Laparoscopic Articles from Laparoscopy Hospital

Dr. sana abd muslim abd alla
M.b .ch.b, dgo

Abstract

Laparoscopy has become an accepted method of management for ovarian cysts. Large ovarian cysts, however, have traditionally been, and continue to be treated by laparotomy. This is mainly due to technical difficulties and the possibility of malignancy. We describe four patients in whom laparoscopy was used to remove large ovarian cysts. Laparoscopic guided aspiration was performed, followed by extra-abdominal excision of the cyst. This approach has the advantages of minimising the risk of spillage of cyst fluid, a smaller incision compared to laparotomy, as well as faster recovery. We advocate this method for large unilocular benign cysts.

Materials and Methods:

A literature review was performed using Springerlink, Pubmed, Highwire press,   search engines like Google, and Yahoo. the following terms were used :ovarian tumors,cystic teratomas, endometriosis . Selected papers were screened for further references.

Key words :

Bordline ovarian tumors cystectomy fertility recurrence surgery

Conclusion :

With proper patient selection, the size of an ovarian cyst is not necessarily a contraindication for laparoscopic surgery

Introduction

Ovarian endometrioma is a common disease lesion among women with endometriosis. Regardless of its symptoms, surgery is most frequently chosen for its treatment because medical treatment alone is inadequate (Jones and Sutton, 2000). In addition, a likelihood of malignant change in this disease is not negligible (Nishida et al ., 2000), and European Society of Human Reproduction and Embryology (ESHRE) guidelines recommend that histology should be obtained to exclude malignancy in cases of endometrioma of more than 3 cm in diameter (Kennedy et al ., 2005) Because this disorder is commonly diagnosed in women of reproductive age (Giudice and Kao, 2004), laparoscopic excision of endometrioma, instead of oophorectomy, is applied for most cases. When it is done in infertile woman, laparoscopic excision is also known to improve fertility (Beretta et al ., 1998). One of the most frustrating aspects of treating endometrioma with laparoscopic excision is disease recurrence after surgery (Busacca et al ., 1999). When planning a laparoscopy, gynaecologists should be aware of each individual’s expected likelihood of recurrence as well as her symptoms and desire for current or future fertility. By having information about factors that may be related to a recurrence of ovarian endometrioma, gynaecologists will be able to distinguish patients at risk, optimize the timing of laparoscopy and plan pre- and post-operative management properly. However, little study has been done to analyse various variants that may have impacts on a recurrence of endometrioma after laparoscopic excision. To date, recurrence of ovarian endometrioma after laparoscopy has always been discussed focusing on a single factor, such as the effect of post-operative (Muzii et al ., 2000) or preoperative (Muzii et al , 1996) medication, the method of laparoscopic treatment (Saleh and Tulandi, 1999) and the anatomical location (Ghezzi et al ., 2001). There is only one multivariate analysis that analysed six variables on the recurrence of K.Koga et al . 2172 endometrioma by Busacca et al . (1999). To analyse risk factors that might influence the recurrence of endometrioma after laparoscopic excision, we retrospectively evaluated 14 variables to assess their independent effects on the recurrence.

The borderline ovarian tumours (BOTs), also referred to as low malignant potential tumours, are a subgroup of epithelial ovarian tumours accounting for 10–15% of all ovarian tumours, which are characterized by histologic features of malignant tumours without identifiable destructive stromal invasion (Acs, 2005 ).

Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the gold standard treatment for BOTs in peri- or post-menopausal women, patients who have completed childbearing or those who have no desire to preserve their fertility (Tinelli et al ., 2006 ) . Because BOTs are characterized by common presentation during the childbearing years at an early stage and by an excellent long-term survival, fertility preservation becomes an important issue in their management (Morice et al ., 2003 ) . In this regard, a fertility-sparing surgical treatment, consisting of uterine preservation and at least a part of one ovary, has been proposed to patients with early-stage BOTs who want to preserve their childbearing potential, and, over the years, this treatment has become a pivotal and well-consolidated approach for patients with BOTs who want to preserve their fertility (Morice et al ., 2003 ; Tinelli et al ., 2006 ) .

Even if obtained in a retrospective fashion, in a non-selected population after laparotomy, the available data suggest that in patients with BOTs, cystectomy is related to a higher recurrence rate compared with oophorectomy (Morice et al ., 2003 ; Tinelli et al ., 2006 ) . For these reasons, salpingo-oophorectomy has been widely used to reduce recurrence and to preserve good reproductive capabilities in patients with unilateral BOTs (Morice et al ., 2003 ) .

BOTs are bilateral in 25 –50% and in 5 –10% of the serous and mucinous histotypes, respectively (Acs, 2005 ; Tinelli et al ., 2006 ) . In these cases, the standard fertility-sparing surgery consists of salpingo-oophorectomy plus controlateral cystectomy (Morice et al ., 2003 ) . At present, it is not known whether patients with bilateral BOTs of reproductive age could benefit by a more minimally invasive approach, such as a bilateral cystectomy. During the last few years, laparoscopic treatment of adnexal masses has proved to be a useful diagnostic and therapeutic tool (Pejovic and Nezhat, 2001 ) . In terms of reproductive outcomes, the laparoscopic approach also seems to be safer than laparotomy in reproductive age patients (Pejovic and Nezhat, 2001 )

The purpose of the present study was to compare the effects of two laparoscopic fertility-sparing surgical procedures, that is, oophorectomy plus controlateral cystectomy versus bilateral cystectomy, on the safety and fertility in young women who desire to conceive as soon as possible and are affected by bilateral BOTs.

Teratomas are neoplasms containing tissue from all three germ cell layers. Most are mature cystic teratomas (MCT) with predominantly ectodermal derivatives such as hair and teeth. Collectively, teratomas constitute half of all ovarian neoplasms in children (Azizkhan and Caty, 1996 ) and 1% of these are malignant immature teratomas (O’Connor, 1996 ) . Traditional management of children with MCT has been oophorectomy via laparotomy (Carney, 1972; Mahour et al ., 1976 ; Azizkhan and Caty, 1996 ) . However, acceptable management in adults is ovarian cystectomy approached by laparoscopy, with laparotomy generally reserved for cases of large MCT tumours or those suspected of malignancy (Bollen et al ., 1992 ; Canis et al ., 1994; Lin et al. , 1995 ). The aim of this study was to examine the contemporary surgical management of MCT in children and adolescents.

Benign cystic teratomas (‘dermoid cysts’) of the ovary constitute some 10–13% of all ovarian tumours and represent the most common benign ovarian germ cell tumours (Peterson et al. , 1955; Peterson, 1956; Woodruff et al. , 1968; Caruso et al. , 1971). Typically these tumours are discovered during Child-bearing age. The spectrum of clinical presentation of these tumours ranges from incidental finding in some cases to chemical peritonitis in others, but usually consists of some form of abdominal pain reaching extreme intensity when ovarian torsion occurs (Cunanan et al. , 1983). Up to 12% of cases involve both ovaries, which in the past has led some authorities to recommend routine contralateral ovarian biopsy (DiSaia, 1994). The advisability of this routine in the absence of obvious involvement may be challenged on the basis of 1% malignant transformation which is specifically rare in the young (Gallion et al. , 1983). 1810 © European Society for Human Reproduction and Embryology Notwithstanding this, any surgical approach to dermoid cysts should take into account the possibility of both chemical peritonitis and malignancy. In addition, maximal ovarian conservation and minimal abrasive tissue handling are advocated when future fertility is of importance. Therefore, laparoscopic surgery emerges as a specifically tailored technique to tackle these demands (Reich et al. , 1989; Nezhat et al. , 1989; Shalev and Peleg, 1993), provided that the chances for chemical peritonitis due to spillage are minimized. We present here our experience with 84 cases, treated laparoscopically. This can serve to delineate the clinical scope of this pathology and the safety and feasibility of its treatment in the era of laparoscopic surgery.

Management of ovarian cysts

Depends on age, menopausal status, and the size and structure of the cyst Ovarian cyst s are present in 6% of asymptomatic postmenopausal women. Most of these cyst s are benign or functional, and the physician’s role is largely to exclude cancer, which has a prevalence of 61 per 100 000 in women aged 68 years. Needle aspiration of ovarian cyst s has been proposed as an alternative to laparoscopic and conventional surgical excision , especially when the cyst is believed on clinical grounds to be benign. Needle aspiration has the important advantage over surgical excision that it can be performed under local anaesthetic and does not require admission to hospital. Nevertheless, there are several important questions concerning needle aspiration of ovarian cyst s.

Firstly, how easy is it to predict whether a cyst is benign or malignant? Clinical examination, ultrasonography, and serum concentrations of CA 125 are the main approaches available. Clinical examination is of ten disappointing, with 30-65% of ovarian tumours (in particular those less then 40-50 mm in diameter) being overlooked. Vaginal ultrasonography is more accurate, predicting the benign nature of a tumour in 96% of cases by showing the presence or not of vegetations. Finkler et al calculated a negative predictive value of 71% in postmenopausal women. None the less, analysis of six screening programmes covering 7476 patients showed a false positive rate of 13.3%. (The false negative rate may be calculated only by performing surgical exploration.) Doppler studies of ovarian cyst s have a sensitivity of 92% and a specificity of 52%, with higher predictive values when combined with transvaginal ultrasonography.

Serum concentrations of CA 125 were normal in 97% of women presenting with benign cyst s and were raised (over 35 UI ml) in 80% of women over the age of 50 presenting with malignant lesions. 5 However, only 50% of women presenting with a stage I ovarian cancer (the most difficult to diagnose) had raised serum concentrations of CA 125. Secondly, is ovarian cytology reliable? Provided that de Brux’s conditions are met (immediate fixation to avoid uninterpretable cells, double centrifugation, personal experience in excess of 200 to 300 analyses), the answer seems to be yes. Of 1632 cases in which cytology was verified, only 19 were unsuspected malignancies and two false negative results. Thirdly, what are the consequences of aspirating a malignant cyst ? Data collected from studies of the risk of dissemination after aspiration of a malignant ovarian cyst show survival rates at five and 10 years that were no worse than the rates for non-aspirated cyst s (76% for poorly or moderately differentiated epithelial cancers classified as stage I or IIA).

Discussion

Many previous studies discussed the recurrence of ovarian endometrioma after laparoscopic excision, in view of requirements of reoperation (Busacca et al ., 1999; Saleh and Tulandi, 1999; Abbott et al ., 2003) or pain recurrence (Busacca et al ., 1999; Abbott et al ., 2003). In this study, we focused on the mechanism of ovarian endometrioma recurrence per se and used a definition of the recurrence as the presence of cysts more than 2 cm in diameter by ultrasonography, which might be rather objective and cover minimum lesions. Under this definition, we observed a recurrence rate of 30.4%. The patient’s age, presence of infertility and pain did not significantly influence the recurrence. The presence of neither uterine myoma nor adenomyosis was significant. As for the characteristics of endometrioma, single or multiple cysts and unilateral or bilateral ovarian involvement were not significant, whereas patients with larger ndometrioma had higher probability of recurrence, which agrees with the finding of earlier studies (Busacca et al ., 1999; Saleh and Tulandi, 1999). Because most ovarian endometrioma are associated with extra ovarian endometriosis (Redwine, 1999), we evaluated revised ASRM score and co-existence of deep endometriosis. Revised ASRM score did not independently correlate the recurrence.

Co-existence of deep endometriosis did not influence the recurrence either. A new observation demonstrated in this study was that previous medical treatment of endometriosis was a significant factor that was associated with higher recurrence, whereas previous surgery of ovarian endometrioma was not. The less-favourable prognosis for women who have already had medical treatment may be explained by two possible reasons. The first is that the medication may mask endometriotic lesions and allow them to escape from removal at operations. Because more than half of the women who were categorized into previous medical treatment group had continued their medication until the time of operation, it may be possible that the medication might yield latent lesions that remain and recur after the operation. Our findings may also support the study of Muzii et al . (1996), which suggests that pre-operative GnRH agonist treatment does not seem to offer any advantage in terms of surgical performance based on various parameters including recurrence rates. The second possible reason for negative impact of medical treatment on endometrioma recurrence is that hormonal suppressive therapy may alter some genomic characteristics of endometriotic lesions. As for malignant transformation of endometriosis, it is proposed that hormonal ablative treatments may cause negative selection, suppress the normal, eukaryotic cells more than aneuploid cells bearing chromosomal aberrations and increase the rate of dyskaryotic cells in the endometriotic implants (Blumenfeld, 2004). We suppose that the ‘negative selection’ may also contribute to the recurrence of disease, making the lesion more active, progressive and prone to recurrence. Patient with post-operative pregnancy had a much lower rate of recurrence, which indicates that subsequent pregnancy may have a protective effect on endometrioma recurrence. On the contrary, laparoscopic excision of endometrioma is known to improve fertility, when it is done in infertile women (Beretta et al ., 1998). Taken together, gynaecologists should optimize the timing of laparoscopy according to the patient’s desire for current and future pregnancy. Our study was in line with previous observations that postoperative medical treatment did not significantly influence disease recurrence (Bianchi et al ., 1999; Muzii et al ., 2000; Busacca et al ., 2001). Three-month GnRH analogue (Busacca et al , 2001) or danazol (Bianchi et al ., 1999) therapy after laparoscopy was demonstrated to provide no significant advantage in preventing disease recurrence. Post-operative administration of low-dose cyclic oral contraceptives for 6 months had also no significant effect on the long-term recurrence rate of endometrioma (Muzii et al ., 2000). However, the treatment period of these studies, and also ours, was less than 1 year, and there is no information about the effect of longer period of treatment. It is therefore possible that medical treatments longer than 1 year may have an effect to prevent endometrioma recurrence. Further studies, e.g. randomized controlled trials, are needed to determine the effectiveness of these therapies. Table III. Univariate and logistic regression analysis of factors related to the recurrence of ovarian endometrioma ASRM, American Society for Reproductive Medicine Factors Univariate analysis

In summary, this study demonstrated significant factors that were independently associated with a higher or lower recurrence of endometrioma after laparoscopic excision. An important finding of the present study was the significant increase in basal FSH value detected after oophorectomy plus controlateral cystectomy. Although no difference in menstrual cyclicity was observed between groups, it could be suggested that the loss of a considerable part of ovarian tissue after oophorectomy plus controlateral cystectomy with subsequent reduction of ovarian reserve could be the explanation. On the contrary, bilateral cystectomy seems to preserve a more intact pituitary–ovary axis, with beneficial effects on the reproductive function. On the basis of these considerations, patients with BOTs who should be undergoing ovarian hyperstimulation and IVF for tubal and or male factor infertility could benefit from an extremely conservative surgical approach.

In conclusion, our findings, although obtained on a small population, demonstrate that laparoscopic bilateral cystectomy followed by non-conservative treatment performed at the first recurrence after childbearing completion is an effective surgical strategy in terms of reproductive outcomes for patients with bilateral early stage BOTs who desire to conceive as soon as possible and accept to undergo a radical treatment. Powered studies on a wider sample are needed to draw definitive conclusions on the safety of this ultra-conservative treatment. Conservative ovarian surgery in childhood and adolescence is important for the development of normal puberty and future fertility. Mature cystic teratomas constitute half of the benign ovarian masses in this population (Azizkhan and Caty, 1996 ) making the appropriate management of this tumour a vital concern to surgeons caring for patients in this age group.

Pre-operative and intraoperative criteria that have been historically used to predict malignancy in adnexal cystic masses include: adnexal masses with extra-ovarian spread, ultrasonically suspicious masses >8 cm in diameter, a thick cyst wall, a lengthened utero-ovarian ligament or numerous vessels starting from the mesovarium with a comb-like pattern, peritoneal metastases and external ovarian or intracystic vegetations (Canis et al ., 1994). Taken together, these criteria have 100% sensitivity for predicting malignancy but result in a 4% rate of unnecessary laparotomy (Canis et al ., 1994). After careful exclusion of an obvious malignancy, ovarian cystectomy has become an accepted option for MCT in adults. If the surgeon is endoscopically experienced, a laparoscopic approach may be considered (Lin et al ., 1995 ). However, there has been concern about the impact of laparoscopy on the incidence of intraoperative MCT spill with the subsequent risk of chemical peritonitis and adhesion formation (Nezhat et al ., 1999 ). In children with an MCT, oophorectomy has traditionally been performed due to concern about occult germ cell malignancy along with the viability of ovarian tissue and potential for MCT recurrence after cystectomy. At present, experience with a laparoscopic approach in children with MCT is limited to case reports (Cohen et al ., 1996 ; Garcia et al ., 1996 ; Jawad, 1998; Liu et al ., 1998 ). The aim here was to address some of these management concerns in children and adolescents.

The results show that abdominal pain and torsion as presenting symptoms were more common among young girls. Adolescent tumours were more likely to be detected on pelvic examination. Ultrasound was the most commonly used diagnostic test and this is appropriate given that the positive predictive ability of ultrasound approaches 100% when two or more characteristic findings for MCT, such as shadowing echodensity and regionally bright echodensity are present (Patel et al ., 1998 ).

A laparoscopic approach to the management of MCT in adults has now become accepted practice among many surgeons (Luxman et al ., 1996 ; Yuen et al ., 1997 ; Morgante et al ., 1998 ) . A consistent benefit to the patient is a shorter hospital stay (Howard, 1995 ; Lin et al ., 1995 ; Morgante et al ., 1998 ; Zanetta et al ., 1999 ). A shorter hospital stay was also demonstrated among our patients approached laparoscopically, suggesting that the benefit afforded adults is also applicable to children. Until recently, inadequate instrumentation made this approach difficult in children and this is reflected in our series where laparoscopy was confined almost entirely to the more recent time period. Among our patients, surgeon type was predictive of operative approach. This may be explained by the greater experience of gynaecologists with laparoscopic adnexal surgery. Our results suggest that young patients particularly suited to a laparoscopic approach are those with smaller tumours (all 8 cm, mean 5.5 cm in our series).

The diagnosis of chemical peritonitis is suspected in the presence of postoperative fever and ileus associated with granulomatous deposits on the abdominal peritoneum and adhesion formation (Huss et al ., 1996 ). This concern has been addressed in the adult literature and chemical peritonitis has been found to occur with an estimated incidence of 0.2% following laparoscopic excision of an MCT (Nezhat et al ., 1999 ) if spillage is managed by immediate copious lavage (Zanetta et al ., 1999 ). In our series, there were no cases of chemical peritonitis, confirming that spill in children can be managed in the same way as adults with similar expectations for a successful outcome.

Intraoperative tumour spillage also raises the concern of postoperative adhesion formation. This issue is confounded in adults because few patients have had second-look procedures. Also, many patients undergoing MCT removal have had concurrent reproductive surgery, including resection of endometriosis, tubal adhesiolysis or myomectomy (Nezhat et al ., 1989 ; Bollen et al ., 1992 ) all of which may themselves promote adhesion formation. Concurrent surgery among our patients was almost entirely elective appendectomy (85.7%) and this has been shown not to affect future fertility (Andersson et al ., 1999 ) . In our series, postoperative intrauterine pregnancy occurred in seven (20.6%) patients, four of whom had intraoperative spill of MCT contents and six who had additional surgery at the time of MCT removal. As in adults (Canis et al ., 1992 ) , this suggests that even if tumour spillage does promote adhesion formation, future fertility is possible.

Biopsy of the contralateral ovary was performed in 12 patients, typically by gynaecologists in the earlier time period. This was likely to be due to concerns about the presence of MCT in the contralateral ovary. However, ovarian wedge biopsy is not without complication and may result in haemorrhage, infection, and adhesion formation (Toaff et al ., 1976 ) . It is unlikely to be positive if the contralateral ovary is normal in appearance since the chance of an occult MCT is 1.1% (Doss et al ., 1977 ; Ayhan et al ., 1991 ) . Therefore, since ultrasound is a good predictor of MCT presence, preoperative ultrasound in combination with careful inspection of the contralateral ovary at the time of surgery offers a safe alternative to wedge biopsy (Commerci et al ., 1994 ) .

In adults, the reported incidence of recurrent MCT following cystectomy is 3–4% (Anteby et al ., 1994 ; Chapron et al ., 1994 ) and usually occurs in patients under 40 years of age (Anteby et al ., 1994 ) . Also, in younger patients with multiple or bilateral MCT there is a 2–3% incidence of the subsequent development of germ cell tumours (Borenstein et al ., 1982 ; Yanai-Inbar and Scully, 1987 ; Anteby et al ., 1994). In our series there were no reported cases of recurrence among the 19 patients (of a total of 25) managed with cystectomy in whom follow-up data were available. However, this may be due to insufficient follow-up time since recurrences and germ cell tumours may occur months to many years following surgery (Chapron et al ., 1994 ) .

This study demonstrates that some of the conclusions regarding the contemporary management of MCT in adults are applicable to children and adolescents. In particular, the benefit of shorter hospital stay achieved in adults with a MCT approached laparoscopically extends to our population. Chemical peritonitis may be avoided and future fertility is possible if intraoperative MCT spill is managed with copious saline irrigation.

In the absence of specific literature investigating MCT recurrence in children, recommendations for postoperative surveillance are empirical. Given the sensitivity of ultrasound in the detection of MCT, annual imaging in prepubertal and young adolescents followed by annual pelvic examinations in older adolescents seems appropriate

Conclusion

We report a prospective pilot study which evaluated the feasibility of combined ultrasonographically guided drainage and laparoscopic excision after pre-operative administration of a gonadotrophin-releasing hormone analogue for 3 months in the management of ovarian endometriotic cysts >5 cm. Ten patients with an ultrasonographic diagnosis of large unilateral or bilateral ovarian endometriotic cysts received an intramuscular injection of leuprorelinum acetate 3.75 every 4 weeks for 12 weeks. After 4 weeks of medical treatment, the endometrioma was carefully drained transabdominally under ultrasonographic control. Within 8 weeks since the last injection, the patients were submitted to a second ultrasonography, and laparoscopy-guided stripping of the endometrioma was performed. A videotape review was undertaken to evaluate duration and complexity of the different phases of surgery. Stripping of endometriomas with preservation of residual ovarian parenchymas was obtained in all cases; adhesiolysis was complete in 6 cases. There were neither intra-operative complications nor conversions in laparotomy. In conclusion, gonadotrophin-releasing hormone analogue and cyst drainage seem to permit an easy laparoscopic approach of large endometriomas; the findings of our pilot phase seem to justify a randomized trial to better define the effectiveness of this approach with respect to standard procedures

References