1. The staging procedure is usually approached through a laparotomy incision. Any free fluid in the cul-de-sac is submitted for cytologic evaluation. Washings of the peritoneal cavity are obtained by instilling and removing 50 to 100 mL of saline. The affected adnexa should be removed intact and a frozen section obtained to determine or confirm the diagnosis. Thorough surgical staging should be carried out in the absence of obvious stage IV disease. Preservation of the uterus and a normal appearing contralateral adnexa is an option in women desirous of maintaining future fertility.

2. All intraperitoneal surfaces should be carefully inspected and suspicious areas or adhesions should be biopsied. If there is no evidence of disease, multiple intraperitoneal biopsies should be performed, including from the cul-de-sac, both gutters, bladder peritoneum, and bowel mesentery.

3. The diaphragm is evaluated by either biopsy or cytologic smear. A complete omentectomy should be performed.

4. The retroperitoneal spaces are explored to dissect the pelvic and paraaortic lymph nodes. Any enlarged lymph nodes should be resected and submitted separately for histopathologic evaluation.

5. For patients with advanced disease, optimal cytoreduction (debulking) should be attempted at the time of initial surgery. The majority of women with EOC (except for those with stage I disease) will require surgery and chemotherapy.

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