Laparoscopic management of benign-appearing ovarian tumors

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摘要

The description of the laparoscopic management of benign-appearing ovarian tumors covers all aspects of the surgical procedure used for the management of benign-appearing ovarian tumors.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: intraperitoneal cystectomy, adnexectomy, results/complications.
Consequently, this operating technique is well standardized for the management of this condition.

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2002-07

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WeBSurg.com, Jul 2002;2(07).
URL: http://www.websurg.com/doi-ot02en278.htm

Laparoscopic management of benign-appearing ovarian tumors

1. Introduction

Ovarian tumors occur frequently. At the present time, other than in clinical research protocols, only benign ovarian tumors are managed laparoscopically (Mettler et al., 1997). Therefore, preoperative workup must be thorough and laparoscopic evaluation must be performed meticulously in order to avoid treating an unsuspected ovarian carcinoma.
In young women, treatment is generally conservative (cystectomy), as preservation of the patient’s fertility is essential. In older or post-menopausal women, treatment is usually radical (adnexectomy).

2. Anatomy

• Regional anatomy

• Attachments

1. Proper ovarian ligament
2. Ovary
3. Infundibulo-ovarian ligament
4. Suspensory ligament of ovary
5. Ovarian fimbria
6. Ampulla
The ovary is a paired organ situated on either side of the pelvis. It is almond-shaped and measures 4x2x1 cm.
Each ovary is suspended by its superior pole from the pelvic wall, by the suspensory ligament. It is also attached to the ampulla at this level, by the fimbria and infundibulo-ovarian ligament.
Its inferior pole is attached to the horn of the uterus by the proper ovarian ligament.

• Relationships

1. Broad ligament
2. Mesosalpinx
3. Mesovarium
4. Ovarian fossa
5. Ovary
6. Fimbria
7. Ureter
Its external surface lies against the internal surface of the pelvic wall at the level of the ovarian fossa.
The internal surface of the ovary is in contact with the ampulla and the infundibulum.
The inferior edge is free, while the superior edge is attached to the broad ligament by the mesovarium.

• Vascular supply

1. Uterine artery
2. Medial ovarian artery
3. Lateral ovarian artery
4. Lateral tubal artery
5. Ovarian artery
The blood supply to the ovary comes from 2 sources:
- the ovarian artery, which is a branch of the aorta and which divides into 2 branches at the superior pole of the ovary: the lateral ovarian artery, which supplies the ovary, and the lateral tubal artery, which supplies the uterine tube.
- the medial ovarian artery, which is the terminal branch of the uterine artery.
Generally, the vessels from the 2 sources anastomose. One source may predominate, and in rare cases may ensure full vascular supply to the ovary.

• Pathological anatomy

All parts of the ovary can give rise to a tumor. The majority of ovarian tumors are cystic tumors that develop from the serosa.

3. Indications

Indications
Surgery is indicated for all organic ovarian tumors.
In young women of reproductive age, the procedure is generally conservative, ie cystectomy.
In older women, the procedure is usually radical: adnexectomy or, more rarely, oophorectomy.
In postmenopausal women, adnexectomy is often bilateral.

Contraindications
Contraindications may be related to:
- the nature of the cyst: cancer of the ovary, borderline tumors;
1. Ovarian carcinoma: atypical vascular supply
2. Ovarian carcinoma: intracystic vegetations
3. Ovarian carcinoma: extracystic vegetations
- the size of the cyst, especially for cystectomies. For tumors larger than 10 to 12 cm, it becomes difficult to perform a cystectomy laparoscopically, particularly in case of ovarian endometrioma.
- other conditions: morbid obesity, abdominal adhesions. In pregnant women, laparoscopy can be performed up to the 18th week of pregnancy.

4. Preop management

Preoperative workup
This aims to rule out cancer of the ovary.
It includes (Salat-Baroux et al., 1996):
- physical examination;
- abdominal and transvaginal ultrasound;
- measurement of tumor markers, particularly CA 125 (serous tumors) and CA 19-9 (mucinous tumors).

Patient preparation
- preoperative fasting;
- bowel preparation with an enema, except in emergencies;
- shaving of suprapubic area;
- 5 mg of midazolam administered by intramuscular injection 1 hour before surgery.

The patient should be informed of:
- the modalities of laparoscopy;
- risks and complications;
- risk of conversion to laparotomy;
- modalities of the procedure: cystectomy or adnexectomy.

5. Operating room set-up

• Patient

- general anesthesia;
- supine position;
- 30° Trendelenburg position;
- legs apart with access to the perineum, which should extend slightly over the edge of the table;
- left arm alongside the body;
- in-dwelling urinary catheter mandatory;
- nasogastric tube;
- uterine cannulation;
The operating field must be wide.
Vulvar, perineal, crural, and vaginal disinfection must be performed.
Drapes are used to separate the perineum from the abdomen.

• Team

1. The surgeon is on the left of the patient.
2. The first assistant is on the right of the patient.
3. The second assistant is seated between the patient’s legs.
4. The scrub nurse is on the surgeon’s left.

• Equipment

1. The first monitor is opposite the patient’s right foot. It is used by the surgeon and first assistant.
2. The second monitor is used by the second assistant and the scrub nurse. It is at the level of the patient’s right shoulder.

6. Trocar placement

• Pneumoperitoneum

1. Palmer’s point
The Veress needle is introduced either in the umbilicus or at Palmer’s point (3 cm below the costal arch on the left mid-clavicular line). The peritoneal cavity is insufflated with CO2 to a pressure not exceeding 14 mm Hg.

• Optical trocar

A: A 12 mm optical trocar is placed at the level of the umbilicus.

• Operating trocars

B and C: Two 5 mm lateral operating trocars are placed at the level of the right and left iliac fossae, two fingerbreadths medial and cephalad to the anterior superior iliac spines.
D: A fourth, 10-12 mm trocar is often useful. It is placed in a midline position, 3 cm above the pubic symphysis. The operative specimens are extracted through this trocar, or through its parietal opening.

• Variation

In case of a voluminous cyst or pregnancy, the insufflation is done at Palmer’s point. Trocar A for the laparoscope is introduced halfway between the umbilicus and the xiphoid process.
Operating trocar D is placed at umbilical level.

7. Instruments

• Optical

1. 0° laparoscope
2. 30° laparoscope
The procedure can be performed with a 0° or 30° laparoscope.

• Operating

1. Bipolar grasper
2. Grasping forceps
3. Babcock clamps
4. Scissors
5. 5 mm suction-irrigation device
6. Retrieval bag
7. Needle for peritoneal cytology

• Retractors

Uterine cannulation with:
1. Asymmetrical grasper
2. Blunt curette

• Optional

1. Endoloop
2. Ultrasonic dissectors

8. Major principles

1. Neoplastic miliary appearance of the cupolas
2. Invasion of the omentum
A thorough macroscopic evaluation of the ovarian tumor, the pelvis, and the greater peritoneal cavity is carried out to check for an undiagnosed ovarian cancer.
In case of doubt, a frozen section should be performed.

The following anatomical structures are examined to check for peritoneal carcinosis:
- abdominal cavity, omentum, diaphragmatic cupulae, and paracolic gutters;
- pelvic cavity, particularly the peritoneum of the ovarian fossae, rectouterine pouch, and vesicouterine pouch;
- surface of the ovary (vascular supply, search for extracystic vegetations).
Peritoneal cytology should be systematically performed during this operative step.

To avoid spreading the contents of the cyst, the ovarian tumor is preserved if possible. In case of rupture, a peritoneal lavage must be done, in addition to an evaluation inside the cyst itself to check for intracystic vegetations. The specimens should be extracted in retrieval bags.

If a cyst that appears to be functional is discovered, simple puncture is insufficient and a biopsy of the wall of the cyst must always be performed.

In case of adhesions, an initial adhesiolysis is performed.

9. Intraperitoneal cystectomy

• Cystectomy

The ovary is grasped with forceps or a Babcock clamp at the level of its antimesosalpingeal border or of the proper ovarian ligament.
The longitudinal incision of the ovarian cortical zone is extended with scissors to the level of the antimesosalpingeal border.
The cortical zone is dissected and the tumor is enucleated with caution.
Hemostasis is rarely necessary. It should be performed, however, if endometriomas are found, and is sometimes needed near the suspensory ligament, the proper ovarian ligament, and the hilum. Bipolar cauterization is recommended in these cases, to limit the risk of devascularization.
Suturing of the ovary is of no use in most cases.

• Variations

• Variation 1

1. Cystoscopy
2. Divergent traction
In case of rupture of the cyst:
- wide opening of the cyst;
- irrigation-suction of peritoneum;
- cystoscopy;
- Two graspers are used to exert divergent traction. One grasps the cortical zone of the ovary, while the other is positioned opposite the first, on the outer surface of the cyst. The 2 grasping forceps should be as close to one another as possible. Opposing traction is exerted on each grasper. The graspers should be manipulated slowly and carefully, to avoid tearing the cortical zone. The thinner the cortical zone, the more cautiously this should be done. The grasping forceps are then moved and repositioned, again as close to one another as possible. When the dissection is well advanced, the ovary is grasped in the cortical zone, on its deep surface, at the level of the reflection line between the cyst and the ovary.

• Variation 2

1. Protruding dome
2. Endometrioma
3. Ovarian parenchyma
In case of ovarian endometrioma, 2 techniques can be used:
a) intraperitoneal cystectomy: resection of the protruding dome is often useful for finding a plane of cleavage between the wall of the cyst and the healthy ovary. The dissection is often difficult and hemorrhagic. Hemostasis is performed step by step and is more difficult to perform at the end of the procedure.
b) opening of the cyst, resection of the protruding dome, and laser vaporization or electrocauterization with a bipolar grasper of the outer surface of the endometrioma (Donnez et al., 1996).

10. Adnexectomy

• Exposure

The ureter is identified.
The ovary is grasped at the level of the infundibulo-ovarian ligament with a Babcock clamp.
Traction is exerted on the ovary, superiorly and medially, to place tension on the suspensory ligament.
The uterus is anteverted and tipped laterally away from the cyst.
Exposure of the suspensory ligament often requires mobilization of the sigmoid colon on the left, and of the cecum on the right.
In the case of a large cyst that is not suspicious, puncture and suction of the cyst may be useful.

• Skeletonization

The suspensory ligament is skeletonized.
This skeletonization is not performed by all surgeons.
It is essential, however, to create a space between the suspensory ligament and the ureter, which is the procedure’s only dangerous relationship.
An extended opening of the summit of the broad ligament is performed with scissors after the peritoneum is tented with grasping forceps. This opening extends from the round ligament to the crossing of the ligament on the iliac axis.
The loose subperitoneal areolar tissue of the broad ligament is pushed away.
The ureter is retracted posteriorly by pushing down with closed scissors, using the deep surface of the posterior surface of the broad ligament as support.
An opening is made in the posterior surface of the broad ligament, and then enlarged with sweeping, cephalad to caudad movements.

• Suspensory ligament

Hemostasis of the suspensory ligament is achieved by cauterization with a bipolar grasper. It should be extended over approximately 2 cm. Division of the pedicle should be performed in several steps, with repeated cauterizations, as the suspensory ligament is a thick pedicle. Secondary bleeding rarely occurs. The skeletonization of the suspensory ligament, which separates it from the ureter, protects the ureter from thermal injury.
Hemostasis can be achieved with an endoloop.
Cauterization with ultrasonic dissectors is effective, but requires specific instruments and equipment.
The use of clips is not advised. Automatic staplers do not always obtain perfect hemostasis, and are costly.

• Utero-adnexal pedicles

The adnexa are isolated on the utero-adnexal pedicles by dividing the posterior peritoneum.
The fallopian tube is electrocauterized with the bipolar grasper. The cauterization should involve the interstitial portion of the tube, to prevent a subsequent pathology of the stump. The stump should be long enough to avoid the formation of a uteroperitoneal fistula.
The proper ligament of the ovary is electrocauterized and divided.

11. Results/complications

Feasibility
Most benign-appearing ovarian tumors can be managed laparoscopically. In a study of 481 patients and 508 ovarian tumors confirmed during laparoscopy, 87% of the ovarian tumors were treated by laparoscopy (Mage et al., 1990).

Mean operating time
The procedure is not very lengthy. In 3 published studies, involving a total of 1221 ovarian cysts, the mean operating time varied from 69 to 76 minutes, with considerable individual variations (Lok et al., 2000; Shushan et al., 1999; Mettler et al., 2001).

Conversion to laparotomy
Conversion to laparotomy is rare. In half of the cases it is the result of an intraoperative suspicion of malignancy, and in the other half it is needed because of technical problems due to adhesions, hemorrhage, or a tumor that is too large for laparoscopy. In the publications of Lok et al. (2000) and Mettler et al. (2001), the rate of conversion to laparotomy was 1% for 587 cysts and 2.4% for 493 cysts respectively.

Hospital stay
Hospital stay is relatively short. In the study of Lok et al. (2000), the mean hospital stay was 2.6 /-1.5 days.

Complications
Serious complications are rare (Lok et al., 2000). Besides digestive and vascular injuries, complications involve ureteral lesions that occur during the adnexectomy.
Ovarian remnant syndrome can be observed following an incomplete oophorectomy, particularly in women with pelvic adhesions or endometriosis (Nezhat et al., 2000).
Granulomatous peritonitis is a rare but serious complication. It is due to the rupture of a dermoid cyst and the spreading of its contents. If rupture occurs, abundant lavage (6 to 9 liters) must be performed to prevent this complication.

Recurrences
After cystectomy, the usual recurrence rate is low. It is highest in cases involving endometriomas (23% of 161 cases after 42 months), particularly after fenestration and vaporization of the outer surface (58% of 70 cases after 42 months) (Saleh and Tulandi, 1999).

Effects on fertility
Cystectomies do not seem to affect fertility (Canis et al., 1992) nor the quality of ovarian response during IVF-embryo transfer (Canis et al., 2001; Donnez et al., 2001).

12. Reference

Canis M, Bassil S, Wattiez A, Pouly JL, Manhes H, Mage G et al. Fertility following laparoscopic
management of benign adnexal cysts. Hum Reprod 1992;7:529-31.
Canis M, Pouly JL, Tamburro S, Mage G, Wattiez A, Bruhat MA. Ovarian response during IVF-embryo
transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum
Reprod 2001;16:2583-6.
Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum
Reprod 1996;11:641-6.
Donnez J, Wyns C, Nisolle M. Does ovarian surgery for endometriomas impair the ovarian response to
gonadotropin? Fertil Steril 2001;76:662-5.
Lok IH, Sahota DS, Rogers MS, Yuen PM. Complications of laparoscopic surgery for benign ovarian
cysts. J Am Assoc Gynecol Laparosc 2000;7:529-34.
Mage G, Canis M, Manhes H, Pouly JL, Wattiez A, Bruhat MA. Laparoscopic management of adnexal
cystic masses. J Gynecol Surg 1990;6:71-9.
Mettler L, Jacobs V, Brandenburg K, Jonat W, Semm K. Laparoscopic management of 641 adnexal
tumors in Kiel, Germany. J Am Assoc Gynecol Laparosc 2001;8:74-82.
Mettler L, Semm K, Shive K. Endoscopic management of adnexal masses. Jsls 1997;1:103-12.
Nezhat CH, Seidman DS, Nezhat FR, Mirmalek SA, Nezhat CR. Ovarian remnant syndrome after
laparoscopic oophorectomy. Fertil Steril 2000;74:1024-8.
Salat-Baroux J, Merviel P, Kuttenn F. Management of ovarian cysts. Bmj 1996;313:1098.
Saleh A, Tulandi T. Reoperation after laparoscopic treatment of ovarian endometriomas by excision and
by fenestration. Fertil Steril 1999;72:322-4.
Shushan A, Mohamed H, Magos AL. How long does laparoscopic surgery really take? Lessons learned
from 1000 operative laparoscopies. Hum Reprod 1999;14:39-43.

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