Technique of laparoscopic adnexectomy
In Case 2, an umbilical site was chosen for the primary cannula. In general, the direction of insertion depends on the patient’s body habitus. Heavier patients have a thicker abdominal wall and an umbilicus below the level of the aortic bifurcation. In these women, the angle of insertion should be adjusted from the usual 45° (for patients of normal weight) to an angle nearer to 90°. Lateral ports are typical, as in Case 1.
Treat every mass like cancer
Laparoscopic excision of an adnexal mass can be safe and effective, with better outcomes and recovery than with laparotomy, provided the surgeon adheres to basic principles ( TABLE 2 ). This means treating every mass as though it is potentially malignant, and thoroughly inspecting the abdominal cavity before and after excision of the mass.
Know the retroperitoneal space
As with Case 1, successful laparoscopic excision of an adnexal mass begins with inspection of the peritoneal cavity, abdominopelvic washings, and identification of both the infundibulopelvic ligament and ureter. Knowledge of the retroperitoneal space can be of great value in difficult cases that involve significant pelvic adhesions or sidewall fibrosis. We generally use a retroperitoneal approach for laparoscopic adnexectomy ( FIGURE 2A ).
In our typical approach, we incise the peritoneum lateral to the uteroovarian ligament and continue the incision up the pelvic sidewall lateral to the infundibulopelvic ligament and up along the paracolic gutter, if needed ( FIGURE 2A ). We then mobilize the medial leaf of the broad ligament from the sidewall using blunt dissection between the external iliac vessels laterally and the ureter medially ( FIGURE 2B ).
Once we have identified the ureter, we use scissors to create a window in the medial leaf of the broad ligament just beneath the gonadal vessels. We then use an energy source to occlude and transect the pedicle. Using this technique, we secure the infundibulopelvic ligaments and safely mobilize the ureter before initiating more aggressive sidewall dissection distally for adhesions or fibrosis.
Once the ureter is mobilized, we excise the involved peritoneum along with the mass. We then seal and transect the uteroovarian ligament.
FIGURE 2 The retroperitoneal approach
Grasp and incise the peritoneum just lateral to the adnexal mass and enter the retroperitoneal space, where loose areolar tissue is visible, with the ureter seen on the medial leaf of the broad ligament.
After dissecting this tissue, identify the ureter and internal iliac vessels.
Remove the mass in a bag
Once the mass is excised, we place it in a laparoscopic bag, as described for Case 1. Solid adnexal masses are problematic because they are not amenable to drainage, and morcellation is usually discouraged. Laparoscopic excision can still be carried out, and a minilaparotomy or posterior colpotomy can be used to extract the mass in a bag. Patients managed in this way still have a complication rate similar to or lower than that of patients undergoing laparotomy for oophorectomy; they also recover faster.
Risks in cases of malignancy
The risk of tumor spillage in laparoscopic surgery can be lowered using laparoscopically guided minilaparotomy techniques. Preoperative rupture appears to be more predictive of outcome.28
The concern about metastatic implants in a laparoscopic port site in patients who have gynecologic cancer is real, with an incidence ranging from 0.97% to 1.1%. The phenomenon usually affects women who had ovarian cancer and is most common after laparoscopy with findings of ascites, carcinomatosis, or persistent disease (in the case of second-look laparoscopy performed after completion of primary therapy for ovarian cancer).
These data suggest that port-site implantation is not a concern that should deter clinicians from laparoscopic evaluation of a suspected ovarian neoplasm unless a patient presents with ascites or carcinomatosis suggestive of advanced disease.29
Data are limited regarding delays in definitive therapy. One study suggests that definitive staging on the day of rupture does not influence overall outcome, but delay by more than 2 weeks may lead to poorer prognosis.30
CASE 2: OUTCOME
Laparoscopy is performed. On initial inspection, the peritoneal cavity is unremarkable. The right ovary is multicystic with normal surface anatomy. The mass is somewhat adherent to the pelvic sidewall. Adnexectomy is performed, and frozen section reveals the mass to be a serous cystadenoma.