The letter from Mahajan et al. again takes up the problem whether an intraoperative controlled drainage would be the better therapy option, and therefore doubts the conclusions of our literature research. Unfortunately, the authors do neither give any evidence on which experiences their suggestions are based nor indicate to which publications they refer.
A limitation to a hypogastric incision extending from umbilicus to pubis is—in our view—unfavorable and irrelevant with tumors weighing more than 40 kg. Nevertheless, a resection of the large quantity of redundant abdominal wall and a reconstructive procedure, in which the epigastric region must be included, become inevitable in any case.
Our analysis of 19 publications demonstrated that in only four cases (21%) an intraoperative controlled drainage (see Table 1(1); refs. 16–19) and in further three cases a controlled pre- and intraoperative drainage (refs. 5, 6, 15) had been carried out. Compared with this, we detected four cases which had been managed successfully without any drainage. In the majority of cases, the course of the circulation and ventilation parameters is only described, however, a simple theoretical consideration is way more interesting (Fig. 1). The crucial point with the “sudden release of pressure” is the relation of the venous pressure (central: usually below 16 cm H2O) and the absolute weight of the tumor. A partial weight reduction to a remainder of more than 1 kg is irrelevant for the venous vessels because in an unpreferable position they will be compressed completely in any case. Additionally, the pressure to the veins of the abdominal wall is already reduced remarkably with the opening of the abdomen and the consequent slackening of the wall. The patient’s positioning is hence more decisive than a slow reduction of volume, respectively, weight by drainage.
Moreover, one must not neglect further disadvantages of intraoperative drainage such as a dissemination of tumor cells and an aggravated adhesiolysis and a mobilization along with a slackened cystic wall (and a minimal operative access).
A report published just recently described the management of a 30-year-old woman with a malignant giant ovarian tumor weighing 100 kg—unfortunately with a fatal outcome(2). The authors reported on an intraoperative aspiration of approximately 70 L of tumor fluid over 3 h which has not affected the cardiorespiratory function significantly, a 30-min lasting cardiac arrest occurring during the following adnectomy, and the patient’s death within 12 h postoperatively. However, the circular insufficiency was obviously not evoked by the removal of the tumor per se during the adnectomy but caused by the massive blood loss from the redundant parietal peritoneum due to disseminated intravascular coagulation.
The hint at the thromboembolic prophylaxis is justified; patients undergoing extended surgery in the abdomen and pelvis, belong to a group exposed to higher risk. According to the interdisciplinary guideline on inpatient and outpatient thromboembolic prophylaxis in surgery and perioperative medicine in Germany(3), a medicinal prophylaxis is indicated along with physical and early-mobilizing measures. Our patient had been treated perioperatively with low molecular weight heparin, wore a surgical hose, and was mobilized early after the operation.