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Surgical Technique


Expert tips for adnexal surgery through the laparoscope

Two cases illustrate the many benefits, and some of the risks, of minimally invasive management.

March 2009 · Vol. 21, No. 03

IN THIS ARTICLE

Watch the laparoscopic cyst removal in Case 1 in the Video Library

The authors report no financial relationships relevant to this article.

CASE 1: Cystic mass in patient’s only remaining ovary

Mrs. R is a 29-year-old G1P1 who underwent a right oophorectomy, with a midline incision, for a dermoid cyst at the time of cesarean delivery. She now has a left ovarian cyst. Preoperative ultrasonography (US) reveals that it measures 3.5×4.2×3.7 cm and has both solid components and a multiloculated appearance, consistent with a dermoid cyst.

How common is this scenario?

Studies predict that one of every three women will undergo surgical management of an adnexal mass at some point in her life. 1 This troubling statistic prompts several critical questions:

  • How do we handle the workup for these women so that only appropriate patients undergo surgery?
  • How often will a mass be malignant?
  • How can we safely remove an adnexal mass to maximize patient safety, reduce overall recovery time, and prevent less favorable outcomes in women who are eventually found to have a malignancy?

A thorough workup and, sometimes, conservative management can prevent unnecessary surgery that may lead to early menopause or surgical complications. And maximizing the use of minimally invasive techniques in women who do require surgery can shorten hospital stay and recovery time. At the time of surgery, careful abdominal entry and meticulous surgical dissection and mass removal can limit the potential risks of laparoscopic excision in women who have an ultimate diagnosis of cancer.

In this article, we review the workup for women who have an adnexal mass, describe patient-selection criteria for laparoscopic surgery, including the risks and benefits of this approach ( TABLE 1 ), and present several techniques to safely manage a mass with potentially malignant histology via laparoscopy.

TABLE 1

There are benefits and risks to managing an adnexal mass laparoscopically

Benefit

Risk

Shorter recovery
Fewer adhesions
Decreased overall cost
Magnification
Decreased pain and narcotic use
Fewer wound complications

Expensive equipment*
Loss of tactile sensation
Concern for malignancy
Risk of tumor dissemination/spillage/chemical peritonitis
Trocar-site metastasis

*Though greater expense is not a risk per se, it does enter into decision making.

Begin with the physical

When a woman is known to have a pelvic mass, the aim of the office exam is to 1) identify characteristics that suggest malignancy and 2) rule out nongynecologic causes of the mass. Physical findings that are worrisome for a malignant process include:

  • fixed or nodular pelvic mass
  • bilateral masses
  • nodular abdominal mass
  • ascites
  • pleural effusion on auscultation or percussion of the lung.

Although these findings can be present under benign conditions, they increase the risk that a malignancy will be detected at surgery.

Other causes of a pelvic mass should also be considered, including infection (pelvic abscess) and tumors of the colon, particularly when the pelvic mass occurs on the left side.

Some symptoms, though vague, are worth noting

Although ovarian cancer was once thought to be a silent disease, recent research has shown that bloating, pelvic or abdominal pain, early satiety, and urinary frequency and urgency are more common among women with ovarian cancer than among healthy controls and patients in high-risk screening clinics. 2-4 Although these symptoms are generally nonspecific, they merit attention if they occur more than 12 times a month and have been present for less than 1 year. When they meet these criteria, the symptoms have a sensitivity for diagnosing early- and late-stage ovarian cancer of 56.7% and 79.5%, respectively. 4

Sensitivity for the diagnosis of early-stage ovarian cancer may be as high as 80% when the symptom index score is combined with an elevated level of the tumor marker CA 125. 3

Transvaginal US is crucial

Transvaginal US is now standard practice to obtain high-resolution images of an adnexal mass. Grayscale US has traditionally been used alone for evaluation.

Specificity is typically lower in women who are premenopausal because many benign lesions, such as endometrioma, have a similar sonographic appearance to cancer.

A number of US scoring algorithms have now been proposed to aid in the triage of women who have an adnexal mass. Sensitivity of these algorithms ranges from 65% to 100%; specificity, from 77% to 95%. 5

CA 125 is the standard tumor marker

For the past two decades, CA 125 has been the standard serum marker in the screening of high-risk women for ovarian cancer and the triage of women who have an adnexal mass.

This blood test has been studied widely since its introduction in 1983. It typically has sensitivity of 75% to 85% and specificity of 85% to 95% in identifying women who have ovarian cancer. However, it is elevated in only 50% to 60% of women who have stage I ovarian cancer. Its lack of specificity and poor positive predictive value have kept researchers busy trying to identify other serum markers, for both ovarian cancer and identification of high-risk pelvic masses.


Our recommended workup and management of adnexal masses In postmenopausal women who had a pelvic mass, one study found that a CA 125 level above 65 IU/mL had sensitivity of 71% and specificity of 92.5% in the identification of ovarian cancer. 6 Another group found that CA 125 levels above 65 IU/mL were more than 95% sensitive in the diagnosis of ovarian cancer in postmenopausal women. 7

Several studies have combined CA 125 with other markers or with US to screen high-risk women or triage those who have an adnexal mass. These studies have shown modest improvements in sensitivity but usually lower specificity than with CA 125 testing alone.

Markers that may be used for suspected sex cord stromas and germ-cell tumors are:

  • lactate dehydrogenase (LDH) for dysgerminomas
  • alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) for yolk sac tumors
  • testosterone for Sertoli-Leydig cell tumors
  • inhibin A and B for granulosa cell tumors.

An algorithm for working up and managing adnexal masses appears above.

How to gain abdominal access

In the opening case, the patient clearly has a benign mass. The treatment? Safe entry into the peritoneal cavity to remove the cyst and as little normal tissue as possible. This is critical in this patient because she has only one ovary.

Peritoneal access for abdominal and pelvic laparoscopy has been studied widely. Options include:

  • direct insertion using a Veress needle
  • open laparoscopy
  • direct trocar insertion.

The technique usually depends on the preference of the surgeon. The primary goal of abdominal entry is to minimize the risk of injury, particularly unrecognized injury.

Data on complication rates show no definite benefit for open versus closed techniques in the prevention of injury to underlying viscera. However, evidence does suggest that the open technique may lower the risk of major vascular injury. 8

We employ direct trocar insertion using radially expanding or optical trocars.

The Veress needle option

When the Veress needle is used to gain intraperitoneal access, data indicate that initial intraperitoneal pressure below 10 mm Hg is a reliable marker for peritoneal entry, even in obese patients. 9 Insufflation pressure as high as 25 to 30 mm Hg prior to placement of the initial trocar is safe from a cardiopulmonary standpoint and may allow easier entry with a nonbladed trocar. 10

Tests to confirm intraperitoneal placement of the Veress needle, such as the hanging-drop test or saline flush, do not appear to offer any additional useful information. 11

Open laparoscopy is suitable when adhesions are unlikely

Open laparoscopy is typically performed by making a minilaparotomy incision at the umbilicus and then dissecting and entering the peritoneal cavity. A blunt-tip trocar is inserted.

The disadvantage of this approach is that there may be extensive adhesions under the umbilicus, and it is difficult to dissect such adhesions sufficiently to introduce a cannula and laparoscope. Adhesions left behind often obscure the field of view after introduction of the trocar.

Our preference? Left upper-quadrant insertion

In Case 1, the previous midline incision mandates an alternative approach. When abdominal entry at the umbilicus is unsuccessful or potentially difficult because of an earlier midline incision, umbilical hernia repair, or history of multiple lower abdominal or pelvic surgeries, a left upper-quadrant insertion is useful. It is, in fact, our preferred technique, and involves a small incision at the midclavicular line 5 cm below the left costal margin, at a site called Palmer’s point.

The direction of insertion usually ranges from 45° to 90°, depending on the patient’s body weight. If the trocar is placed properly, the closest organs are the stomach and the left lobe of the liver (4 to 6 cm). 12 Given the stomach’s close proximity, it should be decompressed with an orogastric tube prior to trocar insertion.

Several studies have demonstrated the safety and efficacy of this entry technique. 12-14 It can be helpful in cases that involve difficult access. We usually use a 5-mm primary trocar site for a 5-mm laparoscope. Modern optics allow for a pristine view with these small scopes, eliminating the need to close fascia and perhaps causing less pain at the incision.

Accessory trocar sites facilitate complex technique

We usually use three accessory sites. Two of them are lower-quadrant ports that are placed 2 cm medial and 2 cm cephalad to the anterior superior iliac spine. This area generally lies well away from the inferior epigastric vessels and remains above the area of the ilioinguinal and iliohypogastric nerves, making it a safer point of insertion. 15 One trocar is 5 mm in size and the other is 10 mm. The larger one is used to extract the specimen.

We place an additional 5-mm port lateral to the rectus muscle at the level of the umbilicus. This allows the principal surgeon to use two instruments (a toothed forceps and scissors) comfortably while the assistant holds the laparoscope and assists with a grasper.

Does the type of trocar matter?

No randomized studies have directly compared all types of trocars. Options include:

  • a pyramidal tip (as in reusable trocars) or shielded tip
  • radial expansion
  • visible entry
  • blunt (Hasson-type) trocar.

Safety data on direct comparison of trocars are limited, but it appears that a radially expanding trocar may offer less port-site pain and potentially less bleeding than a traditional cutting trocar. 16 Moreover, the rate of hernia at the port site appears to be relatively low with a radially expanding trocar, even when fascia is left unclosed at a 10-mm site. 17

None of these trocars appears to be clearly superior at avoiding visceral or vascular injury.

Technique of laparoscopic cyst removal

A video clip of the surgery is linked to this article in the Video Library at www.obgmanagement.com. In this case, a trocar was inserted in the left upper quadrant, and a laparoscopic cystectomy was initiated using the trocars already specified.

The peritoneal cavity and adnexa were inspected, followed by pelvic washings, as detailed in TABLE 2 . Next, the ovarian cortex was incised ( FIGURE 1A ) with scissors using bipolar or unipolar energy, typically at a low power setting, such as 12 to 15 watts.

Continued...
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