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Minimally invasive surgery series

Management of Benign Adnexal Masses: Practical Pearls for Laparoscopic Salpingo-oophorectomy

Mary Ellen Wechter, MD; Tonya L. Floyd-Bradstock, MFA; Arnold P. Advincula, MD

Laparoscopy, which was first introduced more than 30 years ago, has become an essential part of gynecologic surgery. A wide variety of gynecologic conditions are treated with dramatically increasing frequency using laparoscopy. One of these conditions is the adnexal mass. The first reports of laparoscopic salpingo-oophorectomy date back to the 1970s. Although laparoscopy has become the preferred approach to adnexal surgery, controversies exist regarding its role in the management of the adnexal mass, particularly when there is a suspicion of malignancy. This article outlines "practical pearls" for the successful management of benign adnexal masses. It is not intended to be an exhaustive review of the literature addressing adnexal masses; the discussion will rather focus on laparoscopic benefits and controversies, preoperative assessment, and various surgical techniques that can be utilized to perform salpingo-oophorectomy safely and efficiently.

LAPAROSCOPY VERSUS LAPAROTOMY

Though large, prospective, randomized trials are few, multiple retrospective analyses of adnexal surgery have demonstrated significant advantages to laparoscopy over laparotomy, making this the preferred approach for the presumably benign adnexal mass.^1-3 Hospital stays are consistently and significantly shorter for laparoscopy, as are the associated inpatient charges. An interesting comparison, not often addressed, is the effect on cost if a procedure is initiated laparoscopically and converted to laparotomy. Lower estimated blood loss and smaller postoperative analgesic requirements are also factors tipping the balance toward laparoscopy. In addition, shorter overall convalescence, including quicker return to daily activities, work, and pain-free living are demonstrated in patients whose adnexal masses are approached laparoscopically rather than by laparotomy. Patient satisfaction with the experience, though less frequently reported and more difficult to quantify, also favors laparoscopy.^1,4-10

Operative times for laparoscopic adnexal surgery, which were initially significantly longer than for laparotomy, continue to reflect operator experience versus the complexity of the surgery, and inclusion of concurrent procedures such as hysterectomy.⁹ Clean comparison between laparoscopy and laparotomy therefore remains difficult, even as increased operator experience and availability of time-saving equipment expedite the procedure. Most retrospective reviews report either no significant difference in operative time or small differences favoring either laparotomy or laparoscopy.^1,3,5

Complication rates are low for both laparoscopic and open approaches to the adnexal mass,⁷ and are usually reported as being higher for laparotomy.^4,10-12 The rates of postoperative fever and urinary retention, for instance, are reported to be significantly higher following laparotomy than for laparoscopy.^5,6,13 In a retrospective look at 405 patients undergoing adnexal surgery, Hidlebaugh et al⁴ also noted a significantly higher total number of complications for laparotomy over laparoscopy, including fever, ileus, blood transfusion, wound infection, thrombi, pneumonia, reoperation, and ureteral injury, for both oophorectomy (29% versus 3%) and cystectomy (8% versus 1%). Like operative times, complication rates also reflect the complexity of the pathology and the operator’s experience with the chosen approach.

CONTROVERSY

Despite the proven benefits of laparoscopy, laparotomy is still the gold standard for adnexal masses that are highly suspicious for malignancy.⁸ The presence of septations, ascites, ovarian excrescences, peritoneal studding, and/or adenopathy on preoperative imaging should significantly heighten the suspicion for malignancy. The controversy arises for masses with some features suspicious for malignancy, and centers specifically on whether a primary laparoscopic approach is more likely to miss an occult malignancy or worsen the prognosis.

This dilemma is simplified by sensitive, specific preoperative diagnosis, incorporating patient menopausal status and testing for tumor markers as well as ultrasonographic appearance and Doppler studies of the mass.^2,3,8,14 Theoretically, 100% sensitivity for malignancy could be achieved through applying the strictest criteria for laparoscopy; however, this would result in a high primary laparotomy rate of approximately 40%.⁸ Alternatively, 100% sensitivity and 100% negative predictive value could be achieved with a 30% primary laparotomy rate when preoperative suspicion is combined with diagnostic laparoscopy and conversion when necessary to laparotomy, as demonstrated by Chapron et al¹⁵ in a retrospective study on 186 patients undergoing laparoscopy for adnexal mass. Most retrospective studies support these data, reporting laparoscopic treatment of adnexal masses exceeding 70%.^3,9,11,16 Canis et al8 proposed an 80% laparoscopic completion rate if all masses were initially approached laparoscopically and converted only as needed to laparotomy. Support for this approach points to the diagnostic benefits of enhanced visualization of any peritoneal implants or tumor in the upper abdomen, and the opportunity to avoid staging through a transverse incision when malignancy is unanticipated.⁸

There are no compelling data supporting a worsened prognosis for ovarian malignancies approached initially by laparoscopy, as long as definitive management is then pursued without excessive delay. Cyst rupture during adnexal surgery does upstage a stage I ovarian cancer (Ia to Ic), and therefore, should be avoided if possible in any suspicious adnexal mass.¹⁷ However, this does not occur more frequently in laparoscopy than in laparotomy, and does not appear to worsen prognosis if managed appropriately.^6,8,10,18 Key assumptions in this argument are an experienced laparoscopist, attention to removal of the entire cyst or ovary, and the availability of gynecologic oncology backup to complete staging should a malignancy be encountered during laparoscopy.

Based on this evidence, it can be argued that in the proper setting, all but the clearly malignant adnexal mass could initially be approached laparoscopically until the point where indicators such as frozen-section findings or the presence of tumor implants strongly support malignancy.¹¹ Even then, with the increasing reports of laparoscopic staging of gynecologic cancers, many laparotomies might be avoided in the setting of malignancy. Although this itself represents another area of controversy, efforts are currently underway to formally assess laparoscopic staging of gynecologic malignancies in a prospective, randomized fashion. An example is the current Gynecologic Oncology Group trial looking at laparoscopic pelvic and para-aortic node sampling with vaginal hysterectomy/bilateral salpingo-oophorectomy versus open laparotomy with pelvic and para-aortic node sampling for the treatment of early-stage endometrial cancers (GOG-LAP2).

PREOPERATIVE ASSESSMENT

If the suspicion for malignancy is low and the physician and patient arrive at a mutual decision to treat an adnexal mass via laparoscopy, then the next step is to determine whether the patient is suitable for laparoscopy. Three issues to consider are body habitus, suspicion for adhesions, and size of the mass. There is no absolute weight above which laparoscopy is contraindicated, and with the availability of longer Veress needles and trocars, more obese patients can successfully undergo laparoscopy.¹⁹ Although laparoscopic access can be gained in many obese patients, an important consideration is the patient’s ability to tolerate the Trendelenburg position; laparoscopic access to the abdominal cavity is of no value if the patient cannot tolerate the Trendelenburg position. This information can often be determined preoperatively by simply having the anesthesiologist place the patient in a steep Trendelenburg position, followed by close observation of peak inspiratory pressures on the ventilator. Despite these concerns, approaching gynecologic pathology in a minimally invasive fashion is well worth considering in obese patients because they often have the most to gain from avoiding a large abdominal incision. In addition to obesity, pregnancy is another situation where laparoscopy may be beneficial. Although pregnancy can pose a dilemma in terms of surgical approach, laparoscopy in the second trimester has been demonstrated to be safe and effective in experienced hands.^3,20

A suspicion for dense abdominal and pelvic adhesions may also affect the surgical approach. Patients with multiple prior surgeries, particularly laparotomies, advanced endometriosis, and prior pelvic infections, should raise red flags regarding the possibility of encountering dense adhesions. Although not an absolute contraindication to laparoscopy, suspicion of adhesions should not only prompt an assessment of entry technique variations such as open laparoscopy and left upper-quadrant entry,²¹ but should also focus attention on determining the safest and most efficient technique for completing a salpingo-oophorectomy.

Lastly, the size of the mass should be considered when approaching adnexal pathology laparoscopically. Although an actual maximum size limit for laparoscopy does not exist, an adnexal mass extending into the upper abdomen would probably pose a mechanical obstruction to laparoscopy. Proper judgment must be exercised when approaching larger adnexal masses laparoscopically, particularly with regard to trocar placement and risk of rupture.

Optimal preparation for surgery is essential, regardless of the approach. Patients should be medically cleared for the operation. Thorough bowel preparation is indicated for all patients undergoing surgery for adnexal masses. In the case of operative laparoscopy, it helps reduce morbidity in the event of a bowel injury and facilitates both displacement of the bowel out of the pelvis as well as any necessary staging procedures if malignancy is encountered. Once in the operating room, general anesthesia is administered and the patient is placed in the dorsal lithotomy position. The stomach and bladder are then decompressed with an orogastric or nasogastric tube and Foley catheter, respectively. The placement of an adequate uterine manipulator with an anterior-directed curve (such as a ZUMI) is extremely important when performing laparoscopic adnexal surgery. Both primary and accessory trocar placements are typically determined by the operator’s preferences, abdominal-wall topography (eg, scars from previous procedures), and nature of the adnexal pathology.

SURGICAL TECHNIQUES

Once the necessary trocars are placed, the pelvis and adnexal structures are inspected along with the upper abdomen. Pelvic washings should be obtained with a suction/irrigator device. Any signs of malignancy such as ascites, peritoneal studding, ovarian excrescences, and adenopathy should be promptly noted, and a decision made to either convert to laparotomy or continue with the laparoscopy. Again, this is an area of controversy, and will depend on the operator and institution. Although the technique for ovarian cystectomy will not be specifically addressed in this paper, it represents an important alternative for the premenopausal woman with a presumably benign adnexal mass.

In the setting of relatively normal pelvic anatomy, the next step is either transsection of the infundibulopelvic ligament (IPL) or transsection of the utero-ovarian ligament and the adjacent fallopian tube. Identification of the ureter is necessary prior to transsection of the IPL. It is possible to proceed with salpingo-oophorectomy without opening the pelvic sidewall peritoneum, provided the ureter is safely beneath the level of the IPL and the ovary is mobile. However, in the case of adhesions or thickened peritoneum obscuring the course of the ureter, the pelvic sidewall peritoneum should be opened to identify the ureter and skeletonize the IPL. A thorough knowledge of pelvic anatomy is extremely important (Figure 1). In addition, it is vital to develop the ability to operate within the retroperitoneal space, particularly when pelvic anatomy is abnormal.

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Figures 1. View of pelvic structures encountered in laparoscopic salpingo-oophorectomy22

There are a variety of techniques and instruments available for securing vascular pedicles such as the IPL (Table 1). Advantages and disadvantages exist for each one, and the choice of technique and instrument will depend on the availability and cost of the instrument, operator experience, and mobility of the adnexal mass.

View this table

Table 1. Laparoscopic Instrumentation

The oldest and most tried-and-true technique is the burn-and-cut method (Figure 2). This technique typically involves coagulation of the pedicle with the bipolar Kleppinger device, followed by transsection with scissors. The success of this technique relies on the relative normalcy of the pelvic anatomy. Thorough coagulation of the vascular pedicle is required for hemostasis.

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Figures 2. "Burn-and-cut" technique for laparoscopic salpingo-oophorectomy

A second technique involves the use of a pretied ligature or endoloop, the "lasso" illustrated in Figure 3. This technique relies not only on a mobile ovary, but also on a mass small enough to fit through the pretied loop.

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Figures 3. Pretied endoloop "lasso"

Stapling devices are also used to perform laparoscopic salpingo-oophorectomy (Figure 4). This technique optimally requires an isolated pedicle, but nonskeletonized pedicles can be ligated and transected as well. One major disadvantage is the frequent need to use more than one staple load, which in turn increases the cost of this technique.

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Figures 4. Use of stapling device to perform laparoscopic salpingo-oophorectomy

In cases where dense adhesions are encountered or visibility of the ureter is impaired, the ability to open the pelvic sidewall is of utmost importance to successful completion of laparoscopic salpingo-oophorectomy. A safe and inexpensive technique incorporates the use of suture ligation, as illustrated in Figures 5-7. A drawback of this approach is the need for more advanced laparoscopic skills because dissection of the retroperitoneal space and extracorporeal knot-tying techniques are utilized.

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Figures 5-7. Use of suture ligation

Improvements in technology have brought about the use of ultrasonic coagulating cutters and new-generation electrosurgical devices that employ vessel sealing technology instead of the electrocoagulation utilized with older instrumentation.^22-26 These newer devices incorporate impedance-based feedback loops to modify bipolar energy. This in turn creates a coagulum of collagen and elastin, thereby forming a vascular seal. These instruments also provide the added benefit of transsection. Although significant advantages are seen in terms of safety, efficiency, and ease of use, higher cost still remains a major issue.

Once the ovary is free, an endoscopic retrieval bag is utilized for extraction. The specimen can then be delivered through one of the suprapubic or lateral trocar sites. Once brought to the abdominal wall, the contents of the retrieval bag can be aspirated for easier removal. Careful attention is essential to avoid spillage of any cyst contents into the abdominal cavity. Alternatively, the specimen can be extracted through a posterior culdotomy incision, which can then be closed either laparoscopically or transvaginally. It is generally contraindicated for any suspicious adnexal mass to be morcellated in situ or aspirated prior to containment within a retrieval bag. On removal of the mass, gross inspection and a frozen section can be obtained to confirm a benign or malignant diagnosis. Based on the diagnosis, the remainder of the surgery can be undertaken accordingly. Prior to the conclusion of any operative laparoscopy, a low-pressure check should be performed to ensure hemostasis of all vascular pedicles. Finally, any fascial defects should be closed where deemed appropriate.

As in any surgical procedure, identification, awareness, and avoidance of potential pitfalls and use of practical "pearls" make for safer, more efficient laparoscopic surgery. Besides the known potential complications associated with entry into the abdomen and establishment of pneumoperitoneum, possible major complications include injury/ligation/obstruction of the ureter and inadequate ligation of the infundibulopelvic pedicle with retraction, bleeding, or retroperitoneal hematoma. Injury to the iliac vessels or nerves is also a possibility during dissection and identification of the ureter. In addition, incomplete removal of an ovary, noted at a rate of 9% in one study (versus 5% in laparotomy and 29% in a vaginal approach) is an avoidable complication in most cases.²⁷

For laparoscopic salpingo-oophorectomy, conversion to laparotomy occurs in about 25% of cases,⁹ usually secondary to suspected or confirmed malignancy, adhesions, bleeding, excessive mass size, obesity, or technical difficulties.^1,3,4,6,9,15 One of the most common technical difficulties is placement of the first port, particularly in obese patients.

CONCLUSION

Laparoscopic management of an adnexal mass is widely accepted, and is considered by many to be the preferred approach for the presumably benign mass. Despite the proven benefits of laparoscopy, however, laparotomy is still the gold standard for the obviously malignant adnexal mass. Controversy persists regarding the role of laparoscopy in the approach to the mass with some features of malignancy. Though current evidence indicates that the majority of adnexal masses can be managed laparoscopically, proper clinical judgment and careful preoperative assessment should be meticulously applied. Recent advances in surgical technology have provided surgeons with more options for performing salpingo-oophorectomy. Accordingly, familiarity with more than one technical approach, keeping in mind the various pearls and pitfalls discussed here, facilitates safe, efficient laparoscopic salpingo-oophorectomy under a variety of conditions.

MaryEllen Wechter, MD, is house officer in the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor; Tonya L. Floyd-Bradstock, MFA, is a medical illusrator, Center for Creative Education, at the Medical College of Ohio in Toledo; and Arnold P. Advincula, MD, is clinical assistant professor, director of minimally invasive surgery, and director, Chronic Pelvic Pain Program, in the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor.

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