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We present a rare case of a patient who was treated for advanced-stage ovarian cancer with optimal debulking surgery that included a supracervical hysterectomy, instead of total abdominal hysterectomy, who subsequently developed 3 isolated recurrences in the cervix and vagina. We suggest there may be a link between the type of hysterectomy and location of recurrence; we also emphasize the importance of pelvic exam and Papanicolaou smear for patients who have undergone supracervical hysterectomy as part of their ovarian cancer debulking surgery.

We present a unique case of high-grade serous carcinoma isolated to the spleen at the time of diagnosis, without any tumor present in the ovary, fallopian tubes, omentum or uterus, which was pathologically consistent with metastatic Mullerian carcinoma. Tumor sequencing with the MSK-IMPACT (Memorial Sloan Kettering–Integrated Mutation Profiling of Actionable Cancer Targets) multigene tumor panel test was performed, which revealed somatic mutations in PALB2 and in ARID1, as well as a TP53 hotspot mutation.

Eighty percent of women with ovarian cancer have advanced disease (FIGO stage III or IV) at the time of diagnoses and require extensive upper abdominal surgery to obtain complete gross resection (Minig et al., 2015; Eisenhauer et al., 2006). A diaphragmatic hernia is defined as abdominal contents bulging into the thoracic cavity (Spellar and Gupta, 2020). While rare following primary debulking surgery (PDS), these present with a variety of symptoms and are often misdiagnosed. Computed tomography (CT) is the diagnostic gold standard (Vertaldi et al., 2020). This video demonstrates repair of a left-sided complex diaphragm hernia via robotic video-assisted thoracic surgery in a 45-year-old with stage IVB ovarian cancer. She previously underwent extensive PDS, including modified posterior exenteration, bilateral salpingo-oophorectomy, omentectomy, bilateral pelvic lymph node dissection, appendectomy, bilateral diaphragm peritonectomy, splenectomy, resection of a right mediastinal lymph node, and insertion of a right chest tube. Complete gross resection was achieved. No left-sided diaphragm resection or repair was performed during the initial surgery. She received standard adjuvant chemotherapy with paclitaxel, carboplatin and bevacizumab. Six months postoperatively a surveillance CT scan revealed a small left hemidiaphragm hernia containing parts of the stomach. Although initially asymptomatic, she developed mild symptoms on follow-up, especially with lying supine. Imaging showed an increase in the size of the diaphragm defect. After completion of her maintenance bevacizumab therapy, corrective surgery was performed to prevent incarceration of the stomach. This video demonstrates the complex repair of this 4 × 6 cm defect located in the central tendon of the diaphragm. On two-week follow-up after corrective surgery, the patient’s symptoms had resolved.

Over 80% of patients with epithelial ovarian cancer present with advanced disease, FIGO stage III or IV at the time of diagnosis. The majority require extensive upper abdominal surgery to obtain complete gross resection. This may include splenectomy, distal pancreatectomy, partial hepatectomy, cholecystectomy, and usually diaphragmatic peritonectomy or resection. Following surgery, diaphragmatic hernia—a very rare but serious complication—may occur.We describe four cases of left-sided diaphragmatic hernia resulting after debulking surgery, which included left diaphragm peritonectomy and splenectomy, in patients with advanced ovarian cancer. In association with the current shift towards more extensive debulking surgery for ovarian cancer, more patients may present with postoperative left-sided diaphragm hernia, making the prevention, diagnosis, and management of this complication important to practicing gynecologic oncologists. Intraoperatively the diaphragm should be checked thoroughly to rule out any defects, which should be closed. A diaphragmatic hernia may be easily misdiagnosed because the patient can present with various symptoms. While rare, these hernias require prompt identification, intervention and surgical correction to avoid serious complications.