Ovarian Surgery Ovarian Masses Laparoscopic removal of selected ovarian masses is a well-established technique supported by high quality evidence (14–16). Proper patient selection is critical for laparoscopic management of adnexal masses because of the possible adverse effect of laparoscopic approaches on prognosis with malignant tumors (17,18). Preoperative ultrasonography is mandatory. Sonolucent lesions with thin walls and no solid components are at very low risk for malignancy and, therefore, are suitable for laparoscopic removal. For post-menopausal women, the measurement of CA125 levels is useful in identifying candidates for laparoscopic management (19,20). Combining age, menopausal status, an ultrasound score, and the serum CA125 level into a “risk of malignancy index” seems to offer an effective approach to the identification of cysts at high risk for epithelial malignancy (21–23). Lesions with ultrasonographic findings suggestive of mature teratoma (dermoid), endometrioma, or hemorrhagic or other cysts presenting with torsion or other causes of acute pain may be suitable for endoscopic management (24–27). Ovarian tumors should be assessed by frozen histologic section, and any frank malignancy should be managed expeditiously by laparotomy (14,18,20).
The technique for performing laparoscopy for oophorectomy and cystectomy is similar to that used for laparotomy (13). For cystectomy, scissors are used to incise the ovarian capsule, and blunt dissection or aqua dissection is used to separate the cyst from the ovary. If oophorectomy is performed, the vascular pedicles are occluded and transected, usually with radiofrequency electrosurgical coagulation and cutting systems, but in some instances with sutures, clips, or linear cutting and stapling devices. The ureter should be identified and should be clear of the pedicle to be transected. Cysts that appear to be benign may be drained before extraction through a laparoscopic cannula or, less commonly, a posterior culdotomy. If there is concern about the impact of spilled cyst contents, the specimen should be removed in a retrieval bag inserted into the peritoneal cavity through a laparoscopic port. Some authors describe a minilaparotomy technique, or enlarging one port site incision, to exteriorize the mass, drain it externally without intraperitoneal spill, remove the cyst or ovary, and then reintroduce the adnexa into the peritoneal cavity (28).
Although in the past the ovary routinely was closed after cystectomy, this practice may be unnecessary and could contribute to the formation of adhesions (29). There is controversy about this point as at least one randomized clinical trial (class 1) suggested that suture-based closure of the ovary is associated with fewer adhesions than using electrodesiccation alone (30).
Ovarian torsion, previously treated by laparotomy and oophorectomy, often can be managed laparoscopically (31,32). Even if there is apparent necrosis, the adnexa can be untwisted, usually with preservation of normal ovarian function (26,33). Performing a cystectomy at the same time that the ovary is untwisted greatly reduces the likelihood that ovarian function will be maintained. Rarely is adnexectomy indicated.
Polycystic ovarian syndrome can be treated laparoscopically using electrosurgery or laser vaporization to perform ovarian “drilling.” This procedure reduces the volume of ovarian stromal tissue and may lead to a temporary return of normal ovulation (34–36). Although such procedures were successful in a number of randomized trials, postoperative adhesions form in 15% to 20% of patients, which underscores the need to first exhaust medical treatment (37–39).