Laparoscopic surgery for large benign ovarian cysts

Too big to bag? - Technique for bagging very large adnexal masses via vNOTES

The technique to perform adnexectomy for adnexal masses has shifted over the last decades, from open surgery towards minimally invasive approaches. At the same time caution is warranted to prevent perioperative intra-abdominal spilling of cyst content which can be a challenge especially for very large masses. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) combines a vaginal approach with endoscopic overview in performing gynaecological surgery without abdominal scarring. The aim of the video is to demonstrate a vNOTES technique for safely bagging very large adnexal masses.

Predicting nutrition and environmental factors associated with female reproductive disorders using a knowledge graph and random forests

OBJECTIVE

Female reproductive disorders (FRDs) are common health conditions that may present with significant symptoms. Diet and environment are potential areas for FRD interventions. We utilized a knowledge graph (KG) method to predict factors associated with common FRDs (for example, endometriosis, ovarian cyst, and uterine fibroids).

MATERIALS AND METHODS

We harmonized survey data from the Personalized Environment and Genes Study (PEGS) on internal and external environmental exposures and health conditions with biomedical ontology content. We merged the harmonized data and ontologies with supplemental nutrient and agricultural chemical data to create a KG. We analyzed the KG by embedding edges and applying a random forest for edge prediction to identify variables potentially associated with FRDs. We also conducted logistic regression analysis for comparison.

RESULTS

Across 9765 PEGS respondents, the KG analysis resulted in 8535 significant or suggestive predicted links between FRDs and chemicals, phenotypes, and diseases. Amongst these links, 32 were exact matches when compared with the logistic regression results, including comorbidities, medications, foods, and occupational exposures.

DISCUSSION

Mechanistic underpinnings of predicted links documented in the literature may support some of our findings. Our KG methods are useful for predicting possible associations in large, survey-based datasets with added information on directionality and magnitude of effect from logistic regression. These results should not be construed as causal but can support hypothesis generation.

CONCLUSION

This investigation enabled the generation of hypotheses on a variety of potential links between FRDs and exposures. Future investigations should prospectively evaluate the variables hypothesized to impact FRDs.

Clinical efficacy of ultrasound-guided interventional therapy in patients with benign ovarian cysts: a meta-analysis

This study aimed to explore the clinical efficacy of ultrasound-guided interventional therapy in patients with benign ovarian cysts through meta-analysis. A literature search was performed on PubMed, Web of Science, Embase, CNKI, and WanFang databases to obtain clinical randomized controlled trials on ultrasound-guided interventional therapy for benign ovarian cysts published between 2010 and 2022. A total of 1395 studies were initially retrieved, and finally 12 studies were included for meta-analysis. The results showed that the observation group (ultrasound-guided interventional therapy) had higher treatment effective rate than the control group (conventional laparotomy or laparoscopic cyst resection), but the incidence of adverse reactions was markedly lower. Additionally, the length of hospital stay, intraoperative blood loss, and operation time showed significant lower levels in the observation group. In terms of ovarian function, postoperative luteinizing hormone and follicle-stimulating hormone levels in the observation group were lower than the control group, while oestradiol levels were higher. In conclusion, compared with conventional surgical treatment, ultrasound-guided interventional therapy can significantly improve the clinical effective rate, shorten the hospital stay and reduce intraoperative blood loss. Such therapy can protect ovarian reserve, with high value of clinical promotion.IMPACT STATEMENTWhat is already known on this subject? Main surgical methods for ovarian cysts consist of laparotomy, laparoscopic surgery, and interventional therapy.What the results of this study add? With the advancement of surgical techniques and instruments, many minimally invasive surgeries have been applied to treat ovarian cysts with good clinical results. However, there is no exact evidence to prove its clinical efficacy. Given the lack in this field, we conducted a meta-analysis of all clinical studies of ultrasound-guided interventional therapy for ovarian cysts to evaluate its efficacy and safety.What the implications are of these findings for clinical practice and/or further research? Compared with conventional laparotomic or laparoscopic cyst resection, ultrasound-guided interventional therapy for ovarian cysts significantly improves the treatment effectiveness, shortens the hospital stay and reduces intraoperative blood loss. This therapy with good clinical efficacy also has advantages of small wound, rapid recovery and less adverse reactions, and can protect ovarian reserve. This safe and effective surgical method for ovarian cysts is worth promoting clinically.

Predicting nutrition and environmental factors associated with female reproductive disorders using a knowledge graph and random forests

Objective

Female reproductive disorders (FRDs) are common health conditions that may present with significant symptoms. Diet and environment are potential areas for FRD interventions. We utilized a knowledge graph (KG) method to predict factors associated with common FRDs (e.g., endometriosis, ovarian cyst, and uterine fibroids).

Materials and Methods

We harmonized survey data from the Personalized Environment and Genes Study on internal and external environmental exposures and health conditions with biomedical ontology content. We merged the harmonized data and ontologies with supplemental nutrient and agricultural chemical data to create a KG. We analyzed the KG by embedding edges and applying a random forest for edge prediction to identify variables potentially associated with FRDs. We also conducted logistic regression analysis for comparison.

Results

Across 9765 PEGS respondents, the KG analysis resulted in 8535 significant predicted links between FRDs and chemicals, phenotypes, and diseases. Amongst these links, 32 were exact matches when compared with the logistic regression results, including comorbidities, medications, foods, and occupational exposures.

Discussion

Mechanistic underpinnings of predicted links documented in the literature may support some of our findings. Our KG methods are useful for predicting possible associations in large, survey-based datasets with added information on directionality and magnitude of effect from logistic regression. These results should not be construed as causal, but can support hypothesis generation.

Conclusion

This investigation enabled the generation of hypotheses on a variety of potential links between FRDs and exposures. Future investigations should prospectively evaluate the variables hypothesized to impact FRDs.

The Beginner Laparoscopists Trends in the Learning Process of Laparoscopy for Adnexal Gynecological Pathologies-The Experience of Our Center

BACKGROUND

Laparoscopy for benign ovarian pathology is the appropriate surgical approach and it has many well-known advantages. Minimal invasive gynecological surgery increases the quality of life of the patient. The learning process of laparoscopy is difficult and requires many interventions to acquire manual skills. The objectives of the study were to assess the learning process of laparoscopy for adnexal pathology surgery performed by beginner laparoscopists.

MATERIALS AND METHODS

This study included three gynecological surgeons who were beginners in laparoscopy and who were named A, B, and C. We collected information about patients, diagnosis, surgical technique, and complications.

RESULTS

We have analyzed the data from 159 patients. The most frequent primary diagnosis was functional ovarian cyst, and the laparoscopic cystectomy was performed in 49.1% of interventions. The need to convert a laparoscopy into laparotomy was necessary in 1.3% of patients. There were no cases of reintervention, blood transfusion, or ureteral lesions. The duration of the surgical intervention varied statistically significantly according to patient's BMI and to the surgeon. After 20 laparoscopic interventions, a significant improvement was found in the time needed to perform ovarian cystectomy (operators A and B) and salpingectomy (operator C).

CONCLUSIONS

The process of learning laparoscopy is laborious and difficult. We found a significant decrease in operating time after a twenty laparoscopic interventions.

A method of laparoscopic treatment of large adnexal cysts - Two port trocar suction

OBJECTIVE

The size of the adnexal cyst is a limitation to perform laparoscopic adnexal surgery. Large adnexal cysts may constrain the surgery space and may increase the risk of inadvertent cyst rupture during the surgery. Here, we offer a method to solve the difficulty in laparoscopic management of large adnexal cysts.

MATERIALS AND METHODS

This is a retrospective study of 43 patients with large (≧10 cm) adnexal cysts, managed laparoscopically at one center from October 2016 to October 2019. All the surgeries were performed by an experienced laparoscopic surgeon. Malignancy was excluded before the surgeries according to the sonographic features. Cystectomy or salpingo-oophorectomy was decided according to the age, the sonographic pattern of the cyst and the patients' willingness. A 2 cm vertical incision was made at the umbilicus, and an open laparoscopy method was used to enter the peritoneal cavity. A wound protector was applied with a glove and two trocars being set up. The second wound was made at the left abdomen, and a 5 mm trocar was inserted. Then the cyst was punctured by means of the 5 mm trocar, and the content of the cyst was then soon aspirated by means of the air-flow hole of the trocar. Afterward, cystectomy or salpingo-oophorectomy was performed. Data are expressed as mean ± standard deviation unless stated otherwise.

RESULTS

The mean operative duration was 54.7 ± 33.4 min, and the result was shorter than the previous study (P < 0.05, CI (-32.92, -12.38)) according to one sample t-test. Most estimated blood loss (EBL) was minimum. No obvious complication was found.

CONCLUSION

Two-port trocar suction in laparoscopic management of large adnexal cysts is feasible after proper evaluation, and it takes short operative time.

Modified Leak-Proof Puncture Technique for the Aspiration of Giant Ovarian Cysts by Instantly Mounting a Plastic Wrap and Gauze with Cyanoacrylates: A Retrospective Observational Study

Objective

We developed a leak-proof puncture technique for giant ovarian cysts by instantly mounting a plastic wrap to the cysts using cyanoacrylates and aspirating cyst fluid over the wrap. Here, we modified it by inserting a gauze between the wrap and cyst to strengthen the mounting. This study aimed to clarify the feasibility of the modified procedure.

Method

A retrospective observational study was conducted in a single center. Surgical outcomes of 35 women who underwent the modified procedure from December 2013 to July 2020 were compared with those of 51 women who underwent the original procedure.

Results

Mean long-axis diameters of the cysts were 233.1 mm and 229.8 mm in the modified and original procedures, respectively. The median of surgical time, blood loss, and aspirated fluid volume were 109 min, 50 ml, and 3,050 ml, in the modified procedure, all of which were not significantly different from those of the original procedure. One case of mounting disruption and two (5.7%) cases of intraperitoneal spillage of the cyst fluid were observed in the modified procedure, whereas four (7.8%) cases of mounting disruption and five (9.8%) cases of intraperitoneal spillage occurred in the original procedure. These events were caused by aspiration difficulty of the high viscosity fluid and/or multilocular cysts. Laparotomy conversion was observed in five (14.3%) cases in the modified procedure.

Conclusion

Our modified procedure is feasible in select cases. The high viscosity of the cyst fluid and multilocular cyst may cause mounting disruption and intraperitoneal spillage of the cyst fluid.

Emergency treatment in gynecology using different methods of surgery

The aim. Improving surgical treatment of urgent genital pathology based on comparing the effectiveness of different methods of surgery. Materials and methods. 170 women were selected and divided into three groups. Group 1 included women with acute pelvic inflammatory disease (aPID); to 2nd group – 60 women with intra-abdominal bleeding (IAB); to 3rd group - 50 women with impaired blood supply to tumors of the internal genitalia (uterus and ovaries) (IBSTIG). Each group was divided into two equivalent subgroups depending on the method of treatment: laparoscopic or laparotomy. During the study, all examined patients had a medical history, gynecological examination, ultrasound examination, surgical treatment by laparoscopy or laparotomy. Results. The average duration of laparoscopic operations in patients in subgroup 1.1 was 50.4±7.2 minutes and 80.3±10.1 minutes in subgroup 1.2 – with laparotomy method. Intraoperative blood loss was significantly lower in subgroup 1.1 compared with subgroup 1.2 (210.7±31.4 ml and 375.9±44.5 ml) (p <0.01). In the postoperative period in subgroup 1.1, which included women with emergencies due to aPID and in which operations were performed laparoscopically, the maximum temperature rise after surgery was 37.6±0.04 °C, which was significantly lower than in subgroup 1.2, which included women with emergencies due to aPID and in which operations were performed by laparotomy, this figure was 38.0±0.08 °C (p <0.001). The mean duration of the postoperative period in patients of subgroup 1.1 was significantly shorter compared to subgroup 1.2 (7.2±0.6 and 10.2±1.0 days) (p <0.05). The average duration of operations in subgroup 2.1 was significantly shorter than in subgroup 2.1 (39.8±2.1 and 59.1±2.5 minutes, respectively) (p <0.001). Intraoperative blood loss was on average significantly lower in subgroup 2.1 (189.1±19.8 and 388.5±37.2 ml, respectively) (p <0.05). In subgroup 3.1, which included women with IBSTIG and underwent surgical treatment by laparoscopy, the average duration of operations was significantly shorter than in subgroup 3.2, where such women with such pathology received surgical treatment by laparotomy (62.1±4.9 and 89.6±7.8 minutes, respectively) (p <0.01). Blood loss was significantly lower in subgroup 3.1 in contrast to subgroup 3.2 (101.7±10.1 ml and 283.3±12.9 ml, respectively) (p <0.001). Conclusions. The use of laparoscopy for the treatment of urgent genital pathology could increase the effectiveness of surgical treatment. In addition, this method reduces the duration of surgery and surgical blood loss. As a result, it makes it possible to improve the postoperative period.

Use of human fibrin glue (Tisseel) versus suture during transvaginal natural orifice ovarian cystectomy of benign and non-endometriotic ovarian tumor: a retrospective comparative study

Background

To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors.

Methods

A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined.

Results

Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210).

Conclusion

The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses

OBJECTIVE

To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management.

INTENDED USERS

Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers.

TARGET POPULATION

Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer.

OUTCOMES

This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist.

EVIDENCE

Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework.

BENEFITS, HARMS, COSTS

Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Evaluation of the usefulness of laparoscopy in the diagnosis and treatment of adnexal pathologies in the pediatric population

INTRODUCTION

The current trend in adnexal surgery in children is to minimize the invasiveness of diagnostic and therapeutic procedures, reduce the number of complications and reduce the risk of infertility.

AIM

Evaluation of the usefulness and effectiveness of laparoscopy in diagnostics and treatment of pathological lesions of adnexa in the pediatric population and evaluation of the correlation of imaging with the intraoperative diagnosis during laparoscopy.

MATERIAL AND METHODS

The study included 89 patients aged 0-18 years (mean: 12.62) who underwent an emergency or elective laparoscopic procedure due to the suspicion of adnexa pathology in the imaging tests or in which intraoperative pathology of the adnexa was found without previous suspicion of these changes in the imaging tests. Patients were divided into 2 groups according to the procedure (emergency or elective) and into 4 age groups.

RESULTS

The most frequent postoperative diagnosis was an adnexal cyst and ovarian tumor. The ratio of malignant to benign lesions was 0.087. In 32.58% of patients appendix pathology was found. Coexistence of adnexa and appendix pathology was statistically significantly more frequent in patients undergoing emergency surgery (p = 0.013). There was no correlation between the size of the tumor or ovarian cyst and the occurrence of adnexal torsion, and no correlation between the size of the tumor and the degree of torsion of the adnexa. Three conversions were performed. The average operation time was 63.7 min.

CONCLUSIONS

Laparoscopic diagnosis and treatment of adnexal pathology seems to be safe due to the low percentage of perioperative complications. It shows high sensitivity in recognizing adnexal pathologies and other defects.

A 27-kg Giant Ovarian Mucinous Cystadenoma in a 72-Year-Old Postmenopausal Patient: A Case Report

BACKGROUND Mucinous cystadenoma is a benign cystic ovarian tumor arising from the surface epithelium of the ovary; it usually presents with vague, unspecific abdominal symptoms. If not detected early, they have the potential to grow to a substantial size and can present with huge abdominal distention leading to various compression symptoms. Mucinous cystadenomas most commonly occur in the third to sixth decades of life, and rarely occur in extremes of age. The reported incidence of giant ovarian cystadenoma in postmenopausal women is low or relatively unknown due to widespread use of ultrasound and other radiological imaging modalities these days. Here, we report a case of giant mucinous cystadenoma in a 72-year-old postmenopausal woman with multiple comorbidities. CASE REPORT We present the case of a 72-year-old postmenopausal high-risk patient who presented with a huge abdominal distention which started gradually 1 year before. Abdominopelvic ultrasound showed a left giant multiloculated abdominal cyst. An intact 27-kg ovarian cyst was removed, and a total abdominal hysterectomy (TAH) along with bilateral salpingo-oophorectomy (BSO) was performed. The final histopathological report showed a benign ovarian mucinous cystadenoma. CONCLUSIONS Mucinous cystadenoma is a benign neoplastic disease that can reach a massive size. They are rare in the postmenopausal age group, but when they do occur, they pose a diagnostic and therapeutic challenge. This case report highlights the importance of early detection and management of adnexal masses in postmenopausal high-risk patients to decrease preoperative and postoperative complications and improve quality of life.

Laparoendoscopic Single Site Surgery for the Treatment of Huge Ovarian Cysts Using an Angiocatheter Needle

PURPOSE

The aim of this study was to evaluate the feasibility and safety of laparoendoscopic single site (LESS) surgery using an angiocatheter needle in patients with huge ovarian cysts (diameter ≥15 cm).

MATERIALS AND METHODS

Thirty-one patients with huge ovarian cysts underwent LESS surgery using an angiocatheter needle between March 2011 and August 2016. An intra-umbilical vertical incision (1.5-2.0 cm) was made in the midline. After the cyst wall was punctured using an angiocatheter needle, the fluid contents were aspirated with a connected vacuum aspirator. After placing a Glove port in the umbilical incision, LESS surgery was performed using a rigid 0-degree, 5-mm laparoscope and conventional, rigid, straight laparoscopic instruments. Knife-in-bag morcellation was instituted for specimen collection.

RESULTS

The median maximal diameter of ovarian cysts was 18 cm (range, 15-30 cm), the median operation time was 150 minutes (range, 80-520 minutes), and the median volume of blood loss was 100 mL (range, 20-800 mL). Three patients (9.7%) were diagnosed with malignant ovarian cancer using intraoperative frozen examination, and 1 patient was converted to laparotomy due to advanced disease. Thirty patients underwent LESS, and there was no need for an additional laparoscopic port.

CONCLUSION

LESS surgery using an angiocatheter needle, with leaving only a small postoperative scar, was deemed feasible for the management of huge ovarian cysts.

Surgical treatment of large adnexal masses: a retrospective analysis of 330 consecutive cases

Introduction: In the present study, perioperative outcomes of laparoscopy (LPS) were compared to open surgery (OS) for the treatment of large adnexal masses (AM).Material and methods: Retrospective observational cohort study. Data of consecutive patients who underwent ovarian cystectomy or salpingo-oophorectomy for large AM (diameter ≥10 cm) at a referral minimally invasive gynecologic center were analyzed. Propensity score match (PSM) analysis was used to minimize covariate imbalances between the two groups.Results: Overall 330 patients, 285 (86.4%) LPSs and 45 (13.6%) OSs were included. PSM showed LPS (vs. OS) to be associated with less intraoperative blood loss (mL: 131.1 ± 52.6 vs. 545.5 ± 101.2; p = .007), shorter operative time (min: 84.8 ± 77.9 vs. 123.7 ± 70.1; p < .001), but higher rate of spillage (54.5% vs. 12.1%; p < .001). Among the LPS group, a positive correlation between AM size and both conversion to open surgery and need for mini-laparotomy was found (p < .05).Conclusions: An accurate patient selection, a dedicated workup, and an appropriate counselling are mandatory before LPS for large AM. The increased risks of intraoperative spillage associated with the minimally invasive approach should be acknowledged.

A Postmenopausal Woman with Giant Ovarian Serous Cyst Adenoma: A Case Report with Brief Literature Review

Giant (>10 cm) ovarian cyst is a rare finding. In the literature, a few cases of giant ovarian cysts have been mentioned sporadically, especially in elderly patients. We report a 57-year-old postmenopausal woman with a giant left ovarian cyst measuring 43 × 15 × 9 cm. She was referred to us from the local health center in view of palpable pelvic mass for six-month period. Considering the age and menopausal state, we performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy with excision of the giant left ovarian cyst intact and successfully without any significant complication. On histopathological examination, the cyst was confirmed as benign serous cystadenoma of the ovary. During the management of these high-risk cases of multidisciplinary approach, intraoperative and postoperative strict vigilance is necessary to avoid unwanted complications.

Early stage mucinous ovarian cancer: A review

Mucinous ovarian carcinomas (MOCs) are an uncommon subset of epithelial neoplasms, both clinically and molecularly distinct from other ovarian cancers. Pathologic diagnosis proves challenging, and metastatic disease from other sites-especially the digestive tract-must be excluded. Fortunately, most patients are diagnosed at an early stage of disease and often present with large, unilateral adnexal masses. Survival for patients with stage IA disease approaches over 90%, and surgery alone is sufficient. Patients with stage IB-II disease should receive adjuvant treatment but the specific regimen is controversial. In the following review, we provide an overview of mucinous ovarian carcinomas, with a particular focus on the treatment of patients with early stage disease.

Single port access laparoscopic surgery for large adnexal tumors: Initial 51 cases of a single institute

OBJECTIVE

Investigation of initial 51 cases of single port access (SPA) laparoscopic surgery for large adnexal tumors and evaluation of safety and feasibility of the surgical technique.

METHODS

We retrospectively reviewed the medical records of the first 51 patients who received SPA laparoscopic surgery for large adnexal tumors greater than 10 cm, from July 2010 to February 2015.

RESULTS

SPA adnexal surgeries were successfully completed in 51 patients (100%). The mean age, body mass index of the patients were 43.1 years and 22.83 kg/m², respectively. The median operative time, median blood loss were 73.5 (range, 20 to 185) minutes, 54 (range, 5 to 500) mL, and the median tumor diameter was 13.6 (range, 10 to 30) cm. The procedures included bilateral salpingo-oophorectomy (n=18, 36.0%), unilateral salpingo-oophorectomy (n=14, 27.45%), and paratubal cystectomy (n=1, 1.96%). There were no cases of malignancy and none were insertion of additional ports or conversion to laparotomy. The cases with intraoperative spillage were 3 (5.88%) and benign cystic tumors. No other intraoperative and postoperative complications were observed during hospital days and 6-weeks follow-up period after discharge.

CONCLUSION

Our results suggest that SPA laparoscopic surgery for large adnexal tumors may be a safe and feasible alternative to conventional laparoscopic surgery.

Differentiation between borderline and benign ovarian tumors: combined analysis of MRI with tumor markers for large cystic masses (≥5 cm)

BACKGROUND

There is overlap in imaging features between borderline and benign ovarian tumors.

PURPOSE

To analyze diagnostic performance of magnetic resonance imaging (MRI) combined with tumor markers for differentiating borderline from benign ovarian tumor.

MATERIAL AND METHODS

Ninety-nine patient with MRI and surgically confirmed ovarian tumors 5 cm or larger (borderline, n = 37; benign, n = 62) were included. On MRI, tumor size, septal number (0; 1-4; 5 or more), and presence of solid portion such as papillary projection or septal thickening 0.5 cm or larger were investigated. Serum tumor markers (carbohydrate antigen 125 [CA 125] and CA 19-9) were recorded. Multivariate analysis was conducted for assessing whether combined MRI with tumor markers could differentiate borderline from benign tumor. The diagnostic performance was also analyzed.

RESULTS

Incidence of solid portion was 67.6% (25/37) in borderline and 3.2% (2/62) in benign tumors (P < 0.05). In all patients, without combined analysis of MRI with tumor markers, multivariate analysis revealed solid portion (P < 0.001) and CA 125 (P = 0.039) were significant for predicting borderline tumors. When combined analysis of MRI with CA 125 ((i) the presence of solid portion or (ii) CA 125 > 44.1 U/mL with septal number ≥5 for borderline tumor) is incorporated to multivariate analysis, it was only significant (P = 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of combined analysis of MRI with CA 125 were 89.1%, 91.9%, 86.8%, 93.4, and 90.9%, respectively.

CONCLUSION

Combined analysis of MRI with CA 125 may allow better differentiation between borderline and benign ovarian tumor compared with MRI alone.

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.

Laparoscopic ovarian surgery in children and adolescents

Background and Objectives:

Although laparoscopy is widely used in gynecologic surgery in adults, few studies have been undertaken to examine its use in young and adolescent patients. This study was conducted to investigate the safety and feasibility of laparoscopic surgery for the treatment of benign ovarian disease in children and adolescents.

Methods:

A retrospective chart review was conducted on 106 patients (age, <20 years) who underwent laparoscopic surgery at Kangnam Sacred Heart Hospital from 2006 through 2012.

Results:

The mean patient age was 17.1 years, and the youngest one was 8. Pathologic analyses revealed that 32 (30.2%) patients had dermoid cyst, 30 (28.3%) had simple cyst, and 15 (14.2%) had endometrioma. Conservative procedures, such as cystectomy (48.1%), aspiration (5.7%), fulguration (4.7%), and detorsion (3.8%), were performed in 65.1% of all cases. A subanalysis revealed that the surgical outcomes of children (age, ≤15 years), including operative time, estimated blood loss, postoperative hemoglobin decrease, and postoperative length of hospital stay, were comparable to those of adolescents (age, 16–19 years), despite significant differences in mean height between the 2 groups (156.1 ± 10.71 cm in children vs. 162.1 ± 5.14 cm in adolescents; P < .0001). (The age break between the study groups was set at 15 years, because most girls reach their adult height between the ages of 15 and 16 years.) No intra- or perioperative complications were noted. In a comparison study of surgical outcomes in 433 women (age, 20–50 years) and the 106 young and adolescent girls in our sample (age, <20 years), those in our patients were not inferior.

Conclusion:

In children and adolescents, laparoscopic surgery can be successfully performed with conventional instruments designed for use in adults.

Laparoscopic treatment of 1522 adnexal masses: an 8-year experience

Objective. To reevaluate the long-term effectiveness and safety of laparoscopy in benign ovarian pathology. Materials and Methods. 1522 women with benign adnexal cysts, laparoscopically treated in the 3rd Department of Ob/Gyn, General University hospital "Attikon" and "Lito" Maternity Hospital between July 1998 and December 2006, were included. Results. The diagnosis in 1222 (80,6%) cases was endometriosis of the ovary, 60 (4%) hydrosalpinx, 51 (3,3%) serous cystadenomas, 44 (2,9%) dermoid ovarian cyst, 38 (2,5%) borderline tumors, 35 (2,3%) unruptured follicles, and 33 (2,2%) paraovarian cysts. In 174 cases (11,5%) laparoscopy was converted to laparotomy due to technical difficulties or suspicion of cancer. In particular, laparotomy was performed in 119 (8%) women due to severe adhesions and 18 (1,2%) women due to bleeding that could not be controlled safely by laparoscopy. In 36 (2,4%) women frozen section during operation revealed malignancy and laparoscopy was converted to laparotomy. A few operative complications were recorded like post-op fever, small hematomas at the trocar entries. Conclusions. Laparoscopic surgery seems to offer significant advantages such as reduced hospital stay, less adverse effects, better quality of life, and superior vision especially on surgical treatment of cases like endometriosis.

Mucinous tumors of the ovary: current thoughts on diagnosis and management

Mucinous tumors of the ovary represent a spectrum of neoplastic disorders, including benign mucinous cystadenoma, pseudomyxoma peritonei, mucinous tumors of low malignant potential (borderline), and invasive mucinous ovarian carcinoma. These tumors are related closely to each other and are distinct from other histologic subtypes of epithelial ovarian neoplasms from a clinical, histologic, and molecular standpoint. A continuum appears to be present from benign to borderline to malignant, which is different from other types of epithelial ovarian cancer. Mutational profiles are also distinct, as KRAS mutations are common, but p53 and BRCA mutations are infrequent. These characteristics lead to specific biologic behavior and guide both clinical management and research efforts in patients with mucinous ovarian tumors.

Two-port access versus four-port access laparoscopic ovarian cystectomy

Objective

This study was conducted to compare the surgical outcomes between two-port access and four-port access laparoscopic ovarian cystectomy.

Methods

Four hundred and eighty nine patients who had received two-port access laparoscopic ovarian cystectomy (n=175) and four-port access laparoscopic ovarian cystectomy (n=314) in Chungnam National University Hospital from January 2009 to August 2012 were analyzed retrospectively. The data were compared between the bilaterality of the cysts and cyst diameter of less than 6 cm and 6 cm or more.

Results

There were no significant differences in patient's age, parity, body weight, body mass index and history of previous surgery between the two-port and four-port access laparoscopy group. Bilaterality of ovarian cysts was more in fourport access laparoscopy group (13.7% vs. 32.5%, P=0.000). There were no significant differences in operation time, hemoglobin change, hospital stay, adhesiolysis, transfusion, and insertion of hemo-vac between the two-port and four-port access laparoscopy group for size matched compare. However additional analgesics were more in four-port access laparoscopy group for unilateral ovarian cystectomy.

Conclusion

Two-port access laparoscopic surgery was feasible and safe for unilateral and bilateral ovarian cystectomy compare with four-port access laparoscopic surgery.

Incidence of unplanned oophorectomy at laparoscopic ovarian cystectomy for clinically benign cysts

Laparoscopic surgery is the preferred approach in women with ovarian cysts and a low risk of malignancy, and the aim in young women should be to preserve the ovary. We are not aware of any data on the success of conservative surgery in preserving the affected ovary and this is the reason why we decided to investigate the incidence of unplanned oophorectomy, when a woman is originally scheduled for laparoscopic ovarian cystectomy for clinically benign cysts. We reviewed the medical notes of the 123 women who underwent surgery for clinically benign ovarian cysts between November 2004 and May 2012. The operative procedures performed were ovarian cystectomies (n = 119), salpingo-oophorectomy (n = 2) and fenestration (n = 2). In total, 61 women underwent a concomitant procedure. In our study, we found that planned laparoscopic cystectomy was mostly successful, with only 1.6% of patients in our series requiring unplanned oophorectomy.

Single port gasless laparoscopy-assisted mini-laparotomic ovarian resection (SP-GLAMOR): reasonable treatment for large cystic ovarian tumors with suspicion of malignancy

OBJECTIVES

Recent improvements to both optical and laparoscopic instruments have enabled the use of laparoscopic surgery for gynecological procedures as opposed to open abdominal surgery. However, laparoscopic surgery has several potential limitations, including tumor rupture, spillage, incomplete resection of lesions, and trocar insertion site metastasis in surgeries involving large ovarian masses with suspicion of malignancy. Here, we report a case series of large ovarian cystic tumors that were successfully removed by single port gasless laparoscopy assisted mini-laparotomic ovarian resection (SP-GLAMOR), the limitations of which were successfully addressed.

METHODS

We reviewed the medical records of 31 women who visited St. Vincent Hospital from April 2006 until April 2011 and were diagnosed with a large cystic ovarian mass with suspicion of malignancy based on imaging studies and tumor markers. After diagnosis, all of the women underwent SP-GLAMOR.

RESULTS

The median maximal diameter of cysts, median incision size, median surgical duration and median volume of blood loss were 20 cm (range 10.7-45 cm), 3 cm (range 2.5-4 cm), 100 min (range 45-270 min) and 100mL (range 30-500 mL), respectively. Four cases were diagnosed as malignant disease on frozen sections obtained during the operation, and were converted to open abdominal surgery. No major complications were observed. The four patients diagnosed with malignant disease also underwent adjuvant chemotherapy. All patients were followed up to the time of this report.

CONCLUSIONS

The results of our study suggest that the SP-GLAMOR procedure is feasible, with potentially decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results.

Surgical technique to prevent spillage of cyst fluid during operation for cystic ovarian tumors

We describe a new technique to prevent spillage of cyst fluid in patients undergoing surgery for cystic ovarian tumors. The cyst is first covered with a sterilized surgical sheet applied with quick-drying glue and is then punctured. This technique completely prevents spillage of cyst fluid into abdominal cavity.

Laparoscopic management of huge ovarian cysts

Objectives. Huge ovarian cysts are conventionally managed by laparotomy. We present 5 cases with huge ovarian cysts managed by laparoscopic endoscopic surgery without any complications. Materials and Methods. We describe five patients who had their surgeries conducted in a tertiary care center in Riyadh, Saudi Arabia (King Fahad Medical City). Results. Patients age ranged between 19 and 69 years. Tumor markers were normal for all patients. The maximum diameter of all cysts ranged between 18 and 42 cm as measured by ultrasound. The cysts were unilocular; in some patients, there were fine septations. All patients had open-entry laparoscopy. After evaluation of the cyst capsule, the cysts were drained under laparoscopic guidance, 1–12 liters were drained from the cysts (mean 5.2 L), and then laparoscopic oophorectomy was done. The final histopathology reports confirmed benign serous cystadenoma in four patients and one patient had a benign mucinous cystadenoma. There was minimal blood loss during surgeries and with no complications for all patients. Conclusion. There is still no consensus for the size limitation of ovarian cysts decided to be a contraindication for laparoscopic management. With advancing techniques, proper patients selection, and availability of experts in gynecologic endoscopy, it is possible to remove giant cyst by laparoscopy.

Laparoscopic cystectomy for the treatment of benign ovarian cysts in children: an analysis of 21 cases

STUDY OBJECTIVE

To evaluate the outcomes of treatment with minimal invasive surgery in children with benign ovarian cysts.

DESIGN

Retrospective chart review.

SETTINGS

Maternity and children hospital.

PATIENTS

Between May 2007 and May 2011, 21 children were treated by laparoscopic method for ovarian cysts at our clinic. The age, symptoms, ultrasonographic findings, operation records and follow-up times were retrospectively evaluated.

RESULTS

The mean age was 13.2 years. One patient presented with findings of torsion and another presented with findings of rupture; both were urgently operated on. The other patients presented with intermittent abdominal pain and were operated on under elective basis. The mean cyst size was 8.4 cm (5-13 cm). One patient with necrotic ovary and salpinx due to torsion underwent salpingo-oophorectomy while the others were administered ovary-preserving cystectomy. Only 4 patients required iv paracetamol as an analgesic in the postoperative period. Two patients were discharged on the second postoperative day while the remaining 19 patients were discharged on the first postoperative day. During a mean follow-up of 14 months, no recurrence was seen in this period. Cosmetic appearance was good in all patients.

CONCLUSION

The authors demonstrated that laparoscopic cystectomy was a technically feasible and safe method in the treatment of benign ovarian cysts, associated with short hospitalization, minimal analgesic requirement, and a good cosmetic appearance.

Mesial side ovarian incision for laparoscopic dermoid cystectomy: a safe and ovarian tissue-preserving technique

OBJECTIVE

To evaluate safety and efficacy, in terms of spillage risk and ovarian tissue preservation, of mesial incision for laparoscopic dermoid cystectomy.

DESIGN

Randomized controlled trial.

SETTING

University.

PATIENT(S)

Sixty-seven women with dermoid cysts.

INTERVENTION(S)

Laparoscopic dermoid cystectomy performed by mesial incision (33 patients, study group) or antimesial incision (34 patients, control group).

MAIN OUTCOME MEASURE(S)

Spillage of intracystic content rate, operative times, chemical peritonitis rate, and intraoperative blood loss (ΔHb) as primary outcomes. Postoperative ovarian reserve (ΔFSH levels, basal antral follicle number, mean ovarian diameter, and peak systolic velocity at 3 and 12 months after surgery) as secondary outcome.

RESULT(S)

Spillage of intracystic content rate and operative time were significantly lower in the study than in the control group. None developed chemical peritonitis. ΔHb was higher in the study group but not significantly. During the follow-up, median FSH values were significantly lower in the study group, with no differences in the E(2) levels. Moreover, median basal antral follicle number, median ovarian diameter, and median peak systolic velocity were significantly higher in the study group.

CONCLUSION(S)

Ovarian mesial-side incision appears to be a safe as well as tissue-sparing technique.

CLINICAL TRIAL REGISTRATION NUMBER

.

A minimally invasive approach to laparoscopic surgery for large adnexal cysts with a multichannel port using a wound retractor

This study explored and evaluated the feasibility and safety of laparoscopy with a multichannel port using a wound retractor for large adnexal masses. Seven patients scheduled to undergo single-port or 2-port laparoscopy for large adnexal cysts were enrolled. The cystic mass surface was exposed by inserting the wound retractor through the umbilical port, and cystic fluid was aspirated using a suction-irrigation system after puncture with an Ochsner trocar. Then, laparoscopic adnexal surgery was performed in the usual manner. The mean maximal diameter of cysts, mean operation time, and mean postoperative hospital stay were 17.8 ± 5.4 cm, 81.3 ± 28.2 minutes, and 4.4 ± 2.0 days, respectively. Use of multichannel ports for large adnexal cystic masses seems safe and does not require additional cost. The procedure is also cosmetically effective and highly appreciated by patients, because it results in minimal abdominal scarring.

Is tumor size the limiting factor in a laparoscopic management for large ovarian cysts?

PURPOSE

To assess the feasibility and short-term surgical outcome of laparoscopic surgery among women with large ovarian cysts.

METHODS

We retrospectively evaluated consecutive 81 patients who received laparoscopic management for ovarian cysts with diameter ≥ 10 cm and without radiologic features suggestive of malignancy, from March 2008 to September 2011.

RESULTS

Laparoscopic surgery was successful in 77 (95.1 %) of the total patients. The mean (range) operative time, estimated blood loss (EBL) and hospital stay were 107.6 (55-250 min), 226.9 (10-1300 mL) and 6.1 (4-15 days), respectively. The surgical procedures performed included salpingooophorectomy (SO) (n = 44), ovarian cystectomy (OC) (n = 22), adhesiolysis (n = 1), salpingectomy (n = 2) and total laparoscopic hysterectomy (TLH) with SO (n = 8). Conversion to laparotomy occurred with four patients. One patient had postoperative bleeding and one had minor complications associated with wound oozing at the umbilical port site. Histopathological examination revealed benign tumors in 76 patients (93.8 %), borderline ovarian tumor in three patients (3.7 %) and invasive epithelial ovarian cancer in two patients (2.5 %). Clinicopathological variables according to tumor size were not statistically different. Complications did not appear in any patients during the follow-up period.

CONCLUSION

With proper patient selection, laparoscopy is a feasible and safe treatment for women with large ovarian cysts and tumor size did not have effect on laparoscopic management. However, surgeons should carefully consider the potential risk of malignancy in such patients.

Laparoscopic management of giant ovarian cysts in adolescents

A laparoscopic approach to giant ovarian cysts in girls, when the cyst's size exceeds the umbilicus, may be difficult regarding the risk of cyst rupture and limited working space. We present a series of three 12-year-old girls with giant ovarian cysts treated by percutaneous drainage under ultrasonographic guidance followed by laparoscopic resection. Clinical, laboratory and radiological diagnosis showed no signs of malignancy. After induction of general endotracheal anaesthesia, under ultrasonographic guidance, a 10 F vesicostomy catheter was placed into the cyst. Two to 4 l of serous (in one case mucinous) fluid were drained from the cyst. During laparoscopy, the abdominal cavity was inspected by the scope and no signs of malignancy were found. The laparoscopic procedure was completed with excision of the cyst and keeping some ovarian tissue in all cases. No intraoperative complications were observed. The mean operation time was 73 min. Pathological examination revealed a mature cystic teratoma in two cases and mucinous cystadenoma in one. The postoperative recovery was uneventful in all girls and they were discharged home on postoperative day 2-4 with minimal pain. The ultrasound scans and tumour markers were normal on follow-up after 3 and 6 months. Laparoscopic excision of giant ovarian cysts after ultrasound-guided drainage seems to be a safe and applicable treatment modality in pre-menarchal girls with a normal tumour marker profile and benign features of the cyst, excluding the possibility of malignancy.

Transumbilical 1-port laparoscopic resection of benign ovarian tumor

BACKGROUND/PURPOSE

We evaluated the effectiveness of transumbilical 1-port laparoscopic resection of benign ovarian tumors in children with limited working space.

METHODS

This study involved 15 children and adolescents with benign ovarian tumors treated from January 2006 to December 2010. Preoperative evaluation included physical findings, tumor markers, and imaging studies. A single surgeon performed the procedure using a 10-mm 0° operative laparoscope with a 5-mm working channel. The fallopian tube was suspended with transabdominal suspensory sutures passing through the mesosalpinx to expose the tumor and remove it after aspiration of the contents. The tumor was contained in the endobag and chopped into pieces before removal through the small umbilical wound.

RESULTS

The patients' age ranged from 2 to 17 years (mean, 9.7 years). Tumor size ranged from 3.6 to 23 cm. Tumor markers including α-fetoprotein, β-human chorionic gonadotropin, cancer antigen 125, and carcinoembryonic antigen were negative. The average operating time was 134 minutes. Except for 1 patient with associated encephalomyelitis, all patients were discharged within 3 days after surgery. Pathologic examination and follow-up studies revealed benign tumors, with no residual lesions in the abdomen or recurrence.

CONCLUSIONS

Transumbilical 1-port laparoscopic resection is effective for resection of benign ovarian tumors in children, with a satisfactory cosmetic outcome. However, to prevent inadequate resection of a potential malignant lesion, thorough preoperative evaluation with physical signs, tumor markers, and imaging studies, as well as flexible intraoperative tactics, should be adopted.

Laparoscopic Management of Large Ovarian Cysts

The aim of this study was to describe a new technique for laparoscopic removal of large ovarian cystic masses. The authors performed a retrospective study during the period January 2008 to December 2009 in the Second Department of Obstetrics and Gynecology of Aretaieion University Hospital; 19 women with large ovarian cysts were included in the study. During the study period, 53 women underwent laparoscopic excision of ovarian cysts. Among them, 19 had very large complex ovarian cysts with a mean diameter of 8.4 cm. The mean age of the patients was 32.1 years. Ultrasound examination revealed findings suggestive of benign disease in all patients. In 8 out of 19 patients CA-125 levels were elevated, ranging from 40.5 to 194.7 IU/mL. A 5-mm suprapubic trocar was directly inserted into the cyst and fluid contents aspirated, so the decompressed cyst could fit in a 5-cm laparoscopic bag. The cyst wall was carefully detached from the healthy ovarian tissue and placed in the bag without any spillage. The remaining cyst wall was removed from the peritoneal cavity with the laparoscopic bag. The mean operative time was 45 minutes. No operative or postoperative complications were noted. There was no conversion to laparotomy. Mean hospital stay was 1 day. Pathology revealed 7 endometriomas, 3 mucinous cystadenomas, 3 serous cystadenomas, 3 serous cysts, and 3 teratomas. Direct trocar insertion within the ovarian cyst followed by aspiration of the fluid contents is a safe and feasible method for the laparoscopic management of large ovarian cysts.

Minimally invasive management of huge ovarian cysts by laparoscopic extracorporeal approach

Laparoscopy has been widely performed in adnexal surgery for benign masses. For large adnexal masses, laparoscopy has not been commonly used and laparotomy remains the gold standard due to several technical difficulties in the former, including a limited surgical field, risk of unintended cyst rupture during the insertion of the Veress needle or trocar, and the possibility of malignancy. Recent advances in laparoscopic techniques have offered acceptable options for performing laparoscopy in patients with very large adnexal cysts. We performed ovarian cystectomy of huge ovarian cysts via a laparoscopic extracorporeal approach through an umbilical single-site incision, successfully minimizing the possibility of cyst contents leaking into the peritoneal cavity. Use of a single-site incision at the umbilicus for huge adnexal cystic masses appears safe and spares the additional costs of using conventional surgical instruments. It is also cosmetically effective and highly appreciated by patients because it results in minimal abdominal scarring.