Laparoscopic surgery for large benign ovarian cysts

Methods We conducted a prospective study applying laparoscopic surgery among women with ovarian cysts whose maximum diameter was ≥ 10 cm and radiologic and laboratory features suggestive of benign disease. Patients' demographics, clinical and ultrasound features, CA-125 values, surgical procedures, operative and post-operative complications, estimated amount of blood loss (EBL), operative time, conversion to laparotomy and the pathologic findings were recorded. Results Thirty-three consecutive patients underwent laparoscopic surgery over 7 years. The mean (range) age and body mass index were 45.2 (17–73 years) and 30 (21–42), respectively. Laparoscopic surgery was successful in 31 (93.9%) patients. The procedure was converted to laparotomy in 2 patients secondary to adhesions. There were no operative or post-operative complications. The mean (range) operative time, EBL and hospital stay were 82 (45–125 min), 89 (20–250 mL) and 0.94 (0–4 days), respectively. Twenty-three (70%) patients were discharged home the day of the surgery. The surgical procedures performed were: unilateral salpingo-oophorectomy (SO) ( n = 16), bilateral SO ( n = 4), ovarian cystectomy ( n = 2) and laparoscopically assisted vaginal hysterectomy and bilateral SO ( n = 9). The cysts were extracted after aspiration through the vagina ( n = 11), lower quadrant incision ( n = 5) or the umbilical incision ( n = 15). Pathologic findings included serous cystadenoma ( n = 11), mucinous cystadenoma ( n = 6), dermoid ( n = 6), endometriosis ( n = 5), benign epithelial-lined cyst ( n = 3) and borderline ovarian tumors ( n = 2). Conclusion Laparoscopy is feasible and safe for women with large ovarian cysts with benign features and results in a short hospital stay. Keywords Ovarian cysts Laparoscopic surgery Ultrasound for ovarian cysts Introduction Adnexal masses are a common indication for gynecologic surgery. It is estimated that approximately 10% of women in the United States will undergo surgery at sometime in their lifetime for an adnexal mass [1] . Laparoscopy has been applied to different indications in gynecologic surgery including the removal of adnexal masses. The appeal of laparoscopic surgery includes small incisions, less post-operative pain, short hospital stay, earlier recovery and improved quality of life in the post-operative period. Several studies [2–4] 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 [5–12] 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. 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 neoplasms or cause peritonitis among women with dermoid ovarian cysts and concern about incomplete surgical staging of women ultimately found to have ovarian cancer. In 2000, we reported an adolescent girl who had successful management of a large ovarian cyst laparoscopically [11] . Starting in 1999, we have systematically considered laparoscopic surgery for women presenting with large ovarian cysts predicted to be benign. The aim of the current study is to report on the feasibility and the surgical outcome of laparoscopic surgery applied for management of women with large ovarian cysts with benign features. Material and methods We conducted a prospective study between April 1st, 1999, and March 31, 2006, among patients with large ovarian cysts who underwent surgery at Fletcher Allen Health Care, Burlington, Vermont. All patients had a pre-operative ultrasound with or without computed tomography and CA-125 assessment. We calculated each patient's body mass index (BMI) according to the following equation: BMI = weight in kilograms / height in meters 2 . Patients who met the following criteria and who consented to laparoscopic surgery were included in the study: 1. Maximum diameter of the ovarian cyst was ≥ 10 cm. 2. 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. 3. Patients were good candidates for laparoscopic surgery and could tolerate general anesthesia and the Trendelenburg position. We excluded patients who refused laparoscopic surgery or had one or more of the following features: 1. Maximum cyst diameter < 10 cm. 2. Maximum cyst diameter > 30 cm. 3. 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. Among women who had computed tomography, women with ascites, an omental cake or pelvic or para-aortic lymphadenopathy were excluded. 4. 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 cardio-pulmonary disease precluding pneumoperitoneum and Trendelenburg position. All surgeries were performed by the senior author applying similar techniques. Approval of the Internal Review Board of the University of Vermont was obtained. The following patient information was abstracted: age, menopausal status, BMI, pre-operative 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 post-operative complications, length of hospital stay and long-term follow-up. Similar techniques were followed for all the surgeries. All patients had a mechanical bowel preparation, received pre-operative antibiotics and wore sequential compression devices. Pregnant patients and those scheduled to undergo laparoscopically assisted vaginal hysterectomy (LAVH) received 5,000 units of heparin subcutaneously pre-operatively. Patients without allergy received 1 or 2 g of cefazolin and those allergic to penicillin or cefazolin received 600 or 900 mg of clindamycin depending on their body weight. Laparoscopy was performed under general anesthesia with endotracheal intubation. Each patient underwent insertion of an indwelling Foley catheter and orogastric tube suction. Non-pregnant women who had not undergone hysterectomy had an intra-uterine manipulator (the Pelosi manipulator) inserted. In other situations, a sponge stick was inserted vaginally for manipulation. Laparoscopy was performed by the open technique using the Hasson's cannula inserted through a sub-umbilical 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 (0.5–1 cm) were performed in the right and left lower quadrants under direct vision, and pneumoperitoneum was established using carbon dioxide at pressure settings of 15 and 12 mm Hg for non-pregnant and pregnant patients, respectively. In all patients, end tidal carbon dioxide (CO 2 ) was monitored. Among pregnant patients, efforts were made to shorten the period of pneumoperitoneum, and the end tidal CO 2 was kept below 35 mm Hg. The procedure was interrupted and the pneumoperitoneum evacuated when the end tidal CO 2 was observed to be higher than 35 mm Hg. Results During the study period, 33 consecutive patients with large ovarian cysts presumed to be benign underwent laparoscopic surgery. Thirty-one patients were white, one was African American and one was Asian. The mean, median and range of patients' age were 45.2, 42 and 17–73 years and the mean, median and range of patients' BMI were 30, 29 and 21–42. The most common presenting symptoms were abdominal or pelvic pain (69.7%), abnormal vaginal bleeding (9.1%) and abdominal swelling or bloatedness (6.1%). Five patients were asymptomatic and among them the cysts were discovered on imaging studies performed for routine antenatal care or for some other indications. There were four pregnant patients (with estimated gestational ages between 14 and 18 weeks and maximum diameter of ovarian cysts between 11 and 15 cm), all of whom had no symptoms attributable to the ovarian masses that were discovered during routine antenatal ultrasound. Among two pregnant patients, the cysts could not be felt on bimanual pelvic examination. Twenty patients were premenopausal, and 13 patients were postmenopausal. All patients had transvaginal + transabdominal ultrasounds, and 18 patients had computed tomography of the abdomen and pelvis. During the study period, seven patients met eligibility criteria but refused laparoscopic surgery. The mean, median and range of maximum diameter of the ovarian cysts were 13, 12 and 10–22 cm. Four cysts had a maximum diameter exceeding 20 cm. Seventeen cysts (51.5%) were unilocular and 9 (27.3%) had 1–5 septa. Seven cysts (21.2%) had an echogenic area thought to be consistent with dermoids. None of the patients had ascites, omental cake or lymphadenopathy in pre-operative imaging studies. Twenty-eight (84.8%) patients had pre-operative CA-125 values within the normal rage (< 35 IU/mL). Five (15.5%) patients had elevated CA-125 values (42, 43, 53, 70 and 280 IU/mL, respectively). All pregnant patients had CA-125 values within the normal limits. None of the patients had operative or post-operative complications. Laparoscopic surgery was converted to laparotomy in two (6.1%) patients secondary to severe pelvic adhesions. One of those two patients had a prior total abdominal hysterectomy for a fibroid uterus and the other had a radical hysterectomy for stage IB 1 squamous cell carcinoma of the cervix. The final pathology report in the first patient was consistent with a borderline Brenner tumor. Both patients did well post-operatively and had no short or long-term complications. The mean, median and range of the operative time were 82, 80 and 45–125 min, and the mean, median and range of the EBL were 89, 70 and 20–250 mL. The surgical procedures performed included unilateral salpingo-oophorectomy (SO) (16), bilateral SO (4), ovarian cystectomy (4) and LAVH with unilateral or bilateral SO (9). Additional surgical procedures included lysis of adhesions ( n = 4) and laser ablation of pelvic endometriosis ( n = 2). The ovarian cysts were extracted following laparoscopic-guided aspiration with a Bonanno suprapubic catheter (Becton Dickinson, Rutherford, N.J.) introduced in the midline ( Fig. 1 ) using an endobag through the umbilical incision (underneath the guidance of a 5-mm laparoscope introduced through one of the lower incisions) in 15, through one of the lower quadrant incisions in 5, posterior colpotomy in 2, vaginally with the uterus in 9 and via laparotomy in 2 patients, respectively. Fig. 2 shows an extracted and collapsed large ovarian cyst following its laparoscopic removal. Among women in whom the cyst contents were aspirated and measured, the median (range) volume of the contents was 1100 (400–5200) mL. The mean, median and range of the length of hospital stay was 0.94, 0 and 0–4 days. Seventeen patients went home the day of the surgery, 6 patients went home the following day, 5 patients stayed 2 days, 4 patients stayed 3 days and 1 patient stayed 4 days. All pregnant patients were kept for overnight observation. The pathologic findings included serous cystadenoma ( n = 11), mucinous cystadenoma ( n = 6), dermoid cyst ( n = 6), endometriosis ( n = 5), benign-epithelial lined cyst ( n = 3), mucinous borderline ovarian tumor ( n = 1) and borderline Brenner tumor ( n = 1). Long-term follow-up revealed no complications related to the laparoscopic surgery among any of the patients. The two patients who had borderline ovarian tumors underwent SO. They have been followed-up for 6 and 3 years and had no recurrences. Four patients were pregnant at the time of laparoscopic surgery. Among these patients, surgery was performed between 14 and 18 weeks estimated gestational age. The intra-abdominal pressure was kept below 12 mm Hg. Surgery was uncomplicated in all four patients with no post-operative complications or preterm labor. The pathologic findings among these patients included dermoid cyst (2) and benign cystadenoma (2). Discussion The use of laparoscopy in the management of benign adnexal masses has become acceptable by most gynecologists, and the last several decades have witnessed an increasing trend in employing laparoscopic surgery among women with benign adnexal masses. A randomized prospective study [4] comparing laparoscopy and laparotomy in the management of patients with benign ovarian masses less than 10 cm in diameter reported a significant reduction in operative morbidity, post-operative pain and analgesic requirement, hospital stay and recovery period among women undergoing laparoscopy. However, the experience with laparoscopic surgery as a primary treatment modality for large adnexal masses is still limited. Several authors [5–12] reported their experience with laparoscopic surgery among women with large ovarian cysts but the number of patients included in these reports was small. The current paper represents the largest number of women with large ovarian cysts managed laparoscopically in a prospective fashion by the same author using uniform techniques. Concerns regarding laparoscopic surgery among women with large adnexal masses include: concern about rupture of such cysts on introduction of the Veress needle or the laparoscopic trocars with spillage of the cyst contents, limited visualization, technical difficulty of visualizing the ureters and of extracting the mass and concern about the malignant potential of such masses. We defined large ovarian cysts as those with the largest diameter exceeding 10 cm on pre-operative imaging studies. This definition was similar to that adopted by some authors [5] . However, other authors defined large [6] or extremely large [7] ovarian cysts as those reaching above the level of the umbilicus. We believe that using a definite measurement is more reproducible and reflective of the actual size of the ovarian cyst as the level of the umbilicus might vary among women depending on body habitus. Furthermore, the location of ovarian cysts might differ based on the patients' position and displacement by other organs, and an ovarian cyst reaching the level of the umbilicus might not necessarily be very large. We used an infra-umbilical incision or an incision between the umbilicus and the xiphisternum and the open technique for initial trocar insertion in all of our patients. Other authors [6] have described a left upper quadrant incision for initial trocar insertion. The secondary and tertiary puncture sites were sometimes placed at positions higher than the usual. It is possible that the open technique avoided puncture of the large ovarian cysts at the time of initial trocar insertion. We did not find it necessary to aspirate the ovarian cysts prior to initial trocar insertion. In the majority of the cases, we used laparoscopic-guided aspiration of the cysts with a Bonanno catheter. After placement of the tip of the catheter inside the cyst and removal of the stilette, the hub of the catheter was connected to direct suction thus shortening the time needed for full aspiration of the cyst. The curved tip of the Bonanno catheter reduces the chance of spillage of the cyst's contents, and the multiple holes allow for rapid aspiration even when the cyst contents are thick as in dermoid cysts. Cyst size reduction techniques performed by other authors included ultrasound-guided aspiration prior to the laparoscopic procedure [8,10] and aspiration through a nephrostomy tube using the Seldinger technique [9] . Ovarian cysts > 10 cm in diameter are often larger than the available laparoscopic endobags. However, some oblong cysts can be wedged into an endobag prior to aspiration adding an extra security against peritoneal contamination. Among our patients scheduled to undergo LAVH, the ovarian cysts were aspirated vaginally after delivery of the uterus through the vagina thus avoiding intraperitoneal spillage. After the ovarian cysts were aspirated and removed and especially for women with dermoid cysts, we performed copious irrigation with 1–3 L of normal saline and the fluid was then aspirated. In the current study, we set the upper limit of BMI for laparoscopic surgery at 50. However, it is possible that for experienced laparoscopic surgeons and for some women with BMI > 50 and certain body habitus laparoscopic surgery could be safe and feasible. For the morbidly obese patients, laparoscopic surgery has the potential advantages of early ambulation and recovery, decrease in the chance of wound infection and incisional hernias. Four of our patients were pregnant at the time of laparoscopic surgery. Little has been published on laparoscopic removal of ovarian cysts in pregnant patients [13,14] . Laparoscopy is an excellent technique for management of large benign ovarian masses that persist beyond the first trimester. Potential complications of such masses in pregnancy include adnexal torsion, hemorrhage, peritonitis from ruptured cysts and obstruction of labor. Compared to laparotomy, laparoscopy has the following advantages: less post-operative pain and early ambulation which might reduce the chance of deep venous thrombosis and small incisions reducing the chance of hernias. Among our pregnant patients, surgery was performed between the 14th and 18th weeks of gestation, a period considered relatively safe while still providing ample room for laparoscopic surgery. Concerns about the fetal effects of pneumoperitoneum are reduced by reducing the pressure setting (< 12 mm Hg), monitoring of the maternal end tidal CO 2 (keeping it below 35 mm Hg) and shortening the duration of pneumoperitoneum. Although some authors [15] have reported safe and adequate surgical staging of women with early stage ovarian cancer using laparoscopic techniques, we still prefer laparotomy for this purpose. All of our patients scheduled for laparoscopic surgery consented for possible laparotomy should ovarian malignancy be found or suspected intra-operatively. Concerns regarding rupture of malignant ovarian cysts and incomplete surgical staging among women undergoing laparoscopic surgery who are ultimately found to have ovarian cancer can be minimized by proper pre-operative patient selection, avoiding spillage of the cyst contents with the use of the Bonanno catheter for cyst aspiration, and conversion to laparotomy if ovarian cancer is suspected after visualization of the ovaries and the peritoneal cavity. In this regard, the availability of a gynecologic oncologist can prove valuable. The importance of patient selection and availability of a gynecologic oncologist should be stressed before applying the results of the current series to all gynecologic surgeons. In the current series, the operating surgeon was a gynecologic oncologist, capable of converting the procedure to laparotomy and proceeding with full surgical staging if malignancy was found. The Society of Gynecologic Oncologists and the American College of Obstetricians and Gynecologists have published referral guidelines to gynecologic oncologists among women with pelvic masses [16] . In selecting patients for laparoscopic surgery, we relied predominantly on imaging studies especially transvaginal ultrasound. We believe that the ultrasound morphology of ovarian masses is more specific than pre-operative CA-125 values. Our patient who had the highest CA-125 value (280 U/mL) was found to have an ovarian endometrioma. In a previous study [17] , we found that some women with benign conditions could have CA-125 elevation above 1,000 (U/mL). We used similar ultrasound morphologic features to diagnose benign ovarian cysts as those reported by other authors [18,19] . However, in some patients with large ovarian cysts, transvaginal ultrasound might be limited in visualizing the entire cyst contents because of its size. Among these women, transabdominal ultrasound and computed tomography might be of value. We found computed tomography 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 calcification, fat attenuation on computed tomography is diagnostic [20] . The current study adds to accumulating evidence supporting the safety and excellent surgical outcome of laparoscopic surgery for large benign ovarian cysts among gravid and non-gravid women. 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