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Section 9.2. Ovarian Cystectomy
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Camran Nezhat, Ceana Nezhat, and Farr Nezhat
Evolving technology has made it possible to treat most persistent
ovarian cysts laparoscopically. However, these operations mustbe
done judiciously. Although the role of laparoscopy in the management of malignancy is expanding, laparotomy remains the
procedure of choice when ovarian malignancy is encountered or
strongly suspected.
INTRODUCTION
One percent to2% of women developovarian cancer during their
lifetime, and when the disease is detected, two thirds of them are
in stage III or stage IV.[1] During laparoscopy, ovarian cancer
can be discovered so that immediate laparotomy and appropriate
staging are possible. Laparotomy may be required for optimal
surgical therapy, and postoperative radiotherapy or chemotherapy is instituted as needed. A recent study suggested that a delay
between laparoscopy and laparotomy may affect the distribution
of disease stage adversely.[2] Whenever a malignant tumor has
been missed at laparoscopy, restaging is required and should be
considered an oncologic emergency.[3] Given the reduced morbidity, patient disability, and cost, having an oncologist available facilitates the safe treatment of adnexal masses by operative
laparoscopy. Conversion from the laparoscopic approach rarely is
required.[4]
A serious concern is thatanovarian cyst assumed to be benign
subsequently may prove to be a stage I ovarian carcinoma. Even
careful laparoscopic examination may underestimate early-stage
ovarian cancer or borderline tumors.[5,6] If contents spill during their aspiration or with an ovarian cystectomy, the stage is
upgraded from IA to IC. The risks associated with spillage of cystic contents have been evaluated.[7] In a multivariate analysis of
stage I epithelial ovarian cancer, the factors that influenced the
rate of relapse in 519 patients were the tumor grade, the presence
of dense adhesions, and a large volume of ascites. Intraoperative
spillage at laparotomy showed no adverse effect on the prognosis
of stage I ovarian cancer.[8] The survival of women with borderline tumors who were managed initially by cystectomy, with or
without spillage, was not decreased, and there was no evidence
of disseminated disease an average of 7.5 years after diagnosis.[9]
The laparoscopic approach to borderline ovarian tumors is possible in early-stage disease and does not seem to negatively affect
long-term survival.[10]
The risk of spread remains questionable in patients who have
the appropriate operation. In two large studies, the incidence
of ovarian malignancy in patients with a known adnexal mass
was between 1.2% [11] and 0.3%.[12] The results of a 1991
survey of the members of the American Association of Gyneco-
logic Laparoscopists (AAGL) showed that laparoscopic excision
of unsuspected invasive ovarian cancer was uncommon. Only 53
instances were reported among 13,739 laparoscopic ovarian cystectomies, an incidence of 0.4%.[13] Similar results were found
in a countrywide survey undertaken in Austria, which included
16,601 laparoscopies on adnexal masses. Ovarian tumors subsequently were found to be malignant in 108 cases (0.65%).[14]
A laparotomy may be needed to ensure optimal staging and
treatment in cases ofmalignancy. Asurvey of gynecologic oncologists revealed 12 borderline ovarian tumors and 30 invasive ovarian cancers initially managed by laparoscopic excision.[15] Most
patients did nothave a staginglaparotomy for weeksafterthecancer was found. These patients did not have careful preoperative
screening, and appropriate surgical treatment was delayed.
PREOPERATIVE EVALUATION
Laparoscopic treatment of adnexal masses depends on the
patient’s age, findings on pelvic examination, imaging studies,
and serum markers.
Physical Examination
A large, solid, fixed or irregular adnexal mass accompanied by
ascites is suspicious for malignancy (Table 9.2.1). Cul-de-sac
nodularity, ascites, cystic adnexal structures, and fixed adnexa
occur with both endometriosis and ovarian malignancy.
Ultrasound
Transvaginal ultrasound is the primary imaging modality for
evaluating adnexal masses.[16] Cystic, unilocular, unilateral
masses less than 10 cm with regular borders are probably benign.
Malignant ovarian cysts are associated with irregular borders, a
size greater than 10 cm with papillations, solid areas, thick septa
(≥2 mm), ascites, and a matted bowel. Using ultrasonographic
criteria, accuratepredictions of benign masses were made in 96%
of patients.[16,17] Nezhat and coworkers [12] found that none
of the four malignant cysts in their series had any ultrasound criteria for malignancy. However, laparoscopic diagnosis of adnexal
masses that are suspicious at ultrasound prevents many laparotomies for the treatment of benign masses.[18]
The role of ultrasound screening in detecting ovarian cancer in asymptomatic women is still questionable. A systematic
review of prospective screening studies found that the sensitivity
of ultrasound screening at 1 year was around 100% (95% CI,
54–100).[19] However, false-positive rates ranged between 1.2%
187
188 — Camran Nezhat, Ceana Nezhat, and Farr Nezhat
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Table 9.2.1: Malignant Potential of Ovarian Cysts by Physical
Examination
Clinical Findings Benign Malignant
Size ≥7cm ++ ++
Size ≤7cm ++ ++
Unilateral ++++ +
Bilateral ++ ++++
Cystic ++++ +
Solid ++ +++
Solid and cystic + ++++
Mobile ++++ +
Fixed + ++++
Irregular + ++++
Smooth ++++ +
Ascites + ++++
Cul-de-sac nodules ++++
depend on differences in x-ray attenuation between calcium,
water, fat, and air. Soft tissue differences are enhanced with
intravenous contrast. MRI relies on differences in the hydrogen content of fat and water, magnetic relaxation time, and
blood flow, ultimately resulting in additional soft tissue contrast. In one study, MRI had a sensitivity of 95% and a specificity of 88% in distinguishing malignant from benign lesions,
whereas transvaginal ultrasound had 75% sensitivity and 98%
specificity.[22] MRI and the T
detecting the presenceof endometriomas basedon evaluating the
density of the cyst fluid and its iron concentration.[23] Unenhanced and contrast-enhanced MRI was shown to maximize the
discrimination between benign and malignant masses in patients
with sonographically indeterminate ovarian lesions.[24]
Serial turboFLASH (fast, low-angle shot) images with and
without diffusion–perfusion (DP) gradients have been used to
evaluate the contents of cysticovarian lesions. When these images
were used, the apparent diffusion coefficients were calculated
within the cystic contents of these lesions. It was found that
diffusion-weighted MRI could be used to differentiate between
the cystic contents of benign and malignant ovarian lesions.[25]
Meticulous pretreatment evaluationremains basic to thesuccessful management of suspected ovarian masses. The additional
+, least probable; ++++, most probable.
expense of CTandMRI seems justified only inselectedpatients in
whom further characterizationofthe adnexal mass may influence
directly the type of management selected.[26,27]
signal intensity were useful for
2
and 2.5% for gray-scale ultrasound, between 0.3% and 0.7% for
ultrasound with color Doppler, and between 0.1% and 0.6% for
CA-125 measurement followed by ultrasound screening. This
implies that in an annual screening of a population with an incidence of 40 per 100,000, with no cancers missed, between 2.5
and 60 women would be operated on for every primary ovarian
cancer detected.
Functional cysts gradually regressor resolvespontaneously or
with hormonalsuppressivetherapy within 8weeks(Figure 9.2.1).
Persistentcysts thatare functional or hemorrhagic on ultrasound
should be removed.
Serum Markers
CA-125 is a tumor-associated antigen that is used to detect the
nature of an ovarian cyst (Tables 9.2.2, 9.2.3). Levels below 35
U/mL are associated with benign tumors, but the sensitivity and
specificity vary. The presence of other benign conditions can elevate CA-125 levels. In 80% of premenopausal women, elevated
CA-125 levels were associated with pregnancy, endometriosis,
fibroids, adenomyosis, cystic teratomas, and acute or chronic
salpingitis. Only 50% of patients with stage I ovarian cancers
had elevated CA-125 levels, compared with 90% of women with
stage II.[20]
In 70 women with a history of endometriosis, serum CA125 concentrations were not correlated with the persistence or
resolution of ovarian cysts.[21]
Computed Tomography and Magnetic
Resonance Imaging
The role of CT and MRI relative to ultrasound in evaluating
an ovarian cyst is evolving. The resolution characteristics of CT
Cyst Aspiration
Cytologic examination of the cystic fluid does not provide an
accurate diagnosis in many patients.[28] Ten percent to 65%
of aspirates were interpreted as benign when malignancy was
present.[12,29,30] In a review, the accuracy of transvaginal and
transrectal fine-needle aspiration and ultrasound-guided punctures of ovarian cysts was disappointing.[31] The false-negative
rate was especially high for nonfollicular cystic lesions.[32] This
procedure is not suggested for treatment because of the high rate
of recurrence.[33–35]
In a study, 278 women with simple ovarian cysts were allocated randomly to either simple observation or ultrasoundguided fine-needle aspiration. The rate of resolution was 46%
with aspiration and 45% with observation. The authors concluded that expectant management for up to 6 months does not
cause risks for the patients and that aspiration does not provide
better results than does simple observation.[36]
Sonographically guided therapeutic aspiration of symptomatic ovarian cysts may alleviate symptoms.[37] However, this
procedure, although more rapid than extirpation, may be associated with abscess formation.[38]
TREATMENT
Medical Treatment
Oral contraceptives have been prescribed for some cystic adnexal
masses (≤6 cm) in reproductive-age women on the assumption
that decreasing gonadotropin stimulation toafunctional cyst will
hasten its resolution. The results of one study failed to report any
benefit from ovarian suppressive therapy.[39] However, the cysts
were less than 5 cm, and the study included women who had
H&P, CA-125
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ULTRASOUND
Ovarian Cystectomy — 189
AbnormalNormal
REPEAT U/S
IN 3 MOS
REPEAT U/S
IN 1 YEAR
REPEAT U/S
IN 6 WKS
Frozen Tissue
Evaluat.
Figure 9.2.1. Evaluation of a postmenopausal ovarian cyst.
Persistent
MassNo Mass
DIAGNOSTIC
LAPAROSCOPY
Normal Appearance
PERITON. WASHINGS
Benign
TERMINATE
PROCEDURE
OR
POSSIBLE LAVH
No Other
Abnormality
CT SCAN
or MRI
Abnormal
(Malignant)
Suggests
Cancer
Malignant
LAPAROTOMY
& STAGING
received ovulation induction medication. Two additional randomized trials have since shown that although oral contraceptive therapy is very effective in the management of functional
ovarian cysts, expectant management achieves similar success
rates.[40,41]
A randomized study evaluated the effectiveness of various
hormonal regimens in treating 70 women who had unilateral
or bilateral ovarian cysts assumed to be physiologic (functional)
and a history of endometriosis.[21] The patients were assigned
randomly to one of the following groups: group I (control), no
treatment; group II, oral contraceptives (35 μg ethinyl estradiol
and 1 mg norethindrone); group III, oral contraceptives (50 μg
ethinyl estradiol and 1 mg norethindrone); group IV, danazol
800 mg/day. Serum CA-125 concentrations were measured in 32
women. At 6weeks of follow-up,complete resolution ofcysts was
found ingroup I, 12 of 18 (66.7%); group II, fiveof nine (55.6%);
group III,eight of14 (57.1%);and groupIV, seven of 13 (53.9%).
Two of the 22 women with persistent cysts opted for 6 weeks
of additional medical therapy and achieved complete resolution,
19 underwent laparoscopy, and one was lost to follow-up. All
laparoscopic findings revealed benign masses. It was concluded
that no statistically significant effect was found when hormonal
treatment was compared with expectant management.[21]
Hormonal suppressive therapy may be prescribed during the
follow-up of benign-appearing ovarian cysts, but there is little
scientific evidence for its effectiveness compared with expectant
management.
Recommended Approach
Attempts to remove ovarian cysts laparoscopically sometimes
require conversion to laparotomy because cancer may be discovered and an immediate laparotomy then becomes necessary.
Treatment of benign-appearing adnexal masses must follow a
protocol of (1) cytologic examination of pelvic and cyst fluid,
(2) frozen section of a biopsy specimen, and (3) removal of the
mass for histologic examination. Aspirating a cyst and vaporizing or coagulating the capsule are not acceptable choices. The
safe laparoscopic approach to ovarian cysts has been described
by Mage and coworkers.[11] Those authors reported findings in
481 patients (ages 9 to 88) who had ovarian cysts, including 96
functional cysts, 100 endometriomas, 100 serous cysts, 91 teratomas, 51 mucinous cysts, and 58 paraovarian cysts. Among
these patients, 19 underwent laparotomy for confirmed or suspected malignancy based only on laparoscopic evaluation, and
10 of them were benign. Five ovarian cancers and four borderline tumorswere found and handled immediatelyby laparotomy.
Dense pelvic adhesions or cysts larger than 10 cm were the indications for laparotomy in 42 women. Nezhat and colleagues [12]
evaluated 1011 premenopausalwomenwith ovarian cystslaparoscopically and found four ovarian cancers. Preoperative assessment included an initial pelvic exam, vaginal ultrasound, and
the CA-125 level.[11] Three of the four unsuspected cancers
were found on frozen or permanent sections of the cyst wall.
One malignant tumor was 3 cm and grossly appeared to be an
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Table 9.2.2: CA-125 Levels Correlated with Type of Cyst
Age
Patients,
no. Cyst No.
360 Endometrioma 162 2–5 16–54 ≥2–212 45.7 123 68.9 22 22.8 14 7.5 3 0.8
179 6–10 2–195 28.7 115 54 10 –
219 Functional 172 2–5 11–47 ≤2–135 15.7 98 58.0 40 25.1 6 3.7 28 13.2
34 Simple 13 2–5 23–47 5–76 7.0 10 76.5 – 8.8 – 5.9 3 8.8
30 Benign cystic 16 2–5 17–44 ≤5–9 7.0 7 43.3 7 36.7 1 13.3 1 6.7
teratoma 12 6–10 5–29 14.9 6 3 2 1
17 Serous 8 2–5 33–40 14–47 30.5 7 82.4 – 5.9 – 5.9 1 5.9
11 Mucinous 4 25 31–35 ≤5 ≤5.0 2 54.5 2 45.5 – – – –
17 Hydrosalpinges 16 5–10 26–45 ≤5–35 12.8 6 41.2 8 47.1 – – 2 11.8
46 Miscellaneous 30 2–5 22–45 ≤5–135 27.4 19 67.4 2 6.5 – 4.3 9 21.7
Size,
cm
19 11–25 5–237 48.2 10 6 3 –
45 6–10 ≤2–53 11.2 28 14 2 1
2 11–12 6 6.0 1 1 – –
19 6–10 2–195 31.5 14 3 2 –
2 11–12 – – 2–––
2 11–14 12 12.0 – 1 1 –
7 6–10 10–42 23.7 6 1 – –
2 11–15 47–51 49.0 1 – 1 –
5 6–10 ≤5–30 10.6 2 3 – –
2 11–25 9–11 10.0 2–––
1 11–12 ≤5 ≤5.01–––
15 6–10 ≤5–10 5.5 11 1 2 1
1 11–17 36 36.0 1–––
Range,
years Range Mean No. % No. % No. % No. %
CA-125 Level,
U/mL Cystic Semicystic Solid Other
Ultrasonographic Characterstics of Cysts
endometrioma; histologic examination revealed an endometrioid carcinoma (Table 9.2.4).[12] Preoperative examinations did
not detect malignancy.
Although ovarian neoplasms may occurat any age, the risk of
malignancy is highest during prepuberty and menopause. Ovarian activity is associated with an increased incidence of functional ovarian cysts and other benign pathologic conditions.
These observations, combined with age differences in the sensitivity and specificity of clinical testing, have led to the following
recommendations for evaluating and managing adnexal masses.
Although clinical examination and the results of the preoperative work-up often indicate the benign or malignant nature
of cysts, only histology can provide the absolute diagnosis. The
benefits of doing frozen sections during laparoscopic management of organic ovarian cysts were investigated in 228 patients
who underwent adnexectomy for an ovarian mass.[42] After the
preoperative work-up and the diagnostic phase of laparoscopy,
26 patients (11.4%) presented with suspected signs of malignancy restricted to the ovary. Those 26 patients underwent a
laparoscopic adnexectomy with extraction of the excised tissues
using an endoscopic bag, followed by frozen section. For all these
patients, the results of the frozen section were that the lesion was
benign. In every case, the definitive histologic results confirmed
the frozen section findings. This strategy allowed the gynecologist to avoid laparotomy, especially in the nine postmenopausal
patients whose adnexal masses appeared complex onultrasound.
Malignancy is not the only concern in handling an ovarian
cyst. If the risk of malignancy is relatively low, patients who wish
to preserve their reproductiveorgans should have the least aggressive therapy. In premenopausal women, besides ascertaining the
characteristics of the adnexal mass, resection of ovarian tissue
may cause adhesions and should be minimized (Table 9.2.5).
In postmenopausal women, the incidental finding of adnexal
masses will increase with the more frequent application of
Table 9.2.3: Sensitivity and Specificity of Diagnostic Tests
Premenopausal Postmenopausal
Sensitivity,%Specificity,%Sensitivity,%Specificity,
%
Specialist
ultrasound
Clinical
impression
CA-125 50 69 84 92
Modified from Finkler N, Benacerrat B, Lavin F. Comparison of serum
CA-125, clinical impression and ultrasound in the preoperative evaluation of ovarian masses. Obstet Gynecol. 1988;72:659.
50 96 78 92
17 92 68 85
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Table 9.2.4: Findings at Laparoscopy in Four Women Who Had Ovarian Cancer
Case 2 Case 3
Case 1 Endometrioid Papillary Case 4
Serous Low-Malignant- Mucinous Clear Cell
Cystadenocarcinoma Potential Tumor Cystadenocarcinoma Carcinoma
Patientage,years 44 45 43 33
Stage IIIC IA IIA IA
Tumor size, cm 7 3 13 6
Serum CA-125
level, U/mL
Ultrasonographic finding Septated semicystic Cystic Septated semicystic Septated semicystic
N/A 7 17 2
diagnostic imaging. Although routine pelvic sonographic screening of asymptomatic postmenopausal women may find early
ovarian cancer, the procedure is not cost-effective. Wolf and
coworkers [43] screened 149 asymptomatic women more than
50 years of age and discovered cystsin 22 (14.8%), ranging in size
from 0.4 to 4.7 cm. Two additional women had septated masses,
but no ovarian cancers were detected. In a study that screened
5479 women age 45 or older,6.1%hadabnormal scans.[44] When
the scans were repeated 2 to 8 weeks later, only 59% were persistently abnormal. Five ovarian cancers werefound, twoin the first
screen and three in the follow-up screen; all were stage I.
The low prevalence of ovarian cancer in the population and
its rate of progression may limit the potential cost-effectiveness
of screening.[19] Current data do not seem to support the view
that screening asymptomatic postmenopausal women who have
a normal pelvic examination is justified. Although it is clear that
ultrasound and multimodal screening can detect ovarian cancer in asymptomatic women, there is currently no evidence that
screening improves the outcome for women in any risk group.
The preoperative evaluation for an ovarian cyst includes a
history, pelvic examination, ultrasound, and serum CA-125. If
any combinations of these tests are suggestive of malignancy, an
abdominal and pelvic CT scan is done. If the scan shows signs of
malignancy (ascites, omental cake, etc.), the patient undergoes a
staging laparotomy or chemotherapy. When the CT is negative, a
laparoscopy is planned and consent is obtained for laparotomy.
Preoperatively, the patient has a mechanical and antibiotic bowel
Table 9.2.5: Premenopausal Ovarian Cysts
Preoperative Evaluation Intraoperative Evaluation
History and physical
examination
Transvaginal ultrasound Peritoneal washing
Hormonal suppressive Cyst aspiration; therapy if
Informed consent Evaluation of the cyst
Draw blood and save for possible
tumor marker
Diagnostic laparoscopy
examination
indicated
Possible frozen section
Cystectomy or oophorectomy
preparation and a chest radiograph and signs the appropriate
consent.
Intraoperative Therapy
Intraoperative evaluation includes cell washings from the pelvis
and upper abdomen to be saved for evaluation if a malignancy is
found. The upper abdomen and pelvis are explored, and excrescences or suspicious areas are sampledandsent for frozen section.
After the pelvis and upper abdomen are examined, the cyst
contents are aspirated. Once the capsule is opened, the interior
of the capsule is examined and suspicious areas are biopsied, and
then the tissue is sent for frozen section. The entire cyst capsule is removed to search for an early carcinoma that may escape
gross detection.[12] Whether to do an oophorectomy or cystectomy depends on the patient’s age and the characteristics of the
mass.
Ovarian Cystectomy
An ideal ovarian cystectomy consists of the removal of the intact
cyst with limited trauma to the residual ovarian tissue. Alternatively, the cyst fluid may be drained to minimize spillage and
facilitate removal.
Three methods to manage ovarian cysts are drainage, excision, and thermal ablation or coagulation. When the cyst is
excised, histopathologic examination is complete and the risk
of recurrence is lessened. Aspiration is recommended for functional cysts detected laparoscopically and confirmed by frozen
section. Postoperatively,hormonalsuppressive therapy is advised.
Because thermal ablation does not destroy the entirecyst wall and
the underlying ovarian cortex may be damaged by the heat, excision is preferred.
Many cysts are ruptured during their manipulation despite
the use of a delicate technique. The intact removal of a cyst 10 cm
or larger is difficult laparoscopically. Aspiration before removal
of large cysts is practical. It is accomplished with an 18-gauge
laparoscopic needle passed through the suction–irrigator probe
while the cyst is stabilized with suction applied over the cyst. The
needle is inserted into the cyst, and thecontents are aspirated (Figure 9.2.2). The suction–irrigator system reduces the spillage by
applying suction at thecannula. Alternatively, a suction–irrigator
probe may be inserted into the cyst (Figure 9.2.3 inset). Another
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Aspiration of ovarian
cyst contents through
suction irrigator probe
Figure 9.2.2. For pure cysts largerthan 2 cm, an 18-gauge laparoscopic
needle is passed through the suction–irrigator probe. While the cyst is
stabilized with suction applied over the cyst wall, the needle is inserted
into the cyst and the contents are aspirated.
technique involves the passage of a 5-mm trocar and sleeve. The
trocar is placed into the cyst and then removed, and then the
suction–irrigator is inserted (Figure 9.2.3). This method works
well for endometriomas and mucinous cystadenomas but is not
advisable for benign teratomas that contain hair.
The aspirate is sent for cytologic examination, and the ovary
is freed from adhesions to the lateral pelvic wall, uterus, or
bowel. The cyst and pelvis are irrigated continuously, especially for benign cystic teratomas, mucinous cystadenomas, and
endometriomas. The most dependent portion of the cyst wall is
Biopsy of
inner wall
of cyst
capsule
Opened
cyst capsule
Ovarian
cortex
Figure 9.2.4. The most dependent portion of the cyst wall is opened,
and the internal surface is inspected. If excrescences or papillomas are
found, a biopsy specimen (inset) is taken and sent for frozen section.
The ovarian cortex is held apart with graspers.
opened, and the internal surface is inspected (Figure 9.2.4). If
excrescences or papillae are found, a biopsy specimen is sent for
frozen section (Figure 9.2.4 inset). Dilute vasopressin is injected
between the capsule and the ovarian cortex to create a plane for
hydrodissectionand reduce oozing in the capsule(Figure9.2.5A).
The capsule is stripped from the ovarian stroma using two
Outside of wall
collapses
Aspiration of
fluid from cyst
Trocar insertion
for aspiration
of fluid
Figure 9.2.3. The trocar is placed into the cyst and then removed, and the suction–irrigator (inset) is inserted.
This method works well for endometriomas andmucinous cystadenomas but isnot advisable for teratomas that
contain hair. The aspirate is sent for cytologic examination. The cyst and pelvis are irrigated continuously.
Bipolar controlling
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small bleeders
Ovarian Cystectomy — 193
The cyst wall is
being teased off
of the ovarian stroma
BA
Cyst is being
pulled free
C
Figure 9.2.5. (A) Dilute vasopressin is injected between the capsule and the ovarian cortex to create a plane for hydrodissection and to reduce
oozing in the capsule. Sometimes it is difficult to separate the cyst wall from the ovarian cortex, and so this injection technique facilitates the
stripping procedure. (B) The capsuleis stripped from the ovarian cortexby using twograsping forceps andthe suction–irrigator probe for traction
and countertraction. The specimen is sent for histologic examination. (C) Bipolar forceps can be used to control bleeding.
grasping forceps and the suction–irrigator probe for traction and
countertraction (Figure 9.2.5B). It is sent for histologic examination. The laser is used at low power (10 to 20 W continuous) to
seal blood vessels at the base of the capsule and at higher power
to vaporize small remnants of capsule. Bipolar forceps are used
to control bleeding (Figure 9.2.5C).
Sometimes it is difficult to remove the capsule from the ovarian cortex, and so injectingdilutevasopressinbetweenthecapsule
and the cortex facilitates the stripping procedure (Figure 9.2.6).
If the cyst wall cannot be identified, the edge of the ovarian incision can be“freshened” with scissors,and the resulting cleanedge
reveals the different structures. If this does not free the capsule,
the base of the cyst is grasped, and traction is applied to the cyst
with countertraction to the ovary. The entire cyst or portions
of the wall may be adherent to the ovary, requiring sharp or
laser dissection to free it completely. Large cysts require partial
oophorectomy, using a high-power laser or scissorsto remove the
distorted portionof the ovary. The remainingcyst wall isstripped
from the ovarian stroma (Figure 9.2.7).
Teratomas often can beexcised intact, butif the cyst ruptures,
the resulting contamination will be greater than it would if the
cyst were opened and aspirated. The atraumatic development of
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AB
Hydrodissection
around ovarian
cyst
Opened
ovarian
cortex
Figure 9.2.6. (A) A 16- or 20-gauge needle is introduced through an accessory trocar sleeve into the space
between the cyst wall and the ovarian cortex. (B) A plane is developed using the suction–irrigator as a blunt
probe.
the plane betweenthe cyst walland the ovarian tissueis an important first step that is accomplished by using hydrodissection. An
18- or 20-gauge needle is introduced through an accessory trocar sleeve, or a 7.5-inch spinal needle (American Hydro-Surgical
Instruments) is inserted through the abdominal wall into the
space between the cyst wall and the ovary. The plane is developed
by using the suction–irrigator as a blunt probe. After removal
of the cyst, the base of the capsule is irrigated and coagulation
is achieved with a CO
laser or bipolar electrocoagulation. The
2
edges of the ovarian cortex are connected with a low-power laser
(10 to 20 W) or bipolar electrocoagulator. A grasping forceps
helps merge the ovarian edges. If the ovarian edges overlap, the
Unruptured
ovarian cyst
defect is left to heal without suturing because adhesions are more
likely after the use of sutures (Table 9.2.6).[45] If the edges of
the ovarian capsule do not meet, a low-power laser applied to the
inner surface will invert them. In rare instances, one or two fine
absorbable monofilamentsuturesare needed to bring the ovarian
edges together (Figure 9.2.8). Sutures are placed inside the ovary
to decrease the formation of adhesions.
Tissue can be removed from the abdominal cavity by using
one of the following techniques:
1. Containment bags. Excised tissue is placed into a small plastic
prepared bag introduced into the pelvis through a 10-mm
Bipolar coagulator
Unruptured
ovarian cyst
being removed
from ovarian
cortex
A
Figure 9.2.7. (A) The unruptured ovarian cyst is removed from the ovarian cortex. Irrigation helps in the hydrodissection as the ovarian cortex
is held with graspers for countertraction. (B) As the cyst is enucleated, the base of the ovarian bed is coagulated with bipolar forceps to achieve
hemostasis.
Cyst is being
pulled free
B
controlling small
bleeders
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Table 9.2.6: Incidence of Adhesion Formation in Patients with and without Laparoscopic Ovarian Suturing
Ty pe o f Cy s t
Adhesions
Benign Cystic
Suture Endometrioma Teratoma Mucinous Serous Simple None
No 27 4 2 1 2 11 22 2 1
Ye s 1 9 6 0 2 4 5 6 1 5 5
Filmy/Minimal
Vascularity
Dense/
Nonvascular
Dense/
Vascular
trocar (Endobag, Ethicon). The tissue is placed in the bag,
traction is applied to the bag, and after the trocar sleeve is
removed, it is pulled through a trocar incision to the anterior
abdominal wall. The edges of the bag are pulled toward the
anterior abdominal wall. Cystic contents are aspirated, and
the deflated cyst is pulled out of the peritoneal cavity (Figure
9.2.9). A solid mass is morcellatedinsidethebag and removed.
Attempting to pull the bag out of the abdomen before the
cyst is collapsed or morcellated causes rupture of the bag and
contaminationof the abdominal cavity or anterior abdominal
wall.
2. Colpotomy. Through a colpotomy, large pieces of solid tissue
such as myomas and cystic masses can be removed. Some
cystic masses are so fragile and large that it is impossible to
remove them intact through a colpotomy. The tumor mass
is brought to the vaginal incision and drained transvaginally
(Figure 9.2.10). After the mass is removed, the pelvic cavity is
irrigated and suctioned. The colpotomy is repaired vaginally
or laparoscopically. Nezhat and colleagues [46] found that
colpotomy is not associated with significant postoperative
adhesions.
3. Withanother technique, thecystic mass is brought tothe surface of the abdominal incision, drained, and extracted similarly to the method for removal by colpotomy.
No tissue should be left in the pelvic cavity or on the abdominal wall. Implantation of ovarian tissue in the abdominal and
pelvic cavity may cause an ovarian remnant syndrome.[47] Contamination of the anterior abdominal wall should be avoided,
and if this happens, all tissue must be removed and the incision
must be irrigated copiously. Abdominal wall metastasis has been
reported after contamination of the wall during laparoscopy for
ovarian cancer.[48]
Benign Cystic Teratomas
Benign cystic teratomas are germ cell tumors that occur predominantly in young women. Laparoscopic removal may be technically difficult, but it can be done successfully. After laparoscopic
excision and removal by a posterior colpotomy, normal ovaries
and few adhesions were seen at a repeat laparoscopy.[49] If this is
unsuccessful, one should go onto laparotomy to ensurecomplete
excision of the tumor.
The suction–irrigator is placed in the cyst, the contents are
aspirated, and the cavity is irrigated copiously. Theinterior ofthe
cyst is inspected, and its lining is grasped and removed from the
ovary. The lining is removed from the pelvis through a 10-mm
accessory trocar, the operating channel of the laparoscope, a
colpotomy, or an Endobag. The cyst wall is inspected and sent for
One suture is placed
inside to approximate
the ovarian edges
Interceed
Ovarian
cortex
A
Figure 9.2.8. (A) In some instances, one or two fine monofilament absorbable sutures are required to approximate theedges of the ovarian cortex. The sutures areplaced inside the ovary to lessen the formation ofadhesions.
(B) Interceed (Gynecare) may be placed over the sutured site.
B
196 — Camran Nezhat, Ceana Nezhat, and Farr Nezhat
https://t.me/med1917
Unruptured
cyst placed in
Endopouch
Endopouch
Suction
irrigator
probe
Endopouch
A
B
Figure 9.2.9. (A) The unruptured cyst is placed in an Endopouch introduced into the pelvic cavity through a
10-mm trocar sleeve. (B) The plastic containment bag is pulled to the level of the anterior abdominal wall. If the
mass is cystic and too large to be pulled through the cannula, a suction–irrigator probe is used to aspirate the
cystic fluid and reduce the size of the mass. If the excised tissue is solid, it can be cut into pieces or morcellated
until the material can be pulled safely through a 10-mm trocar sleeve. Pulling the bag before the included tissue
can be pulledthroughthesleevecan rupture the cyst andcontaminate theanteriorabdominalwall and peritoneal
cavity.
Uterus
Bladder
Ovarian cyst
in the posterior
cul-de-sac
Aspirating needle
Figure 9.2.10. A colpotomy may be used to remove large pieces of myoma or cystic masses. The cystic mass
is brought into the cul-de-sac and drained transvaginally. The culdotomy may be repaired either vaginally
or laparoscopically. After the mass is removed, the pelvis is irrigated copiously and suctioned. Laparoscopic
culdotomy has not been associated with significant pelvic adhesions.
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