Laparoscopic Surgery for Large Benign Ovarian Cysts: Experience in a Tertiary Care Hospital in Bangladesh

Abstract

Background: Laparoscopic surgery is the method of choice for treating women with benign adnexal masses. The aim of the current study is to assess the feasibility and surgical outcome of laparoscopic surgery among women with large benign ovarian cysts with a minimum risk of converting the operation to a laparotomy. Materials and methods: Symptomatic women (abdominal pain or mass) with a clinical or ultrasound diagnosis of an adnexal mass were offered a detailed transvaginal ultrasound scan in order to assess the feasibility of laparoscopic cystectomy/oophorectomy. The following patient information was abstracted: age, menopausal status, body–mass index, preoperative imaging studies, cyst dimensions, preoperative CA-125, date of surgery, surgical procedures, estimated amount of blood loss (EBL), conversion to laparotomy and its causes, operative time, operative and postoperative complications, length of hospital stay, and long-term follow-up. Results: All patients had transvaginal and transabdominal ultrasounds and 18 patients had computed tomography of the abdomen and pelvis. The mean and range of maximum diameter of the ovarian cysts were 16 (10–22 cm). Twenty-seven (27) cysts (51.5%) were unilocular and 16 (27.3%) had one to five septa. Fourteen (14) cysts (21.2%) had an echogenic area thought to be consistent with dermoids. None of the patients had ascites, omental cake, or lymphadenopathy in preoperative imaging studies. Fifty-two (84.8%) patients had preoperative CA-125 values within the normal range (<35 IU/mL). Five (5; 15.5%) patients had elevated CA-125 values (42, 43, 53, 57, and 67 IU/mL, respectively). None of the patients had operative or postoperative complications or had to be converted to laparotomy. The mean (range) operative time, EBL, and hospital stay were 32 (20–45 minutes), 27 (5–55 mL), 8 (4–12 hours), respectively. The pathologic findings included endometriosis (n = 14), dermoid (n = 13), para-ovarian cyst (n = 9), serous cyst adenoma (n = 9), benign epithelial-lined cyst (simple cyst) (n = 5), mucinous cystadenoma (n = 4), borderline ovarian tumors (n = 2), and peritoneal pseudocyst (n = 1) Conclusions: Laparoscopic surgery among women with large benign ovarian cyst is feasible with a minimum risk of converting the operation to a laparotomy. (J GYNECOL SURG 27:83)

Introduction

Laparoscopic surgery is the method of choice for treating women with benign adnexal masses. The appeal of laparoscopic surgery includes small incisions, less postoperative pain, short hospital stay, faster recovery, reduction in postoperative intra-abdominal adhesions, and improved quality of life in the postoperative period.^1–3

Presumed limitations of laparoscopic surgery in the management of large ovarian cysts include technical difficulty in trocar insertion, visualization as well as removal of the cyst, concern regarding cyst rupture, which might upstage women found to have malignant ovarian neoplasm or cause peritonitis among women with dermoid ovarian cysts, and concern about incomplete surgical staging of women ultimately found to have ovarian cancer. Severe pelvic adhesions and pelvic endometriosis can also cause difficulties during pelvic surgery and increase the risk of complications.^4–6

Many operations can be performed as day surgery procedures, with patients being discharged home a few hours after operation. In order to ensure optimal use of day surgery facilities, it is important to make sure that the risk of converting a laparoscopic procedure to a laparotomy is minimal.

Several studies^7–9 have attested to the safety of laparoscopic surgery in women with ovarian cysts. However, most of the patients included in these studies had small cysts. Several case reports and retrospective studies^10–17 reviewed the feasibility and surgical outcome of laparoscopy applied to large ovarian cysts. However, most patients with large ovarian cysts are still managed by conventional laparotomy.

Some authors advocate open surgery for large dermoid cysts with a mean diameter >10 cm as they are difficult to remove from the abdominal cavity without rupture.¹⁸ Laparoscopic surgery should not be performed on women with invasive ovarian cancer. Ultrasound examination and the tumor marker are the tools used to diagnose adnexal tumors and to differentiate between benign and malignant lesions. The aim of this study is to report on the feasibility and the surgical outcome of laparoscopic surgery applied to management of women with large ovarian cysts with benign features.

The aim of the current study is to assess the feasibility and surgical outcome of laparoscopic surgery among women with large benign ovarian cysts with a minimum risk of converting the operation to a laparotomy.

Materials and Methods

This prospective study was conducted from January 2005 to January 2010 among women who had large benign ovarian cysts and who underwent surgery at the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) Hospital, Dhaka, Bangladesh. All patients had a preoperative ultrasound scan with or without computed tomography and CA-125 assessment. The body–mass index (BMI) of all patients was calculated. Patients who met the following criteria and who consented to laparoscopic surgery were included in the study.

Inclusion criteria

Maximum diameter of the ovarian cyst was ≥8 cm.

The sonographic and computed tomographic features of the ovarian cysts were consistent with benign disease. Criteria for benign disease included single unilocular cysts, cysts containing thin septa ≤5 in number, cysts containing a solid area if they had features consistent with a dermoid cyst.

The patients had no cardiac or pulmonary disease, could tolerate general anesthesia, and had no contraindications for lithotomy position or the Trendelenburg position.

Exclusion criteria

Patients who refused laparoscopic surgery or had one or more of the following features:

Minimum cysts diameter ≤8 cm.

Maximum cysts diameter ≥25 cm.

Sonographic features suspicious for malignancy including thick irregular septa, internal or external excrescences, solid ovarian masses, ovarian masses with complex consistency other than dermoid cysts and ovarian masses with ascites, extensive papillarities (defined as the presence of multiple papillary projection greater than 3 mm in diameter covering large section of the inner cyst wall) arising from the inner cyst wall,^21–23 irregular solid component within the cyst with evidence of necrosis (ill-defined anechoic areas within a predominantly solid lesion), and absence of any healthy ovarian tissue adjacent to the cyst (negative ovarian crescent sign).^24,25 Among women who had computed tomography, women with ascites, an omental cake, or pelvic or para-aortic lymphadenopathy were excluded.

Patients who were not good candidates for laparoscopic surgery including patients with BMI >50, patients with severe hip disease precluding the dorsal lithotomy position and patients with severe cardiopulmonary disease precluding pneumoperitoneum and Trendelenburg position.

Symptomatic women (abdominal pain or mass) with a clinical or ultrasound diagnosis of an adnexal mass were offered a detailed transvaginal ultrasound scan in order to assess the feasibility of laparoscopic cystectomy/oophorectomy. In all cases an attempt was made to establish a likely histological diagnosis using the pattern recognition method.

Laparoscopic surgery was classified as successful if the mass was removed completely without resorting to laparotomy.

All surgeries were performed by the senior author applying similar techniques. The following patient information was abstracted: age, menopausal status, BMI, preoperative imaging studies, cyst dimensions, pre-operative CA-125, date of surgery, surgical procedures, estimated amount of blood loss (EBL), conversion to laparotomy and its causes, operative time, operative and postoperative complications, length of hospital stay, and long-term follow-up. All patients had a mechanical bowel preparation, and received preoperative antibiotics half an hour before induction of anesthesia. Patients without allergy received 1 or 2 g of ceftriaxone and 500 mg of metronidazole and received 600 or 900 mg of clindamycin, depending on their body weight. Laparoscopy was performed with patients under general anesthesia with endotracheal intubation. No patient underwent insertion of an indwelling Foley catheter. Laparoscopy was performed by the open technique through a subumbilical incision. On occasions when mandated by the cyst size, incision for the initial trocar insertion was made between the umbilicus and the xiphisternum. Secondary and tertiary punctures (0.5–1cm) were performed in the right and left lower quadrants under direct vision, and pneumoperitoneum was established using CO₂ at pressure settings of 15 mm Hg. The ovarian cysts were extracted following laparoscopic-guided aspiration using an endobag through the umbilical incision (underneath the guidance of a 5-mm laparoscope introduced through one of the lower incisions) in 30 women, through one of the lower quadrant incisions in 16, posterior colpotomy in 2, and vaginally with the uterus in 9 women, respectively. In all patients, end-tidal CO₂ was monitored.

Results

During the study period, 57 consecutive patients with large ovarian cysts presumed to be benign underwent laparoscopic surgery over 6 years. The mean (range) age and BMI were 40 (17–73 years) and 32 (22–42), respectively. The most common presenting symptoms were abdominal or pelvic pain (79.9%), per vaginal bleeding (9.1%), and abdominal swelling or bloatedness (11%).

All patients had transvaginal and transabdominal ultrasounds, and 18 patients had computed tomography of the abdomen and pelvis (Tables 1 –3).

Table 1.

Demographic Features and Adnexal Tumor Characteristics of Women Scheduled for Laparoscopy

Intention to treat
Characteristics	Laparoscopy
Age (yr) (median [range])	40 (17–73)
Parity (median [range])	12 (0–4)
BMI (median [range])	32 (21–42)
Abdominal or pelvic pain	79.9%
Per vaginal bleeding (%)	9.1%
Abdominal swelling or bloatedness (%)	11%
Diameter of ovarian cysts (median [range]) cm	16 (10–22)
Preoperative CA–125 (IU/mL)	36 (5–67)

Table 2.

Histological Subtypes of Adnexal Tumors Operated on by Laparoscopy

Operated by
Hystological subtype	Laparoscopy n (%)
Endometriotic cyst (chocolate cysts)	14 (25%)
Dermoid	13 (23%)
Parovarian cyst	9 (16%)
Serous cystadenoma	9 (16%)
Benign epithelial lined cyst	5 (9%)
Mucinous cystadenoma	4 (7%)
Borderline ovarian cyst	2 (4%)
Pseudocyst	1 (2%)

Table 3.

Characteristic and Clinical Outcomes of the Study Subjects

Parameters	Amount
Operative time (min [range])	32 (20–45)
Estimated blood loss (mL [range])	27 (5–50)
Postoperative pain control (diclofenac mg)	75.18 ± 16.45^a
Hospital stay (hours [range])	8 (4–12)
Time to return to work (days) normal activity	2.42 ± 1.06^a
Operative time and postoperative complications	None
Conversion to laparotomy	None

Mean standard deviation.

The mean and range of maximum diameter of the ovarian cysts were 16 (10–22 cm). Twenty-seven (27) cysts (47.37%) were unilocular and 16 (28.07%) had one to five septa. Fourteen (14) cysts (24.56%) had an echogenic area thought to be consistent with dermoids. None of the patients had ascites, omental cake, or lymphadenopathy in preoperative imaging studies. Fifty-two (52; 91.23%) patients had preoperative CA-125 values within the normal range (<35 IU/mL). Five (5; 8.77%) patients had elevated CA-125 values (42, 43, 53, 57, and 67 IU/mL), respectively.

None of the patients had operative or postoperative complications or had to converted to laparotomy.

The mean (range) operative time, EBL, and hospital stay were 32 (20–45 minutes), 27 (5–50 mL), 8 (4–12 hours), respectively, and postoperative pain central (diclofexal mg) 75.18 ± 16.45, time to return to work (days), normal activity were 2.42 ± 1.06, respectively. All patients were discharged on the day of the surgery. The surgical procedures performed were as follows: unilateral salpingo-oophorectomy (SO) (n = 16), bilateral SO (n = 4), ovarian cystectomy (n = 28), and laparoscopically assisted vaginal hysterectomy with unilateral or bilateral SO (n = 9). The cysts were extracted following laparoscopic guided aspiration (1) using an endobag through the umbilical incision (underneath the guidance of a 5-mm laparoscope introduced through one of the lower incisions). Among women in whom the cyst contents were aspirated and measured, the median (range) volume of the contents was 2800 (400–5200 mL). The pathologic findings included endometriosis (n = 14), dermoid (n = 13), parovarian cyst (n = 9), serous cyst adenoma (n = 9), benign epithelial-lined cyst (simple cyst) (n = 5), mucinous cystadenoma (n = 4), borderline ovarian tumors (n = 2), and peritoneal pseudocyst (n = 1). Operative details were recorded in all patients. Surgery in all patients was carried out by a single team of surgeons, all of whom had considerable experience in intermediate-level laparoscopic surgery.¹⁰

The employment of laparoscopy for the surgical management of benign ovarian cysts has become popular, although it is a challenging task when the cysts are large. A randomized prospective study²⁶ comparing laparoscopy and laparotomy in the management of patients with benign ovarian masses <10 cm in diameter reported a significant reduction in operative morbidity, postoperative pain and analgesic requirement, hospital stay, and recovery period. However, the same result can be obtained with large cysts also.

The results of this study have shown that preoperative ultrasound examination may be used to identify women in whom there is a low risk of converting minimally invasive surgery for an ovarian tumor into a laparatomy.²⁷ The most important prerequisite for performing safe laparoscopic surgery is the accurate diagnosis of a benign cyst.²⁷ It is therefore reassuring that there were no cases of invasive ovarian cancer in the study population. The current study was in agreement with other reports²⁸ that examined the value of ultrasound pattern recognition for the diagnosis of ovarian cancer. Computed tomography was found to be very helpful in diagnosing dermoid ovarian cysts. While the ultrasound appearance of dermoid cysts might vary depending on the density of their contents and the presence of calcifications, fat attenuation on computed tomography is diagnostic.²⁹ As demonstrated in this study, pattern recognition was highly accurate in identifying benign lesions suitable for conservative surgery. Approximately 80% of all presumed benign ovarian cysts were selected for a laparoscopy, which was successfully completed in 100% of cases. This indicates that the criteria in this study for performing laparoscopy may be used to identify those women in whom the risk of conversion is absent. There is no doubt that the success of laparoscopic surgery is mainly dependent on the skill and expertise of the operating surgeons and preoperative diagnosis.

Conclusions

This study has shown that a detailed preoperative ultrasound examination is helpful for assessing the feasibility of intermediate-level laparoscopic surgery in women with benign adnexal lesions. However, the assessment of tumor consistency and morbidity helps to identify women in whom the risk of conversion to laparotomy is minimal, and surgery may be performed as a day case even in cases with a large ovarian cyst.

The authors believe that in selecting the patients, one must consider both general health condition and the morphology of the cysts, with preoperative imaging indicating benign features of the cysts. Thus, laparoscopic surgery among women with large benign ovarian cyst is feasible with a minimum risk of converting the operation to a laparotomy.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Lin

, Falcon

, Tulandi

. Excision of ovarian dermoid by laparoscopy and by laparotomy. Am J Obstet Gynecol, 1995; 173:769.

Howard

. Surgical management of benign cystic teratoma: Laparoscopy vs laparotomy. J Reprod Med, 1995; 40:495.

Mais

, Ajossa

, Piras

, Maronginu

, Guerriero

, Melis

. Treatment of nonendometriotic benign adnexal cysts: A randomized comparison of laparoscopy and laparotomy. Obstet Gynecol, 1995; 86:770.

Huus

, Lafay Piller

, Lecuru

et al. Granulomatous peritonitis after laparoscopic surgery of an ovarian dermoid cyst: Diagnosis, management, prevention, a case report. J Gynecol Obstet Biol Reprod (Paris), 1996; 25:365.

Coccia

, Becattini

, Bracco

, Scarselli

. Acute abdomen following dermoid cyst rupture during transvaginal ultrasonographically guided retrieval of oocytes. Hum Reprod, 1996; 11:1897.

Remorgida

, Magnasco

, Pizzorno

, Anserini

. Four year experience in laparoscopic dissection of intact ovarian dermoid cysts. J Am Coll Surg, 1998; 187:519.

Canis

, Mage

, Poully

, Wattiez

, Manhes

, Bruhat

. Laparoscopic diagnosis of adnexal masses: A 12 year experience with long term follow up. Obstet Gynecol, 1994; 83:707.

Parker

, Berek

. Management of selected cystic adnexal masses in postmenopausal women by operative laparoscopy: A pilot study. Am J Obstet Gynecol, 1990; 163:1574.

Yuen

, Yu

, Yip

, Lau

, Rogers

, Chang

. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol, 1997; 177:109.

10.

, Liu

, Zabriskie

, Rowbotham

. Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter. J Laparoendosc Adv Surg Tech A, 2001; 11:125.

11.

Salem

. Laparoscopic excision of large ovarian cysts. J Obstet Gynaecol Res, 2002; 28:290.

12.

Sagiv

, Golan

, Glezerman

. Laparoscopic management of extremely large ovarian cysts. Obstet Gynecol, 2005; 105:1319.

13.

Nagele

, Magos

. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol, 1996; 175:1377.

14.

Ates

, Karakaya

, Hakguder

, Olguner

, Secil

, Akgur

. Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage. J Pediatr Surg, 2006; 41:E9.

15.

Garzetti

, Ciavattini

, Tirduzzi

. Combined ultrasonographically guided drainage and laparoscopic excision of large endometriomas: A pilot study. Gynecol Obstet Investig, 1998; 45:266.

16.

Eltabbakh

, Kaiser

. Laparoscopic management of a large ovarian cyst in an adolescent: A case report. J Reprod Med, 2000; 45:231.

17.

Goh

, Yam

, Loh

, Wong

. Minimal access approach to the management of large ovarian cysts. Surg Endosc, 2007; 21:80.

18.

Mettler

, Jacobs

, Brandenburg

, Jonat

, Semm

. Laparoscopic management of 641 adnexal tumors in Kiel, Germany. J Am Assoc Gynecol Laparosc, 2001; 8:74.

19.

Parker

. Management of adnexal masses by operative laparoscopy: Selection criteria. J Reprod Med, 1992; 37:603.

20.

Kindermann

, Maassen

, Kuhn

. Laparoscopic preliminary surgery of ovarian malignancies: Experiences from 127 German gynecologic clinics. Geburt Shilfe Frauenbeilkd, 1995; 55:687.

21.

Valentin

. Use of morphology to characterize and manage common adnexal masses. Best Pract Res Clin Obstet Gynaecol, 2004; 18:71.

22.

Timmerman

, Valentin

, Bourne

, Collins

, Verrelst

, Vergote

. International Ovarian Tumor Analysis (IOTA) Group. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: A consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol, 2000; 16:500.

23.

Jokubkiene

, Sladkevicius

, Valentin

. Does three dimensional power Doppler ultrasound help in discrimination between benign and malignant ovarian masses? Ultrasound Obstet Gynecol, 2007; 29:215.

24.

Hillaby

, Aslam

, Salim

, Lawrence

, Raju

, Jurkovic

. The value of detection of normal ovarian tissue (the ‘ovarian crescent sign’) in the differential diagnosis of adnexal masses. Ultrasound Obstet Gynecol, 2004; 23:63.

25.

Yazbek

, Aslam

, Tailor

, Hillaby

, Raju

, Jurkovic

. A comparative study of the risk of malignancy index and the ovarian crescent sign for the diagnosis of invasive ovarian cancer. Ultrasound Obstet Gynecol, 2006; 28:320.

26.

Zhu

, Lix Chen

, Lin

, Zhang

. Ovarian interstitial YAG-laser: An effective new method to manage anovulation in women with polycystic ovary syndrome. Am J Obstet Gynecol, 2006; 195:458.

27.

Parker

. Management of adnexal masses by operative laparoscopy: Selection criteria. J Reprod Med, 1992; 37:603.

28.

Valentin

, Hagen

, Tingulstad

, Eik-Nes

. Comparison of “pattern recognition” and logistic regression models for discrimination between benign and malignant pelvic masses: A prospective cross validation. Ultrasound Obstet Gynecol, 2001; 18:357.

29.

Outwater

, Siegelman

, Hunt

. Ovarian teratomas: Tumor types and imaging characteristic. Radiographics, 2001; 21:475.