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Surgery is the main treatment for most ovarian cancers. The extent of surgery depends on how far the cancer has spread and your overall health. For women of childbearing age with certain kinds of tumors that are found at the earliest stage, it may be possible to treat the cancer without removing both ovaries and the uterus.

Surgery for epithelial ovarian cancer

For epithelial ovarian cancer, surgery has 2 main goals: staging and debulking. If your cancer isn’t properly staged and debulked, you may need to have more surgery later, so it’s important that this surgery is done by a gynecologic oncologist who’s trained and experienced in ovarian cancer surgery.

Staging epithelial ovarian cancer

The first goal of ovarian cancer surgery is to stage the cancer to see how far the cancer has spread from the ovary. Staging is very important because ovarian cancers at different stages are treated differently. If the staging isn't done correctly, the doctor may not be able to decide on the best treatment.

Usually staging ovarian cancer involves removing:

• The uterus (hysterectomy)
• Both ovaries and fallopian tubes (bilateral salpingo-oophorectomy or BSO)
• The omentum (omentectomy), a layer of fatty tissue that covers the abdominal contents like an apron, where ovarian cancer sometimes spreads

Other biopsy samples might also be taken to help in staging:

• Lymph nodes in the pelvis and abdomen, to see if the cancer has spread
• A peritoneal lavage—washing the abdominal cavity with salt water (saline) to collect fluid that can be checked for cancer cells
•  Tissue biopsies from different areas inside the abdomen and pelvis to look for cancer cells

Debulking epithelial ovarian cancer

The other important goal of ovarian cancer surgery is debulking – removing as much of the tumor as possible. Debulking is very important when ovarian cancer has already spread throughout the abdomen (belly) at the time of surgery.

• A cancer is considered optimally debulked when no visible cancer has been left behind or no tumors larger than 1 cm (less than 1/2 an inch). This
• If more cancer remains, the cancer is considered sub-optimally debulked.

People whose tumors have been optimally debulked have a better outlook (prognosis) than those left with larger tumors after surgery.

In some cases, other organs might be affected by debulking:

• A piece of colon may be removed. Often, the 2 ends are sewn back together. If they can’t be reconnected right away, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes to get out. This is called a colostomy. This is usually temporary, and the ends of the colon can be reconnected later in another surgery.
• A part of the small intestine may also need to be removed. In most cases, it can be reconnected. If not, an ileostomy might be needed. This is also usually temporary, but will need special care. Before surgery, ask your doctor if this is a could be needed.
• If a piece of the bladder is removed, a catheter will be placed during surgery to drain urine. It will stay until the bladder heals enough to empty on its own.
• The spleen, gallbladder, or parts of the stomach, liver, or pancreas may also need to be removed.
• If both ovaries and/or the uterus are removed, you will not be able to become pregnant. It also means you will go into menopause if you haven’t done so already.

What to expect after surgery

After ovarian cancer surgery, most women will stay in the hospital for 3 to 7 days and can resume their usual activities within 4 to 6 weeks.

Intraoperative imaging during surgery

To help find and remove ovarian cancer, surgeons may use a special imaging system for intraoperative imaging:

• A fluorescent drug called pafolacianine (Cytalux) is injected into your blood a few hours before surgery.
• The drug travels through the body and attaches to a specific protein found on ovarian cancer cells.
• During surgery, the imaging system gives off near-infrared fluorescent light that will cause the drug to light up so the surgeon can see which areas need to be removed.

Common side effects from pafolacianine (Cytalux) include belly pain, heartburn, itching, chest pain, nausea, vomiting, and flushing.

Your doctor may ask you to avoid supplements with folic acid for a few days before surgery, because these can interfere with the imaging.

Surgery for ovarian germ cell tumors and ovarian stromal tumors

For germ cell tumors and stromal tumors, the main goal of surgery is to remove the cancer.

Most ovarian germ cell tumors are treated with a hysterectomy and bilateral salpingo-oophorectomy. If the cancer is in only one ovary and you still want to be able to have children, only the ovary containing the cancer and the fallopian tube on the same side are removed (leaving behind the other ovary and fallopian tube and the uterus).

Ovarian stromal tumors are often confined to just one ovary, so surgery may just remove that ovary. If the cancer has spread, more tissue may need to be removed. This could mean a hysterectomy and bilateral salpingo-oophorectomy, and even debulking surgery.

Sometimes, after child bearing is finished, surgery to remove the other ovary, the other fallopian tube, and the uterus may be recommended, for both germ cell and stromal ovarian tumors.