achieve optimal surgical results for these patients.
authors.affiliation: *Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany; and †Department of General Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Gynecologic Cancer Unit, Medical University of Vienna, Vienna, Austria.
authors.forename: Christoph
authors.initials: C
authors.lastname: Grimm
authors.forename: Philipp
authors.initials: P
authors.lastname: Harter
authors.forename: Florian
authors.initials: F
authors.lastname: Heitz
authors.forename: Andreas
authors.initials: A
authors.lastname: du Bois
mesh_terms: D003964:Diaphragm / Q000473:pathology / Q000601:surgery*; D005260:Female; D013509:Gynecologic Surgical Procedures; D006801:Humans; D009367:Neoplasm Staging; D018365:Neoplasm, Residual / Q000473:pathology / Q000601:surgery*; D010051:Ovarian Neoplasms / Q000473:pathology / Q000601:surgery*; D011379:Prognosis