Laparoscopic management of ovarian dermoid cysts: potential fear of dermoid spill, myths and facts

The objective of this study was to evaluate the safety and potential advantages of laparoscopic approach for management of ovarian dermoid cysts and challenge the potential fear of spillage of contents of dermoid cyst during laparoscopic surgery. Out of 384 operative laparoscopies conducted at Al Ebtesama Hospital, Unit of Advanced Laparoscopic Surgery, and Cairo University Hospital, during the period May 1999 to February 2005, 26 patients underwent laparoscopic removal of dermoid cysts. We employed the three-puncture technique: a 10-mm umbilical trocar for the telescope and two auxiliary 5-mm punctures for operative intervention. Thirty-one dermoid cysts with a mean diameter of 7.5 cm were removed successfully in 26 patients. The operative techniques employed were ovarian cystectomy for 28 cysts, salpingo-oophorectomy for three cysts, and one case had salpingo-oophorectomy together with laparoscopy-assisted vaginal hysterectomy (LAVH). In one case, we performed concomitant hysteroscopic excision of complete uterine septum. Fourteen cysts were removed through enucleation and removal through the trocar sleeve. Ten cases were treated via enucleation and removal within impermeable endobag. Seven cases were managed by removal of cysts via posterior colpotomy; one was managed during LAVH. We encountered 14 spillages during the procedures: in ten cases (71%) of trocar removal without the use of endobag, in one case (10%) of removal within an impermeable endobag, and in three cases (42%) of colpotomy removal. After a review of 14 studies in the literature, added to our study, we found only 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. Laparoscopic approach allows proper exposure of the cul-de-sac and forceful jet lavage aspiration, ensuring pelvic clean out from any microscopic material of the dermoid cyst. Such a situation may not be available during open laparotomy.     

Laparoscopic approach to dermoid cysts: combined surgical technique and ultrasonographic evaluation of residual functioning ovarian tissue

STUDY OBJECTIVE: To estimate how and if laparoscopic removal of ovarian dermoid cysts is a tissue-sparing procedure. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: University-associated hospital. PATIENTS: Fifty-five women. INTERVENTION: Laparoscopic removal of ovarian dermoid cysts by a combination of hydrodissection and blunt dissection, and transvaginal sonographic (TVS) evaluation of residual ovarian tissue. MEASUREMENTS AND MAIN RESULTS: Within 1 week before surgery all recruited patients underwent TVS evaluation of ovarian volume, size, and morphology of dermoid cysts and measurement of surrounding ovarian cortex. Mean cyst diameter was 5.5 +/- 2.2 cm (range 2.1-15.0 cm). Within 6 to 12 months after laparoscopic excision, TVS measurements of residual ovarian tissues were obtained. Ovarian residual cortex surrounding the cyst was not visible at TVS in 24 ovaries, whereas in 56 ovaries residual tissue volume was greater than 3 cm3 after laparoscopic excision. CONCLUSION: We propose laparoscopic removal of dermoid cysts by combining hydrodissection and blunt dissection with maximum tissue sparing, even when the cyst seems to fill the ovary and no surrounding ovarian cortex can be seen on ultrasound.     

阴式附件手术与腹腔镜附件手术临床对照分析

目的:比较阴式附件手术与腹腔镜附件手术的临床指标、并发症发生情况及卫生经济学指标。方法:回顾分析阴式附件手术92例的临床资料并与同期腹腔镜手术102例的手术时间、失血量、术后病率、并发症发生率及住院费用比较。结果:92例阴式附件手术均获成功。术中出血量、并发症、术后病率等与腹腔镜相比无统计学差异(P>0.05),手术时间、住院费用少于腹腔镜手术(P<0.05),术后白细胞计数低于腹腔镜手术(P<0.05)。结论:与腹腔镜比较,附件良性囊肿阴式手术是可行的,手术时间短,对患者全身状况、腹腔脏器干扰小,并发症发生率低且能节省手术费用。     

Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue

OBJECTIVE: The aim of this study was to determine whether and to what extent laparoscopic removal of ovarian endometriotic cysts is a tissue-sparing procedure. STUDY DESIGN: At the University Hospital, 77 women of reproductive age with endometriomas and 55 with dermoid cysts underwent laparoscopic removal of the ovarian disease by stripping. Within 1 month before and within 36 months after surgery all patients underwent transvaginal sonographic evaluation of ovarian volume of the endometriomas or dermoid cysts and measurement of the residual ovarian tissue. RESULTS: The residual ovarian volume after surgery was significantly less for the endometrioma group than for the dermoid group. Comparison of the volume of the treated ovary with that of the untreated contralateral ovary showed a significant difference (4.3+/-2.3 cm(3) vs 9.7+/-3.9 cm(3)) only in the endometrioma group. CONCLUSION: Ovarian stripping of endometriomas, but not of ovarian dermoids, is associated with a significant decrease in residual ovarian volume which may result in diminished ovarian reserve and function.     

A randomized study of total abdominal, vaginal and laparoscopic hysterectomy.

OBJECTIVES: To evaluate operative time, blood loss and inflammatory response in patients submitted to hysterectomy. METHODS: Sixty patients referred for hysterectomy were prospectively randomized to total abdominal hysterectomy (n=20), vaginal hysterectomy (n=20), or laparoscopic hysterectomy (n=20). The operative time, blood loss (variation in erythrocyte and hemoglobin) and inflammatory answer (CRP and interleukin-6 dosages) were compared by using Kruskal-Wallis, Dunn non-parametric test and variance analysis with repeated measurements. RESULTS: Operative time was shorter for vaginal hysterectomy, and there was no significant difference between total abdominal hysterectomy and laparoscopic hysterectomy. Reduction in erythrocyte and hemoglobin was more noticeable after vaginal hysterectomy, followed by total abdominal hysterectomy and laparoscopic hysterectomy. CRP levels increased steadily from vaginal hysterectomy to laparoscopic hysterectomy and then to total abdominal hysterectomy. The increase in interleukin-6 was substantially higher in total abdominal hysterectomy, whereas no difference was noted between vaginal and laparoscopic hysterectomy. CONCLUSIONS: Vaginal hysterectomy presents superior results in terms of operative time and inflammatory response when compared with total abdominal and laparoscopic hysterectomy and it should be the first option for hysterectomy. Laparoscopic hysterectomy should be considered when the vaginal approach is unfeasible, showing clear advantages over abdominal hysterectomy.     

Use of laparoscopic support to avoid laparotomy in vaginal ovarian cystectomy

The objective of our study was to evaluate the use of a procedure for vaginal ovarian cystectomy that is supported by the option to convert to laparoscopy. The ovarian cystectomy was initially approached transvaginally, and then if impossible, completed laparoscopically. We applied this operation system to 38 patients with benign ovarian cysts. Preoperative characteristics of patients, outcomes of colpotomy and vaginal ovarian cystectomy, conversion rate from a vaginal approach to a laparoscopic procedure or a laparotomy, completion rate, operating time, blood loss, complications, and postoperative outcomes were examined. Colpotomy was successfully performed in 37 (97%) of 38 cases and vaginal ovarian cystectomy was accomplished in 35 (92%) cases. Three (8%) cases, including 1 case of failed posterior colpotomy and 2 cases of intrapelvic adhesions, were converted from a vaginal approach to a laparoscopic procedure. In all (100%) cases, cystectomy was successful without laparotomy. Support by laparoscopy preserves the minimal invasiveness of vaginal ovarian cystectomy in cases that would normally require conversion to laparotomy. Thus, this operation system is an alternative procedure to an exclusively vaginal ovarian cystectomy.     

Hysterectomy for benign uterine pathology among women without previous vaginal delivery

OBJECTIVE: To evaluate the feasibility and the complication rate of vaginal hysterectomy in benign uterine pathology (except for uterine prolapse) among patients without previous vaginal delivery. METHODS: A review of the medical records in patients without previous vaginal delivery who underwent hysterectomies between January 1995 and June 2004 was carried out. Patients were divided into two different groups: group 1 included patients with first-intention abdominal hysterectomy; group 2 included patients with vaginal approach further stratified into 2a without and 2b with laparoscopic assistance. RESULTS: Three hundred patients without previous vaginal delivery underwent hysterectomy during this period. Vaginal hysterectomy was planned in 75.7% of cases. Success rate for planned vaginal hysterectomies was 92.1%. The mean weight of uteri extracted by vaginal and abdominal approaches were 326 g and 1,047 g, respectively (P<.001). The mean operative time was significantly longer in the laparoscopic-assisted approach (160 minutes) than in the abdominal approach (120 minutes), and significantly shorter in exclusively vaginal (75 minutes) than in other procedures (P<.001). The use of the laparoscopic assistance in hysterectomy decreased significantly over the period of the study (P<.001). The mean duration of hospital stay was significantly shorter in group 2 than in group 1 (3.8 days compared with 6.2 days, P<.001), but no differences were noted between subgroups 2a and 2b. CONCLUSION: Vaginal hysterectomy should not be contraindicated in patients lacking previous vaginal delivery. In these particular patients, most of the procedures can be performed by vaginal approach, with the benefit of limiting the costs and the duration of hospital stay.     

Laparoscopic excision of ovarian dermoid cysts with controlled intraoperative spillage. Safety and effectiveness.

OBJECTIVE: To compare the operative and postoperative course in patients undergoing laparoscopy for dermoid cyst to that observed in subjects with other types of ovarian masses and of patients undergoing laparotomy for teratomas. STUDY DESIGN: Retrospective analysis. From 1994 to 1996, 49 women underwent laparoscopic cystectomy for dermoid cysts. The operative and postoperative course was compared to that of 190 patients undergoing operative laparoscopy for other adnexal masses and to that of 43 patients undergoing laparotomy for dermoid cysts from 1992 to 1996. The cysts were aspirated to reduce spillage and removed via a laparoscopic bag inserted in a 10-mm trocar. Culdotomy was never used. The abdominal cavity was abundantly flushed during the procedure and before closure. RESULTS: Dermoid cystectomy was successfully performed laparoscopically in 47 of 49 cases. Spillage occurred in 43 cases (88%), and postoperative fever occurred in 3 (6.1%). No case of peritonitis was recorded. Significant differences between laparoscopy and laparotomy were observed in the rate of bilaterality (4% vs. 25%), spillage (88% vs. 9%) and mean hospital stay (37 vs. 83 hours). When laparoscopic excision of dermoid cysts and other masses was compared, we did not observe any significant difference in operative time or complication rates, apart from transient fever. CONCLUSION: Laparoscopy is safe and effective for dermoid cysts and allows shorter hospitalization than laparotomy. As observed for other benign cysts, laparoscopy should become the technique of choice for the removal of most, if not all, ovarian dermoid cysts.     

Laparoscopic radical trachelectomy for stage Ib1 cervical cancer

Radical trachelectomy by vaginal approach is an alternative for young women with early-stage cervical cancer. We modified this procedure to treat two patients with stage Ib1 cervical cancer. With 100% laparoscopic pelvic lymphadenectomy and 80% laparoscopic approach, the technique is laparoscopic radical trachelectomy (LRT). Under direct enhanced vision of the laparoscope, it is easy to identify and preserve ascending branches of the uterine arteries and to divide ligaments surrounding the cervix and vagina. Vaginal procedures require only colpotomy, amputation of cervix, dividing caudal paracolpium, and corpus-vagina anastomosis. Short-term follow-up results of our first patients are satisfactory. Thus, LRT could be a useful alternative for women with early cervical cancer who want to preserve fertility.     

Laparoscopic treatment of ovarian dermoid cysts: eleven years' experience

STUDY OBJECTIVE: To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered. DESIGN: Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III). SETTING: The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece. PATIENTS: Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy. INTERVENTIONS: Cystectomy either by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result. CONCLUSION: Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.     

Laparoscopic surgery of dermoid cysts--intraoperative spillage and complications

OBJECTIVE: To assess the risks of complications including intraoperative spillage following laparoscopic dermoid cyst enucleation. STUDY DESIGN: A retrospective case series comparison of 390 patients who had surgery at our hospital from 1992 to 1998 for teratomas of the ovary. RESULTS: 43 patients were treated with laparotomy. Two malignant teratomas were observed in this group. In seven patients, the dermoid cysts were removed as part of a vaginal hysterectomy. Three hundred and forty patients had surgery via laparoscopy. Enucleation of the dermoid cyst in toto using a salvage bag for removal was only possible in few cases without contamination of the abdominal cavity by spillage of cyst contents. There were no serious complications in any patients including those with laparoscopic cystectomies and intraperitoneal spill. CONCLUSION: The laparoscopic treatment of benign teratomas is a safe procedure. Primary laparotomy as well as adenectomy is also to be taken into consideration with young patients, if suspicion of malignancy, rapid growth, doubtful infiltration or large size of tumor is present.     

Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies

STUDY OBJECTIVE: The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences. DESIGN: Observational case series (Canadian Task Force classification II-3). SETTING: Large, urban, university teaching hospital. PATIENTS: All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed. INTERVENTIONS: Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate. MEASUREMENTS AND MAIN RESULTS: From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH. CONCLUSIONS: Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.     

The Safety of Laparoscopic Treatment for Ovarian Dermoid Tumours

Summary: Whilst laparoscopic surgery has largely replaced laparotomy as the standard surgical option for the management of benign ovarian cysts, concern remains regarding the safety of laparoscopy for benign cystic teratomas. This is based on a higher rate of cyst content spillage compared to laparotomy and the known sequelae of chemical peritonitis and granuloma formation. We present 18 cases of laparoscopic dermoid cystectomy with recommendations for specimen removal from the peritoneal cavity. Our findings together with evidence from the literature confirms the safety of laparoscopy for the treatment of ovarian dermoid cysts.     

The Safety of Laparoscopic Treatment for Ovarian Dermoid Tumours

Summary: Whilst laparoscopic surgery has largely replaced laparotomy as the standard surgical option for the management of benign ovarian cysts, concern remains regarding the safety of laparoscopy for benign cystic teratomas. This is based on a higher rate of cyst content spillage compared to laparotomy and the known sequelae of chemical peritonitis and granuloma formation. We present 18 cases of laparoscopic dermoid cystectomy with recommendations for specimen removal from the peritoneal cavity. Our findings together with evidence from the literature confirms the safety of laparoscopy for the treatment of ovarian dermoid cysts.     

Laparoscopic management of stage I ovarian cancer. A case report

A woman with stage I ovarian cancer refused traditional treatment and was managed laparoscopically. Both ovaries were removed intact via a culdotomy incision. Vaginal hysterectomy, omentectomy and laparoscopic lymphadenectomy followed. With the increasing frequency of laparoscopic oophorectomy, it clearly seems prudent to remove ovaries intact through the cul-de-sac whenever ovarian pathology is in doubt. Although the laparoscopic approach is as yet unproven, it is an alternative for a select group of well-informed women with borderline or low-grade ovarian malignancy.     

Management of ovarian dermoids without laparoscopy or laparotomy

OBJECTIVE: To report experience of managing ovarian dermoids via the vaginal route. STUDY DESIGN: A series of 26 cases managed this way either with or without hysterectomy and for comparison 10 women managed by laparotomy and 6 who underwent laparoscopic ovarian cystectomy or oophorectomy were considered. RESULTS: The vaginal approach was successful in all patients, without need for laparoscopic assistance or a switch over to laparotomy. Spill was minimal or absent in the vaginal group and recovery significantly faster in the vaginal and laparoscopic groups compared to the laparotomy group. Hospital stay was slightly shorter in the vaginal than the laparoscopic group. No disposable material or equipment was used in the vaginal or laparotomy group. CONCLUSION: For mobile, benign ovarian teratoma, the vaginal route should be strongly considered to minimise invasive surgery, particularly when the operator is an experienced vaginal surgeon or laparoscopic equipment or laparoscopic surgeons are not easily available. Reduced spillage and speedier recovery are important advantages.     

The place of ovarian drilling in the management of polycystic ovarian syndrome (PCOS)

The surgical approach has been a long-lasting option for ovulation restoration in patients presenting with polycystic ovarian syndrome. It consists of ovarian drilling with monopolar, bipolar energy or laser through laparoscopic or vaginal hydrolaparoscopic route. It is intended to be used as a second line therapy as an alternative to gonadotropins in patients with resistance or failure after clomiphene citrate. The results in terms of ovulation restoration and live births make it an attractive alternative with less complications such as multiple pregnancies and ovarian hyperstimulation syndrome.     

Peritoneal implantation of squamous cell carcinoma following rupture of a dermoid cyst during laparoscopic removal.

BACKGROUND: In recent years, there has been a move toward using laparoscopy in the management of presumed benign ovarian masses. This paper discusses the use of laparoscopy for ovarian masses (particularly dermoid cysts). The focus is on the implications for unexpected malignancies. CASE: We report here a case involving a dermoid cyst that was removed at laparoscopy and was subsequently found to contain a squamous cell carcinoma. Spillage of the cyst's contents occurred at the time of removal. At staging laparotomy, peritoneal implants of the tumor were found, upgrading the tumor from FIGO stage Ia to IIc. CONCLUSION: Spillage rates of dermoid cyst content with laparoscopic removal are inevitably higher than with excision at laparotomy. It remains controversial whether upstaging from FIGO stage Ia to IIc affects prognosis; however, in this case it led to aggressive adjuvant therapy which imposed significant additional morbidity, including loss of fertility, on the patient. One should be aware of the possibility of unexpected malignancy when the decision to manage an ovarian mass laparoscopically is made.     

Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap

BACKGROUND: Vaginal evisceration is generally repaired by vaginal or abdominal route. We describe two cases of vaginal evisceration using a combined laparoscopic and vaginal approach employing an omental flap. CASES: Case 1: A radical abdominal hysterectomy was performed in a premenopausal patient for a FIGO IB1 cervical cancer. Four months later, she was found to have a vaginal cuff dehiscence which was repaired by a vaginal approach. Two months later, she had a vaginal cuff evisceration which was repaired using a combined laparoscopic and vaginal approach employing an omental flap with good success. Case 2: A postmenopausal woman who underwent an abdominal hysterectomy and pelvic lymphadenectomy for a FIGO IB endometrial cancer was noted to have a vaginal evisceration two months after primary surgery. This was also successfully repaired using a combined laparoscopic and vaginal approach employing an omental flap. CONCLUSION: The combined laparoscopic and vaginal approach with omental flap is effective for repair of a vaginal cuff dehiscence with bowel evisceration. The addition of laparoscopy provides an opportunity for inspection of the small bowel, the peritoneal toilet, and mobilization of an omental flap.     

Laparoscopic management of adnexal masses. Safety and effectiveness

OBJECTIVE: To evaluate the effectiveness and safety of the laparoscopic approach to adnexal masses. STUDY DESIGN: Sixty-one patients who underwent laparoscopic intervention due to various types of adnexal masses between March 1997 and April 1999 in a teaching hospital were assessed retrospectively. Patients with strong evidence of advanced ovarian cancer, such as large masses, ascites or omental cake, were excluded. Frozen section was performed intraoperatively, if indicated. In cases of malignancy, laparotomy was performed. RESULTS: Mean operation time was 67.2 minutes; average hospital stay was 1.2 days. Cyst enucleation was performed in 34% of patients. Two of 61 patients were diagnosed as having malignant disease and converted to laparotomy. Chemical peritonitis was encountered after dermoid cyst removal due to spillage of contents in spite of using an endobag and irrigating copiously with saline. No other complications were seen. CONCLUSION: Laparoscopy is a safe approach to adnexal masses and may decrease the rate of unnecessary laparotomies for benign cysts, which give no suspicious ultrasonographic signs.