Before choosing the appropriate surgical procedure, a two-pronged approach--transvaginal ultrasonography and CA-125 assessment--is the best way to determine the benign or malignant nature of an ovarian mass.
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Before choosing the appropriate surgical procedure, a two-pronged approachtransvaginal ultrasonography and CA-125 assessmentis the best way to determine the benign or malignant nature of an ovarian mass.
Ovarian cysts are the fourth most common indication for gynecologic admissions in the United Statesand more and more, laparoscopy is becoming the method of choice for managing benign adnexal masses. In Finland alone, for example, the number of operative laparoscopic procedures climbed from 1,437 in 1990, to 3,335 in 1994, an increase of 232%.1
Among my goals in this review are to look at the pros and cons of laparoscopy versus laparotomy and to discuss the characteristics of benign versus malignant ovarian masses. I'll also outline the various surgical procedures for benign adnexal masses and the different laparoscopic techniques demanded by larger cysts.
Several factors that account for the appeal of laparoscopy are listed in Table 1. A laparoscopic approach, however, does have limitations (Table 2).
Compared to laparotomy, laparoscopy is minimally invasive and can be performed through small incisions with better cosmetic results, less postoperative pain, no bowel manipulation, and fewer adhesions to the abdominal scars.
It is usually an outpatient procedure, which lowers the overall medical cost.
It typically produces less postoperative pain, which often reduces a woman's postoperative use of narcotics.
Decreased bowel manipulation and narcotics often bring about an early return of bowel function, permitting a woman to resume her regular diet sooner.
Patients who have less pain often walk around sooner and have a shorter recovery and earlier return to full activity and work.
Laparoscopic surgery sometimes provides a better view of the pelvic structures, liver, and diaphragm than is possible via small laparotomy incisions.
First and foremost, absence of three-dimensional vision, which decreases depth perception.
Absence of tactile sensewhich is especially important in detecting malignancies and assessing the degree of adhesions.
Increased dependence on proper surgical instrumentation.
Need for the highly-skilled training required for advanced laparoscopic surgical procedures.
Increased dependence on patient positioning, making it inappropriate for patients who can't tolerate the lithotomy position.
A requirement for general anesthesia and steep Trendelenburg positioningwhich makes patient ventilation more difficult. Patients with compromised pulmonary functionparticularly those who are obesemay not tolerate prolonged laparoscopic surgery as well as laparotomy.
Laparoscopy doesn't permit the surgeon to explore the bowel and the retroperitoneal space as extensively as does laparotomy and is probably less safe and less effective for treating bowel and ureteral adhesions.
Unsuitability for patients with large, solid ovarian masses like ovarian fibromas, which must be removed through an enlarged secondary incision when they can't be removed vaginally.
In women with ovarian cancers, potential for intraoperative leakage of fluid from the cyst (which can worsen the prognosis), incomplete tumor removal, incomplete surgical staging, delay in definitive treatment, and port site implantation.
Increased risk of cyst rupture.
Possible increased risk of trocar site tumor implantation because of the positive intraperitoneal pressure required for laparoscopy.
Many retrospective reviews attest to the safety and efficacy of laparoscopic surgery in women with benign ovarian cysts.2,4 In addition, prospective comparisons of laparoscopic versus laparotomy management of ovarian cysts show that the laparoscopy is associated with significantly less operative morbidity, postoperative pain, and need for narcotics; shorter hospital stays and recovery periods; and higher rates of patient satisfaction with the operative scar.5,6
With proper patient selection, it is unusual for a surgeon to unexpectedly find a malignancy in a woman undergoing laparoscopic surgery for an ovarian mass. Fewer than 1% of women with nonsuspicious ovarian masses are unexpectedly found to have ovarian cancer.7-9 Transvaginal ultrasonography combined with CA-125 testing is the best way to preoperatively determine the nature of an ovarian mass.
Benign ovarian masses are usually unilateral and unilocular, have regular borders, thin septa, no solid areas, and no internal excrescences on ultrasonography. Malignant ovarian masses, on the other hand, can be bilateral or unilateral, often have irregular borders, thick septa, solid areas, or internal excrescences and are sometimes associated with intraperitoneal fluid.10 Color Doppler may improve the accuracy of ultrasound in differentiating benign from malignant ovarian masses. The resistance index (systolic peak - diastolic peak/systolic peak) and the pulsatility index (peak systolic flow velocity - end diastolic flow velocity/mean flow velocity) are significantly lower in malignant ovarian masses.
There is some overlap of CA-125 values between benign and malignant ovarian masses, particularly in premenopausal women. However, a CA-125 value higher than 200 U/mL or an elevation associated with a complex adnexal massespecially in a postmenopausal womanis more likely to be associated with malignancy.11 In uncertain cases, follow-up CA-125 values can help. Falling CA-125 levels are more often associated with benign disease than are rising CA-125 levels.
In selecting appropriate patients for laparoscopy, also consider the possibility of operative complications, and conversion to laparotomy. Conversion occurs in 10% of women but the risk varies depending on the surgeon's threshold for laparoscopic surgery, the patient's history of adhesions, and the nature of the ovarian mass. Operative complications and conversion to laparotomy are most likely among women who've undergone many previous laparotomies, those with a history of dense adhesions, a body mass index above 30, and those undergoing complex laparoscopic procedures.12-14 Women with a history of bowel perforation especially are more prone to having diffuse, dense peritoneal adhesions that preclude laparoscopic surgery.
Improper trocar insertion causes most of the operative complications of laparoscopic surgery. Examples are injury to the bowel, major vessels, bladder, inferior epigastric vessels, and subcutaneous emphysema. Other complications include thermal injury to the bowel, abdominal wall contusions, trocar-site herniation with possible bowel obstruction, and trocar-site tumor implants. Fortunately, the overall incidence of complications is relatively low (about 2%).15
Obtain appropriate consent from patients scheduled for laparoscopic surgery for an adnexal mass and counsel them about the possibility of conversion to laparotomy. The main reasons for conversion to laparotomy are: (1) extensive adhesions precluding safe operative surgery; (2) intraoperative complications (e.g., bowel, bladder, or uretal injuries); and (3) suspicion or diagnosis of malignancy. If you do suspect malignancy, discuss with the patient beforehand her feelings about proceeding directly from intraoperative pathologic evaluation to definitive treatment and staging surgery at the time of laparoscopy. In that situation, you should have a gynecologic oncologist on call.
An intrauterine manipulator (like the sturdy, nondisposable Pelosi manipulator, which I prefer) helps to elevate the uterus and adnexa out of the pelvis and give you a clearer view of the adnexal structures. The size of the ovarian mass and the site of previous laparotomy scars should determine where you insert the laparoscope. Omental or bowel adhesions at laparotomy sites are not unusual. An indwelling Foley catheter will help prevent bladder injury and orogastric tube suction minimizes bowel distension.
Choice of open versus closed laparoscopic technique should be based on the physician's training and the patient's characteristics. No randomized comparisons of complication rates and operative time with the two techniques have been done, but retrospective reports show similar complication rates. I prefer the open technique because I believe it is safer, especially in women with previous laparotomies.13,16,17
After inserting the laparoscope, start the procedure by visualizing the upper abdomen, including both hemidiaphragms, areas that are occasionally the key to diagnosis of an ovarian mass (e.g., omental or diaphragmatic tumor nodules). Next, with the table tilted in the Trendelenburg position, inspect the pelvic organs and, under laparoscopic guidance, make secondary and tertiary punctures, preferably in the right and left lower quadrants or in the midline suprapubic area. Be sure to avoid the inferior epigastric vessels (Figure 1).
Thoroughly inspect the pelvic organs, peritoneum, and both ovaries and be sure you can see both ureters to avoid ureteral injury, especially among patients undergoing salpingo-oophorectomy. Table 3 outlines the differences between functional and neoplastic ovarian masses, while Table 4 gives characteristics of benign versus malignant ovarian masses. Figure 2 shows a suspicious ovarian mass that turned out to be a serous borderline ovarian tumor.
|Functional cyst||Neoplastic cyst|
|Thin cyst wall||Thick cyst wall|
|Few ovarian surface vessels||Numerous ovarian surface vessels|
|Usually < 10 cm in diameter||Can be >10 cm in diameter|
|Usually found in premenopausal patients||Pre- or postmenopausal patients|
|Cyst fluid is usually yellow||Cyst fluid is clear, dark brown, mucinous, or consistent with a dermoid cyst|
|Benign masses||Malignant masses|
|Smooth outer capsule, usually no significant adhesions||Outer capsule may have irregular surface or show penetration with adhesions into surrounding structures|
|Uniformly cystic||Mixed consistency with cystic and solid areas|
|No external excrescences||May have external excrescences|
|Usually no ascites||May be associated with ascites|
|No tumor nodules in omentum, peritoneum, or diaphragm||Tumor nodules in omentum, peritoneum or diaphragm may be present|
If you suspect ovarian malignancy, you can terminate the laparoscopic procedure, obtain a biopsy or frozen section, or consult a gynecologic oncologist, depending on both the circumstances and the preoperative plan. Although some studies have reported successful laparoscopic staging in some women with early-stage ovarian cancer, I prefer to convert the procedure to laparotomy and perform adequate surgical staging.18 At the start of laparoscopic surgery for an ovarian mass, the surgeon should perform peritoneal washings, aspirate the fluid, and send it for cytology, if needed (Figure 3). Do not handle the ovarian cyst until you accomplish this step, as that may lead to its rupture.
Surgical procedures for managing benign adnexal masses include aspiration, fenestration, ovarian cystectomy, unilateral or bilateral salpingo-oophorectomy, and laparoscopically-assisted vaginal hysterectomy (LAVH) with unilateral or bilateral salpingo-oophorectomy (BSO).19
Aspiration. This procedure is rarely performed alone due to the high recurrence rate. In a retrospective review, Marana and colleagues reported an 84% recurrence rate among women with ovarian cysts treated with laparoscopic cyst aspiration, versus a 4% recurrence rate among counterparts treated with laparoscopic cyst excision.20 Moreover, a benign finding from cytology of the aspirated fluid does not rule out malignancy. Ovarian cyst aspiration is used under unusual circumstances, such as when a shortened operative time is required or when suspicion of malignancy is very low.
Fenestration. For this procedure, an elliptical segment of the cyst wall is removed and the cystic fluid drained. Hasson reported on 83 women with ovarian cysts treated by laparoscopic fenestration and biopsy, with or without coagulation or removal of the cyst lining.21 Only one of 56 functional, simple, or paraovarian cysts recurred. Two of 18 ovarian endometriomas treated with fenestration and coagulation or removal of the lining recurred, whereas eight of nine endometriomas recurred when treated with fenestration alone.
Ovarian cystectomy. The surgeon performing an ovarian cystectomy completely excises the cyst wall. If a cyst is small (4 to 5 cm), keep the wall intact for as long as possible to facilitate intact removal of the cyst. The preferred approach for larger cysts is controlled aspiration followed by cystectomy. Once you have entered the cyst, hold the cyst wall and the ovarian cortex separately and firmly and tease them apart. Sometimes, aquadissection will facilitate the process. Large cysts may require that you twist the forceps holding the cyst wall in order to keep the cyst wall under pressure. Once the cyst wall is detached from the ovary, it can be removed through the secondary or tertiary ports, preferably in an endobag. A very large cyst wall can be removed through a posterior colpotomy performed in the posterior vaginal fornix.
Ovarian cysts can sometimes be removed intact from the rest of the ovary. In these cases, the surgeon makes an incision at the antimesenteric border of the ovary using the needle tip cautery. The incision is enlarged (using scissors) until the cleavage plane between the cyst wall and the ovary is visible. Either scissors or aquadissection can be used for dissection in this cleavage plane. After removing the cyst wall, coagulate the bleeding points using bipolar diathermy. It isn't necessary to reconstruct the ovary following laparoscopic cystectomy.
When removing dermoid ovarian cysts, it's important to avoid intraperitoneal spillagewhich can result in chemical peritonitis, severe adhesions, and possible fistula formationand to try to tease the cyst intact from the ovary. Place the cyst in an endobag and drain it under control inside the endobag or remove it intact and drain it through a posterior colpotomy. Dermoid cysts sometimes can be left intact and removed with the uterus in women undergoing LAVH. Should intraperitoneal spillage occur, copious irrigation and suction- ing often prevent postoperative complications. 22
Salpingo-oophorectomy. At times unilateral or BSO is the best way to manage ovarian cysts. This procedure is indicated, for example, when the ovary appears unsalvageable or the nature of the ovarian cyst is questionable, in women with a family history of ovarian cancer, patients with estrogen receptor-positive breast cancer, and postmenopausal women.
Inspect the ureters before beginning salpingo-oophorectomy. Elevate the fimbrial end of the fallopian tube and the ovary to stretch the infundibulopelvic ligament. Create a window in the peritoneum of the broad ligament to grasp the infundibulopelvic ligament without risking injury to the ipsilateral ureter. Secure the ligament with bipolar coagulation, and cut it with a scissors or transect it using a laparoscopic stapler. Occasionally, you can clamp, sever, and ligate the infundibulopelvic ligament using an extracorporeal knot technique (Figure 4). It's my practice to use bipolar cautery, as it is inexpensive, safe, and readily available. After severing the coagulated infundibulopelvic ligament with scissors, the posterior leaf of the broad ligament is cut, up to its attachment to the uterus. Coagulate the uterine end of the fallopian tube and the ovarian ligament using bipolar diathermy and cut them using scissors. Alternatively, you can ligate these structures with an endoloop and then cut them with scissors. Place the separated tube and ovary in an endobag and remove them through the secondary or tertiary incisions (which may first need to be enlarged).
Different techniques are available to manage large (>10 cm) ovarian cysts laparoscopically. These include ultrasound-guided aspiration, intraoperative aspiration using a needle or a Bonanno suprapubic catheter (Becton Dickinson, Rutherford, N.J., Figure 5), drainage and aspiration in an endobag, drainage through the vagina following hysterectomy or through a posterior colpotomy.23-25 Figure 6 depicts removal of a large ovarian cyst with the help of controlled drainage in an endobag to avoid spillage.
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At the completion of laparoscopic surgery, copious irrigation should be performed and hemostasis secured. It's a good idea to lower the intraperitoneal pressure by allowing the intraperitoneal gas to escape through one of the ports. At the same time, inspect the pedicles for evidence of bleeding, because positive intraperitoneal pressure sometimes produces a false sense of hemostasis by tamponading the vessels. Even after hemostasis occurs, additional irrigation may be needed, especially for patients with either mucinous or dermoid ovarian cysts that were leaking intraoperatively. It's my practice to remove the appendixes of women with mucinous ovarian tumors because these tumors are occasionally associated with appendiceal abnormalities. Next, allow the intraperitoneal CO2 to escape and remove the trocars under vision. For incisions of 10 mL or more, I close the fascia with a figure of eight 0 Vicryl suture, approximate the subcutaneous tissue using 3/0 Vicryl sutures, and suture the edges of the skin using 4/0 Monocryl in a subcuticular fashion. The final step is to apply steri-strips and bandages.
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