Laparoscopically Guided Minilaparotomy: A Modified Technique for the Management of Large Benign Ovarian Cysts | BMC Women’s Health

Laparoscopic management of ovarian cysts depends on many patient factors, one of which is the history of previous abdominal surgeries. This technique is associated with many benefits such as minimal blood loss, less postoperative pain, more convenient scar appearance, and shorter hospital stay. Therefore, the laparoscopic approach has become standard for small, benign ovarian cysts. [8].

The difficulty in laparoscopic management of large ovarian tumors is related to the restricted pelvic space, thus increasing operative time and blood loss with greater possibility of conversion to laparotomy [9].

In laparoscopic ovarian cystectomy for large cysts, the conversion rate to laparotomy was 0.45% and 2.6% and perioperative complications were reported in 1.3% and 1.6% in the Company’s trials Japanese Endoscopic Surgery and Ghezzi, respectively. [10, 11].

In our experience, we observed a major problem in the management of large ovarian cysts laparoscopically, which was the increased need for cauterization of the remaining ovarian tissue to control blood loss. To our knowledge, none of the investigators who used laparoscopy to manage large cysts commented on or rated ovarian reserve after the procedure.

In 2004, Pelosi and her colleagues tried a technique for managing large ovarian cysts. They claimed that all procedures were successful without resorting to laparoscopic aid or conversion to laparotomy with better cosmetic scarring. They approached the cyst in 38 women through a cruciform incision where the transverse branch was made at the level of the skin while the vertical branch was at the level of the anterior rectus fascia. They used a large adhesive plastic surgical dressing attached to the surface of the cyst to prevent the contents of the cyst from spilling into the peritoneal cavity, then they suctioned the cyst until it shrank to a size that could be delivered by the incision. They performed the conventional cystectomy or oophorectomy, then returned the remains to the abdominal cavity [12].

Although this technique provided better complete removal of the cyst wall without resorting to excessive ovarian cautery, this seemingly good technique had one major flaw. Extrusion of the cyst was done blind, which exposes the patient to the risk of injury to the pelvic or abdominal organs as a result of traction and cutting of adhesions between the cyst and these organs blind.

In our technique, we avoided this serious invisible injury by using laparoscopy to locate the cyst and free it of any surrounding adhesions under laparoscopic vision before delivering it.

In our new technique, all procedures were performed with only 4 of 112 cases requiring conversion to laparotomy. The need for a laparotomy arose from the failure of laparoscopy. No operative complication was reported and especially the ovarian reserve evaluated after 6 months of intervention seemed to be preserved. Although we observed a statistically significant decrease in AMH level (from 2.82 ± 0.44 to 2.50 ± 0.42 which has minimal clinical significance), this was offset by a significant increase in AFC. This minimal ovarian reserve impairment was related to the use of a microsurgical technique avoiding both diathermy and cold knife dissection since both affect normal ovarian tissue adjacent to the cyst wall.

Exteriorization of the cyst also allowed reconstruction of stretched ovarian tissue over a large cyst (which is not always feasible with laparoscopic surgery). This clearly allowed the preservation of most of the ovarian tissue, hence minimal damage to the ovarian reserve.

Our technique has been successful in unilateral and bilateral ovarian cysts. None of the operated women showed any malignancy after pathological examination because we have strict selection criteria and an appropriate preoperative evaluation.

If there had been an Alexis retractor available, we might have considered including patients with cysts suspected of malignancy (keep in mind that large cysts are more likely to be malignant, which was a difficult limitation in patient selection). Alexis O Retractor Protector has been shown to reduce scarring pain, blood loss, and surgical site infections or conditions from malignant spillage (a common site of metastasis). It provides 360 degrees of atraumatic and circumferential retraction and protection [13].

We also expect our new technique to be better than laparoscopy and laparotomy in minimizing pelvic adhesions. In fact, all risk factors for adhesions were avoided, namely peritoneal trauma and exposure, avoidance of multiple ovarian tissue trauma associated with laparoscopy and towel trauma associated with laparotomy as well as avoidance of the inevitable contamination expected with laparoscopy in cysts with irritating contents. in the form of dermoid and mucinous cysts.

The main limitation of our study was the inability to confirm minimal adhesions, as second-look laparoscopy was required to assess it, which was impractical for most of our patients. The reasons we believe postoperative pelvic adhesions are less with our technique would be less peritoneal trauma and exposure, absent peritoneal contamination with cyst or blood contents, and perfect closure of the cyst by knotless microsurgical techniques. suture to the outer surface of the cyst.

Another obvious advantage of our technique is the assurance of complete cyst removal which can never be confirmed at laparoscopy and which is ultimately reflected in the low recurrence rate reported by our patients.

Machida and her colleagues compared the results of laparoscopic surgery in women with different sizes of ovarian cysts. They categorized the women into groups A, B, and C with a cyst diameter of 5, 6–9, and more than 10 cm respectively. They concluded that operative time and blood loss were positively correlated with cyst size. No correlation was found between the occurrence of per or postoperative complications or conversion to laparotomy and the size of the cyst. However, this study did not comment on the use of ovarian cautery and the effects on ovarian reserve. [9].

In a small trial involving just 12 women with large ovarian cysts, Roda and colleagues concluded that large ovarian cyst is not an absolute contraindication to laparoscopic management. [14].

Another study was conducted by Alobaid on just 5 huge ovarian cysts managed by laparoscopy and found that laparoscopy can be used to manage huge cysts after proper patient selection with the availability of an expert gynecological endoscopy surgeon. [15].

Panici et al. randomized 60 women with nonendometriotic ovarian cysts 7 to 18 cm in diameter for laparoscopy or laparoscopically guided minilaparotomy. They found that intraperitoneal spillage was reduced with a slight increase in recovery time and patient discomfort in those who underwent laparoscopically guided minilaparotomy. And concluded that laparotomy is the standard treatment because there is a lack of information on the effects of peritoneal spillage. We thought the increased recovery and discomfort was related to their 3-7cm large skin incision compared to our 3cm incision. The inclusion of 7-10 cm cysts was not appropriate as they are not considered large cysts. Again, they did not comment on the ovarian reserve of women managed in either group. [16].

Chong and colleagues compared the results of single-port assisted extracorporeal cystectomy, laparoscopy, and laparotomy in 25, 33, and 25 patients with ovarian cysts. They claimed comparable results with less abdominal spillage in the first procedure. However, their study was retrospective with inclusion of cysts of 8 cm or more. [17].

To the best of our knowledge, our study is unique and has evaluated a new technique and may be a standardized technique for the management of large benign ovarian cysts. The limitation of this technique is the presence of dense adhesions surrounding the cyst making its laparoscopic dissection hazardous and which was not encountered in our study due to appropriate patient selection for the technique. The main limitation of our study was the absence of a control group with conventional management of large ovarian cysts by laparotomy. We believed that all patients deserved to benefit from our technique.

The future of this technique is to apply it to women with endometriosis because they are generally young and in search of fertility and laparoscopic management with excessive cauterization could affect their ovarian reserve. We are concerned, however, that the dense adhesions normally seen with endometriosis may pose difficulties in exteriorizing the ovary or cause intraperitoneal opening of the cyst and subsequent spillage during attempts at laparoscopic adhesiolysis. The results still need to be studied before such a statement can be made with certainty.

We can conclude that laparoscopically guided minilaparotomy is a safe and effective technique for the management of large benign ovarian cysts with minimal recurrence rate, ovarian reserve disease and adhesions.

We recommend this new technique to all women with large benign ovarian cysts who wish to preserve their fertility for future fertility. Additionally, this technique can be used in older women with confirmed benign nature of the cyst who are not candidates for hysterectomy because it has better postoperative recovery than laparotomy, as confirmed by our results. We aspire to further extend our study by studying the hypothesis of less adhesions using this technique by also performing a second look laparoscopy.

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