Endoscopic management of adnexal masses

Abstract

Background: The laparoscopic management of suspicious adnexal masses and early ovarian malignancies is discussed with the aim of maintaining accepted oncologic treatment principles. Comparative survival data of patients with gynecological malignancies managed by laparoscopy or laparotomy are still very scarce and the survival of cancer patients must not be compromised by new techniques. It is time to closely analyze laparoscopy and determine if it has a positive impact on the diagnosis and treatment of ovarian malignancies. In this paper we will address the following points: 1) Which ovarian cysts can be surgically treated by laparoscopy (pelviscopy)? 2) Is staging laparoscopy an accepted technique? 3) Is laparoscopy, as a second-look procedure, of benefit? 4) Is laparoscopic staging, together with histologic tissue sampling, adequate surgical technique in inoperable ovarian cancer with ascites and peritoneal carcinomatosis? 5) Does endoscopic biopsy of ovarian cancer stage Ia change the destiny of a patient into ovarian cancer Ic?

Data base: The above questions are analyzed based on our experience with the laparoscopic treatment of 1,225 patients with ovarian cysts and 165 ovarian cancer patients stage I to IV treated immediately by laparotomy during the years 1992-1995.

Conclusions: Ovarian cystic tumors with no signs of malignancy can be dealt with by laparoscopic means with the option of immediate conversion to laparotomy or within one week if an ovarian malignancy is diagnosed. Today sampling laparoscopic lymphadenectomy of both pelvic and para-aortic is feasible and adequate. On a curative level, the number of lymph nodes to be resected has yet to be determined. The adnexa can be extracted from the abdominal cavity with bag extraction without the danger of spillage. The uterus can be removed transvaginally with laparoscopic assisted vaginal hysterectomy (LAVH). We must be cautious to advocate laparoscopy for ovarian cancer. However, it is an excellent tool when used as a staging procedure. A careful preoperative screening of the patient and an exact definition of existing cysts with imaging techniques allows us to frequently apply laparoscopic surgery for ovarian cysts, leaving only readily detectable cancer cases for laparotomy. Many gynecological oncologists employing staging and second-look procedures for ovarian cancer agree that initiating a case with laparoscopy may preclude laparotomy for many patients. Tumor propagation by performing a biopsy in FIGO stage Ia ovarian cancer patients does not occur if the patient receives adequate radical surgical treatment within one week. According to the reports of Sevelda et al. and Dembo et al., the degree of differentiation and the existence of ascites are more relevant to decreasing the five-year survival rate of patients with ovarian cancer stage I than the rupture of capsule or penetration of the tumor. A dependency on the first two parameters was found in these two large statistical studies. As the question of endoscopic operations for adnexal mass is predominantly put for the sanitation of small ovarian tumors (ovarian tumors with solid particles in the cysts can be put into the section of primary laparotomies) there remains a wide field of indications for the laparoscopic treatment of adnexal mass and ovarian cysts with benign indications. For many young patients with non-malignant ovarian lesions such as endometriosis, benign cysts, benign cystic proliferations and fibromas, a laparotomy can be avoided and these lesions treated by laparoscopy.

Figure 1.

Pelviscopic enucleation of an ovarian cyst and suture of the ovarian lining.

1. 1. Capsular incision

2. 2. Cyst resection

3. 3. Ovarian suture

4. 4. Final aspect after endoscopic ovarian cyst resection

Figure 2.

Bag extraction of endoscopically resected adnexa.

1. 1. Positioning of adnexa into an endobag

2. 2. Closing the bag by pulling the string

3. 3. Insertion of bag into the trocar

4. 4. Bag extraction

Figure 3.

Endoscopic ovarian cyst resection in a series of pictures.

1. 1. Ovarian cyst to the right side

2. 2. Cyst resection

3. 3. Cyst inspection

4. 4. Ovarian suture

5. 5. Endobag extraction

Figure 4a.

Endoscopic oophorectomy using the 3-loop ligation technique in four steps.

1. 1. Positioning of the frist Roeder loop

2. 2. After placement of 3 loops ovarian resection

3. 3. Endocoagulation of the ovarian stump

4. 4. Ovarian morcellation using 15 or 20 mm trocars

Figure 4b.

Endoscopic adnexectomy using the 3-loop ligation technique in four steps (1-4) or in three steps using stapling techniques (A-C).

1. 1. Placement of first loop

2. 2. Cutting the loop

3. 3. After positioning of 3 loops adnexal resection

4. 4. Endocoagulation of the stump

1. A. Adnexal resection using a stapling device at the ovarian ligamnet

2. B. Dissection of infundihulo pelvic ligament

3. C. Adnexal resection

Figure 5.

Statistical evaluation of 1225 patients treated by endoscopic ovarian surgery according to their ages, size of ovarian cysts, color of cyst fluid and uni- or bilateral localization.

Figure 6.

Conversion rate of pelviscopy to laparotomy between 1992-1995 at ovarian endoscopic surgery.

Figure 7.

Suspect diagnosis at pelviscopic screening for ovarian surgery

Figure 8.

Specification of ovarian malignancies screened endoscopically but treated surgically by laparotomy