Laparoscopic Ovarian Surgery

Adnexal structures in females include the ovaries, fallopian tubes, and ligaments that support their association with the uterus. Congenital and acquired conditions including benign and malignant diseases can develop at all points in a female’s lifespan. Laparoscopy remains the ideal choice for operative access to diagnosis and treatment of adnexal diseases and disorders. It has the advantages of being a safe, cost-effective, and minimally invasive approach. Numerous studies have supported the advantages of decreased blood loss, return to productivity, and diminished adhesion formation in adolescents.

Access to the adnexa is usually initiated using the umbilicus for placement of the telescope and camera with lateral accessory ports inserted depending on the findings at operation. Occasionally, large masses or a history of previous operations requires the use of the left upper quadrant or alternative abdominal wall sites for the initial entry.

Increasing emphasis has been placed on conservative surgery for benign disease in the adnexa whenever safe and possible. Fertility-sparing and -enhancing techniques, including gentle manipulation of the fallopian tubes, adhesiolysis, and anatomically restorative procedures of the ovary along with avoidance of oophorectomy, are now appreciated as important in managing adnexal conditions. Oophorectomy, particularly for benign conditions, is associated with adverse reproductive outcomes and diminished fertility reserve as well as an earlier onset of menopause.

Most adnexal masses in girls younger than the age of 21 are categorized as either benign or congenital masses. Malignant neoplasms make up around 5% of all masses, but the incidence is influenced by age, the internal characteristic architecture of the mass, the presence of malignant serum markers, and the size of the mass.

While there is no absolute clinical tool to preoperatively diagnose all adnexal masses, several algorithms are being proposed to stratify those that likely represent a malignant process. By utilizing radiologic and serum markers of malignancy, laparoscopic ovarian cystectomy can be utilized for benign cystic diseases more efficiently, thereby allowing for fertility sparing. One study using preoperative characteristics of complexity of the mass on imaging and a size greater than or equal to 8 cm reduced the number of benign lesions treated with laparotomy while ensuring malignant masses were managed appropriately. More extensive operative approaches with oophorectomy and associated staging procedures can then be reserved for those cases that are likely malignant.

Operative Technique

Ovarian Cystectomy

Indications

Benign adnexal cysts and tumors in children and adolescents range from stromal tumors to epithelial tumors, though the most common types are functional cysts, such as hemorrhagic or follicular, and benign germ cell tumors. The most common germ cell tumor is a benign ovarian teratoma ( Fig. 21-1A ). Teratomas usually present with classic features on imaging, such as the appearance of hypoechoic fluid or hyperechoic lesions suspicious for calcification. Other features include the presence of fat or hair. A small proportion of these cysts can present with neural tissue as well. There is also a special circumstance in which patients with these teratomas can present concurrently with psychological changes and paraneoplastic encephalitis with neural mediated anti-N-methyl D-aspartate (NMDA) receptors. In such patients, since the tumor is the source of these receptors, it is imperative that the teratoma is removed once the diagnosis is established, with the expected gradual return to the patient’s psychological baseline and resolution of the encephalitis in most cases. The most important point to appreciate is that, in the setting of negative tumor markers (α-fetoprotein [AFP], lactate dehydrogenase [LDH], human chorionic gonadotropin [HCG], cancer antigen 125 [CA125]), most germ cell tumors can be approached laparoscopically. Additional markers (estradiol, inhibin, carcinoembryonic antigen [CEA], testosterone) can be useful when making decisions about cystectomy versus oophorectomy if the history and imaging suggests a different tumor type.

Traditional Operative Technique

When functional cysts are encountered at laparoscopy, these can be drained or incised, or the cyst wall can be completely removed. When benign cysts or tumors are found, the goal is to remove the cyst completely to avoid leaving tumor behind and to avoid recurrence. The ovarian cortex is incised with cautery to expose the cyst wall beneath it. With careful dissection, the cyst can be fully exposed, while also paying attention to any vessels requiring coagulation ( Fig. 21-1B through 21-1D ). Ideal instruments to accomplish this excision include bipolar or monopolar cautery, but also having access to a vessel-sealing device such as a Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH) or Ligasure (Medtronic, Minneapolis, MN) or the 3-mm vessel sealer (Bolder Surgical, Louisville, CO) is helpful as well.

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