The extremely large ovarian cyst presents a major challenge for the gynecological endoscopic surgeon. Increased probability of malignancy, technical problems related to the removal of such cysts, and perioperative problems related to cardiorespiratory functional changes may complicate surgery for such cysts.1 Very large ovarian cysts are conventionally treated by laparotomy. Recent advances in endoscopic surgical techniques have offered new possibilities for laparoscopic treatment of such very large ovarian cysts. We report on our experience with 21 cases of extremely large ovarian cysts that were managed laparoscopically.
MATERIALS AND METHODS
From July 2000 to December 2003, we managed laparoscopically 21 patients clinically diagnosed with large adnexal masses and low probability for malignancy. Inclusion criteria included absence of ascites, absence of suspect sonographic and computed tomography (CT) features of the adnexal mass (absence of papillations, no suspect areas, no reduced resistance index), no evidence of intraperitoneal spread, no enlarged pelvic lymph nodes, and only mildly elevated serum tumor marker levels (mainly serum CA 125 levels (<130 mIU/mL). Each patient had an adnexal mass reaching the umbilicus or higher. In each case informed consent was obtained, including a statement that laparotomy might be required if cancer is detected by frozen section or if the mass could not be properly managed by laparoscopy alone. All the operations were performed under general endotracheal anesthesia with a nasogastric tube in the stomach.
Open laparoscopy was the method of entry chosen in all of the cases. An incision of about 1.5 cm at the umbilical or supraumbilical area was made, and dissection of abdominal layers was performed under vision until the peritoneal cavity was entered. The intra-abdominal management of all patients was carefully standardized, including inspection of the pelvis, ovaries, upper abdomen, omentum, liver, and diaphragmatic surfaces for any growths or other signs of malignancy. Peritoneal washing was obtained for cytology. A biopsy specimen for frozen section was obtained or the removed specimen was sent for frozen section. If malignancy was suggested by frozen section, the laparoscopic procedure was converted to laparotomy performed by the oncogynecologic team. The management of the adnexal mass included aspiration of the fluid content and cystectomy or oophorectomy, depending on the patient's age, obstetric history, and desire of future fertility. The specimen was removed by a special removal bag through the 10-mm suprapubic trocar incision following a small extension or through a posterior colpotomy.
After the tissue was removed, the abdominal and pelvic cavities were thoroughly irrigated with copious amounts of normal saline. Before the procedure was terminated, any additional pelvic abnormality such as adhesions was treated, and homeostasis was secured. All patients except for 2 who had conversion to laparotomy were discharged on the day after surgery.
The mean and median ages of the patients were 45 ± 20 and 46 years, respectively (range 17–89 years). Seven women were postmenopausal, and the rest were premenopausal. Thirteen patients presented with symptoms of abdominal pain, urinary retention, or urinary urgency. Eight patients were asymptomatic, and the cysts were diagnosed on an incidental sonography (Table 1). Twelve patients had normal serum CA 125 levels (range 5.3–21 mIU/mL), and 9 had slightly elevated levels of CA 125 (range 37–127 mIU/mL). The mean and median volumes of the removed cystic fluid were 2,844 ± 2,422 and 2,000 mL, respectively (range 1,000–11,000 mL). The patients underwent cystectomy or adnexectomy, depending on each patient's age and obstetric history (Table 2). The mean and median operating times were 95 ± 26 and 90 minutes, respectively. Frozen section specimens were obtained during surgery in all but one patient with a paraovarian cyst. Two laparoscopies were converted to laparotomy: one because of technical difficulties related to morbid obesity and severe intra-abdominal adhesions and one because of ovarian malignancy. The diagnosis of ovarian malignancy was established by frozen section during surgery in a 75-year-old patient who was initially examined for abdominal pain. The diagnosis of a huge left ovarian cyst was confirmed by physical and pelvic bimanual examination, transvaginal ultrasound examination, and a CT scan. On CT scan, the adnexal mass appeared as a huge semisolid left ovarian mass extending beyond the umbilicus but was not associated with any ascites or enlarged pelvic or para-aortic lymph nodes. The serum CA 125 level was 11 mIU/mL. At laparoscopy, inspection of the abdominal and pelvic cavities revealed no evidence of any metastatic spread. Peritoneal washing for cytology was performed, and 4 L of fluid were aspirated from the cystic mass. Special care was taken to minimize spillage. The left adnexa was completely excised and removed through a posterior colpotomy. The frozen section of the specimen revealed ovarian malignancy. The laparoscopic procedure was converted to laparotomy and a hysterectomy, with contralateral adnexectomy, intracolic omentectomy, and lymph node sampling for staging, was performed. The postoperative period was uneventful.
All of the other 20 patients had benign tumors (Table 3). As expected, the most common histopathologic pattern was that of a mucinous cystadenoma. Although all the patients were operated on electively, 4 of them had unexpected adnexal torsion. Three of these had various complaints of abdominal pain. One woman was asymptomatic. One patient presented with repeated huge ovarian cyst on the same side. The second laparoscopic cystectomy was performed about 4 months after the first one. The histopathology at both operations showed benign mucinous cystadenoma. There were no complications and blood loss in all procedures was minimal.
Ovarian cysts are the fourth most common reason for gynecologic admission in the United States.1 The safety of laparoscopic management of benign adnexal masses has been amply demonstrated. The procedure is associated with reduced operative blood loss, fewer postoperative complications, shorter hospitalization, and earlier recovery compared with laparotomy.2–5 Operative laparoscopy is regarded today as the gold standard for the surgical treatment of ovarian cysts. However, the size of ovarian cysts is still considered a major limiting factor for wider application of laparoscopic management. Some authors2,6 have limited laparoscopic surgery to women with an adnexal mass size less than 10 cm. When confronted with extremely large, apparently benign ovarian cysts, only few surgeons advocate laparoscopic management.5,7,8 Nagele and Magos1 and Eltabbakh and Kaiser9 suggested preoperative ultrasound-guided aspiration of the cyst, followed by removal through a laparoscopic incision. Salem10 reported on 15 cases of large benign ovarian cysts reaching above the level of the umbilicus, which were managed laparoscopically. We have chosen to use open laparoscopy as described by Hassan et al11 because we felt that abdominal entry would be safer and would prevent inadvertent puncture of these large ovarian cysts. Our experience demonstrates that, with proper patient selection, laparoscopy can be applied in the management of a selected group of patients with extremely large ovarian cysts.
One major concern with laparoscopic management of a large adnexal mass is the possibility of encountering and cutting into a malignant neoplasm. This may cause intraperitoneal spillage and trocar site implantation of malignant cells. The possible adverse effect of operative spillage is still controversial. Maiman et al12 have reported that surgical rupture may unfavorably influence prognosis. However, this has not been confirmed by others using multivariate analysis.13–15 Nevertheless, a serious attempt should be made to avoid spillage as much as possible. Port-site metastasis after laparoscopic removal of malignant adnexal tissue is another reported complication,16–19 with a reported incidence of 1–16%.20,21 No port-site metastasis occurred in our patient with malignancy. An adverse effect of delayed definitive surgery on the stage of the disease has been clearly demonstrated in several studies.12,22,23 The observed progression from apparently early to advanced stage of malignant disease was assumed to be directly related to duration of the delay to definitive surgery. We believe that when malignancy is suspected by frozen section examination during laparoscopy, immediate definitive surgical treatment is indicated either by laparoscopy or by conversion to laparotomy.
With proper patient selection, the size of an ovarian cyst does not necessarily constitute a contraindication for laparoscopic surgery. The presence of both an expert laparoscopist and a gynecologic oncologist on call is mandatory. To draw final conclusions, more data are required and a multicenter study trial should be done to compare laparoscopic and laparotomy approaches.
1. Nagele F, Magos A. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol 1996;175:1377–8.
2. Yuen PM, Yu KM, Yip SK, Lau WC, Rogers MS, Chang A. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol 1997;177:109–14.
3. Mais V, Ajossa S, Piras B, Marongiu D, Guerriero S, Melis GB. Treatment of nonendometriotic benign adnexal cysts: a randomized comparison of laparoscopy and laparotomy. Obstet Gynecol 1995;86:770–4.
4. Pittaway DE, Takacs P, Bauguess P. Laparoscopic adnexectomy: a comparison with laparotomy. Am J Obstet Gynecol 1994;171:385–91.
5. Nezhat F, Nezhat C, Welander CE, Benigno B. Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses. Am J Obstet Gynecol 1992;167:790–6.
6. Lin P, Falcone T, Tulandi T. Excision of ovarian dermoid cyst by laparoscopy and by laparotomy. Am J Obstet Gynecol 1995;173:769–71.
7. Howard FM. Surgical management of benign cystic teratoma: laparoscopic vs laparotomy. J Reprod Med 1995;40:495–9.
8. Amos NN, Brodbent JAM, Hill NCW, Magos AL. Laparoscopic “oophorectomy-in-a-bag” for removal of ovarian tumors of uncertain origin. Gynecol Endoscop 1992;1:85–9.
9. Eltabbakh GH, Kaiser R. Laparoscopic management of a large ovarian cyst in an adolescent. J Reprod Med 2000;45:231–4.
10. Salem HA. Laparoscopic excision of large ovarian cysts. J Obstet Gynaecol Res 2002;28:290–4.
11. Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol 1971;110:886–7.
12. Maiman M, Seltzer V, Boys J. Laparoscopic excision of ovarian neoplasm subsequently found to be malignant. Obstet Gynecol 1991;77:563–5.
13. Sevelda P, Dittrich C, Sazer H. Prognostic value of the rupture of the capsule in stage I epithelial ovarian cancer. Gynecol Oncol 1989;35:321–2.
14. Dembo AJ, Davy M, Stenwig AE, Berll EJ, Bush RS, Kjorstad K. Prognostic factors in patients with stage I ovarian carcinoma. Obstet Gynecol 1990;75:263–73.
15. Vergote IB, Kaern J, Abeler VM, Pettersen EO, De Vos LN, Trope CG. Analysis of prognostic factors in stage I epithelial ovarian carcinoma: importance of degree of differentiation and deoxyribonucleic acid ploidy in predicting relapse. Am J Obstet Gynecol 1993;169:40–52.
16. Childers JM, Aqua KA, Surwit EA, Hallum A, Hatch KD. Abdominal-wall tumor implantation after laparoscopy for malignant conditions. Obstet Gynecol 1994;84:765–9.
17. Gleeson NC, Nicosia SV, Mark JA, Hoffman MS, Cavanagh D. Abdominal wall metastases from ovarian cancer after laparoscopic removal. Am J Obstet Gynecol 1993;169:522–3.
18. Wang PH, Yuan CC, Lin G, Ng HT, Chao HT. Risk factors contributing to early occurrence of port site metastases of laparoscopic surgery for malignancy. Gynecol Oncol 1999;72:38–44.
19. Hopkins MP, von Gruenigen V, Gaich S. Laparoscopic port site implantation with ovarian cancer. Am J Obstet Gynecol 2000;182:735–6.
20. Magrina JF. Laparoscopic surgery for gynecologic cancer. Clin Obstet Gynecol 2000;43:619–40.
21. Kruitwagen RF, Swinkels BM, Keyser KGG, Doesburg WH, Schijf CPT. Incidence and effect on survival of abdominal wall metastases at trocar or puncture sites following laparoscopy or paracentesis in women with ovarian cancer. Gynecol Oncol 1996;60:233–7.
22. Lehner R, Wenzl R, Heinzl H, Husslein P, Sevelda P. Influence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found to be malignant. Obstet Gynecol 1998;92:967–71.
23. Kindermann G, Maassen V, Kuhn W. Laparoscopic management of ovarian tumors subsequently diagnosed as malignant. J Pelvic Surg 1996;2:245–51.
© 2005 The American College of Obstetricians and Gynecologists
Figure. No Caption Available.