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Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage
Journal of Pediatric Surgery (2006) 41, E9 – E11
www.elsevier.com/locate/jpedsurg
Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage Og¯uz AtesSa,*, Erdal Karakayaa, Gu¨lce Hakgu¨dera, Mustafa Olgunera, Mustafa Sec¸ilb, Feza M. Akgu¨ra a
Department of Pediatric Surgery, Dokuz Eylu¨l University, Medical School, I˙zmir 35340, Turkey Department Radiology, Dokuz Eylu¨l University, Medical School, I˙zmir 35340, Turkey
b
Index words: Ovary; Cyst; Laparoscopy; Ultrasound-guided drainage
Abstract The laparoscopic approach to giant ovarian cysts in pediatric population may be difficult regarding the risk of cyst rupture and limited working space. We herein report a 16-year-old adolescent girl that presented with a giant ovarian cyst. To reduce the limitations of the laparoscopy, we performed laparoscopy after draining the cyst under ultrasonographic guidance. Under local anesthesia, a nephrostomy catheter was placed into the cyst by the Seldinger technique. During laparoscopy, abdominal cavity was explored by the scope and then the nephrostomy catheter was removed. Laparoscopic procedure was completed easily. No pre- and postoperative complications were encountered and the patient was discharged on the second postoperative day. The pathologic examination of the cyst revealed as follicular cyst. Laparoscopic excision of giant ovarian cysts after ultrasound-guided drainage seems to be safe and applicable treatment modality in children. D 2006 Elsevier Inc. All rights reserved.
Treatment strategies of ovarian cysts are determined by patient’s age, menstrual status, symptoms, and cyst size and structure [1]. If operative treatment is inevitable, laparoscopic approach is more advantageous over laparotomy, considering better cosmetic results, lesser blood loss, lesser pain and analgesic requirement, faster recovery, and shorter hospitalization time [2]. Laparoscopic approach to giant ovarian cysts, in cases when the cysts’ sizes exceed to the umbilicus, may be difficult regarding the risk of cyst rupture and limited working space [3-5]. However, if the laparotomy is chosen
* Corresponding author. Dokuz Eylql Universitesi, TVp Faku¨ltesi, C ¸ ocuk Cerrahisi Anabilim DalV, Balc¸ova, I˙zmir 35340, Turkey. Fax: +90 232 279 21 01. E-mail address: [email protected] (O. AteY). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.06.023
as the operative treatment, a larger incision is required to excise the cyst. In a child with giant ovarian cyst, to avoid potential laparoscopic difficulties, the cyst may be drained under ultrasonographic guidance before the laparoscopy. Afterward, the cyst can be excised laparoscopically. We present a case of giant ovarian cyst that was treated in such manner with laparoscopy.
1. Case report A 16-year-old adolescent girl was admitted to our hospital with an abdominal pain for 20 days and abdominal distension for 1 year. During her physical examination, a soft, round mass was palpated extending from symphisis pubis to the epigastric area, filling the whole abdominal cavity. Ultrasound (US) examination of the mass revealed a
E10 hypoechogenic, thin-walled cystic lession filling almost the whole abdominal cavity. The cyst had no septation formation and solid components. On color Doppler US examination, no blood supply to the cyst was demonstrated. Computed tomography scan of the abdomen and pelvis showed a smooth surface cyst without septation, which was concurrent with benign ovarian cyst (Fig. 1). The cyst was measured as 20 20 30 cm. Laparoscopic excision of the cyst, after US-guided drainage, was planned. Preoperative serum alfa-fetoprotein, b-human chorionic gonadotropin, CA 125, and hormone levels were evaluated and found to be normal. Before the operation, under ultrasonographic guidance, a 9F nephrostomy catheter (Urotech, Bruckmqhl, Germany) was placed into the cyst by Seldinger technique under local anesthesia. Six liters of serous fluid was drained from the cyst. Control US examination showed that the cyst had been completely drained. After induction of general endotracheal anesthesia, a 10-mm trocar was placed through the umbilicus by the Hasson technique. A 308 scope was placed through the umbilical port after 10 mm Hg pneumoperitoneum was established. On laparoscopic examination, the cyst originating from the right ovary was seen. The cyst had been completely drained and there was no intraperitoneal fluid spread around. There was no ovarian tissue visible on the cyst wall. The right tuba was intact. The left tuba and ovary were normal. The nephrostomy catheter was removed. Two additional 5-mm trocars were placed on the lower abdominal quadrants bilaterally, and the third trocar was placed through the cyst drainage hole. The cyst was excised by preserving the right tuba and was taken out of the abdomen through infraumbilical incision (Fig. 2). The operation lasted for 60 minutes, with 10-mL blood loss, without any complication. Postoperative recovery of the patient was uneventful. The patient was discharged on the second postoperative day. The cyst was reported as follicular cyst
Fig. 1 Computed tomography scan of the abdomen; the cyst has filled both the abdomen and the pelvis.
O. AtesS et al.
Fig. 2 The thin-walled giant cyst (drained) is taken out from the abdomen through the umbilical port incision.
in pathologic examination and there was no ovarian tissue determined in the specimen.
2. Discussion Benign ovarian cysts can be detected during US examination [3]. On US examination when the cyst is determined as unilateral, unilocular, and smooth surface with a thin wall, without solid parts and ascites, malignancy risk is very low [3]. The normal levels of tumor markers, especially serum CA 125 level, support the benign characteristic of the cyst. Malignant tumors are complex soft tissue masses with ill-defined, irregular borders with central necrosis, thick septations, and papillary projections. They have external ovarian or intracystic vegetations. If such anatomic variations are seen during US evaluation, a greater concern about malignancy should be taken. When the malignancy risk is high, this technique seems inappropriate. In our patient, there were no malignancy criteria in both computed tomography and US. Therefore, we have preferred the laparoscopic approach. The main principles in the management of benign ovarian cysts are preservation of the reproductive and hormonal functions of the ovaries and preventing recurrence. However, in our patient, there was no apparent ovarian tissue seen during laparoscopic exploration once the cyst was removed; therefore, we could only spare the ipsilateral tube. Giant ovarian cysts that exceed to the umbilicus carry risk of perforation while trocar insertion during laparoscopy [4]. In addition, the cyst content can be spread intraperitoneally during laparoscopic excision of large cysts [3,5]. Therefore, laparoscopic excision is suggested only for the cysts that did not exceed to the umbilicus or that are in intrapelvic localization [6]. Giant ovarian cysts that are exceeding to the umbilicus and filling the abdomen may limit the working space during laparoscopy. On the other
Laparoscopic excision of a giant ovarian cyst hand, larger incision is needed if laparotomy is performed for excision of giant over cysts. In recent years, with the minimal invasive approach becoming a widespread practice, laparascopic excision is preferred in management of benign giant ovarian cysts that exceed to the umbilicus [6,7]. Salem operated on 15 adult patients with giant ovarian cysts laparoscopically (cyst sizes are larger than 10 cm). To prevent cyst rupture, he had inserted the trocars from the left subcostal area [6]. Although the method is successful in adults, it cannot be applied to children as there is not enough working space as the giant cyst is filling up the abdomen. However, to establish enough working space, giant ovarian cysts can be drained before the laparoscopic approach. Nagele and Magos [8] had drained a large ovarian cyst with a Veress needle under ultrasonographic guidance before laparoscopy. Cevriog˘lu et al [9] have performed laparoscopic cyst excision after US-guided drainage with a spinal needle in a patient with a giant paraovarian cyst. During US-guided cyst drainage, the needle could release from the cyst wall, and the cyst contents could spill intraperitoneally. Although there is no risk of malign cell spillage in benign cysts, the cyst content can cause chemical peritonitis [5]. Therefore, a permanent catheter to drain the cyst could be placed into the cyst before the laparoscopic excision to avoid spillage. We performed US-guided drainage of the cyst before the laparoscopic excision to achieve enough working space and also to prevent intraperitoneal spillage. We preferred to use a nephrostomy catheter during this process to drain the cyst completely. Until the cyst had drained completely, we did not move the catheter to prevent intraperitoneal spillage. Before laparoscopy, we had confirmed that the cyst has been drained completely with US examination. During laparoscopic excision, the catheter insertion hole was used for placing the third trocar to prevent to create an extra scar. The frequently seen ovarian cystic masses of childhood are the functional cysts including follicular cysts, corpus luteum cysts, and theca lutein cysts [10]. Among them, follicular cysts are the most common cysts during childhood. All follicular cysts are benign cysts and they are selflimited. Although pathologic examination revealed follicular cyst in our patient, there is no ovarian tissue found in the specimen. To the best of our knowledge, there is no
E11 information or a case reported about follicular cysts that exceed to this size during childhood. Because most of the ovarian cysts resolve during adolescence, for most patients, just follow-up will be enough rather than an intervention. Hormonal suppression, such as oral contraceptive pills, does not change the outcome in adolescent girls with ovarian cysts and it is not recommended [11]. Therefore, we prefer to follow our patient with only serial US examinations during the postoperative follow-up period. The excision of giant ovarian cysts by laparotomy requires larger incision. Laparoscopic excision of giant ovarian cysts carries a risk of perforation during trocar insertion and intraabdominal spillage of the cyst content. However, laparoscopic excision after US-guided drainage of giant ovarian cysts seems to be a safe and applicable treatment modality even in children.
References [1] Helmrath MA, Shin CE, Warner BW. Ovarian cysts in the pediatric population. Semin Pediatr Surg 1998;7:19 - 28. [2] Yuen PM, Yu KM, Yip SK, et al. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol 1997;177:109 - 14. [3] Knudsen UB, Tabor A, Mosgaard B, et al. Management of ovarian cysts. Acta Obstet Gynecol Scand 2004;83:1012 - 21. [4] Ma KK, Tsui PZY, Wong WC, et al. Laparoscopic management of large ovarian cysts: more than cosmetic considerations. Hong Kong Med J 2004;10:139 - 41. [5] Mecke H, Savvas V. Laparoscopic surgery of dermoid cysts— intraoperative spillage and complications. Eur J Obstet Gynecol Reprod Biol 2004;96:80 - 4. [6] Salem AFH. Laparoscopic excision of large ovarian cysts. J Obstet Gynaecol Res 2002;28:290 - 4. [7] Ou CS, Liu YH, Zabriskie V, et al. Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter. J Laparoendosc Adv Surg Tech 2001;11:125 - 31. [8] Nagele F, Magos AL. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol 1996;175:1377 - 8. [9] Cevriog˘lu AS, Polat C, Fenkc¸i V, et al. Laparoscopic management following ultrasonograhic-guided drainage in a patient with giant paraovarian cyst. Surg Endosc 2004;18:346. [10] Quint EH, Kozlowski K. Adnexal masses in teenagers. J Pediatr Adolesc Gynecol 2000;13:145 - 6. [11] Strickland JL. Ovarian cysts in neonates, children and adolescents. Curr Opin Obstet Gynecol 2002;14:459 - 65.
www.elsevier.com/locate/jpedsurg
Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage Og¯uz AtesSa,*, Erdal Karakayaa, Gu¨lce Hakgu¨dera, Mustafa Olgunera, Mustafa Sec¸ilb, Feza M. Akgu¨ra a
Department of Pediatric Surgery, Dokuz Eylu¨l University, Medical School, I˙zmir 35340, Turkey Department Radiology, Dokuz Eylu¨l University, Medical School, I˙zmir 35340, Turkey
b
Index words: Ovary; Cyst; Laparoscopy; Ultrasound-guided drainage
Abstract The laparoscopic approach to giant ovarian cysts in pediatric population may be difficult regarding the risk of cyst rupture and limited working space. We herein report a 16-year-old adolescent girl that presented with a giant ovarian cyst. To reduce the limitations of the laparoscopy, we performed laparoscopy after draining the cyst under ultrasonographic guidance. Under local anesthesia, a nephrostomy catheter was placed into the cyst by the Seldinger technique. During laparoscopy, abdominal cavity was explored by the scope and then the nephrostomy catheter was removed. Laparoscopic procedure was completed easily. No pre- and postoperative complications were encountered and the patient was discharged on the second postoperative day. The pathologic examination of the cyst revealed as follicular cyst. Laparoscopic excision of giant ovarian cysts after ultrasound-guided drainage seems to be safe and applicable treatment modality in children. D 2006 Elsevier Inc. All rights reserved.
Treatment strategies of ovarian cysts are determined by patient’s age, menstrual status, symptoms, and cyst size and structure [1]. If operative treatment is inevitable, laparoscopic approach is more advantageous over laparotomy, considering better cosmetic results, lesser blood loss, lesser pain and analgesic requirement, faster recovery, and shorter hospitalization time [2]. Laparoscopic approach to giant ovarian cysts, in cases when the cysts’ sizes exceed to the umbilicus, may be difficult regarding the risk of cyst rupture and limited working space [3-5]. However, if the laparotomy is chosen
* Corresponding author. Dokuz Eylql Universitesi, TVp Faku¨ltesi, C ¸ ocuk Cerrahisi Anabilim DalV, Balc¸ova, I˙zmir 35340, Turkey. Fax: +90 232 279 21 01. E-mail address: [email protected] (O. AteY). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.06.023
as the operative treatment, a larger incision is required to excise the cyst. In a child with giant ovarian cyst, to avoid potential laparoscopic difficulties, the cyst may be drained under ultrasonographic guidance before the laparoscopy. Afterward, the cyst can be excised laparoscopically. We present a case of giant ovarian cyst that was treated in such manner with laparoscopy.
1. Case report A 16-year-old adolescent girl was admitted to our hospital with an abdominal pain for 20 days and abdominal distension for 1 year. During her physical examination, a soft, round mass was palpated extending from symphisis pubis to the epigastric area, filling the whole abdominal cavity. Ultrasound (US) examination of the mass revealed a
E10 hypoechogenic, thin-walled cystic lession filling almost the whole abdominal cavity. The cyst had no septation formation and solid components. On color Doppler US examination, no blood supply to the cyst was demonstrated. Computed tomography scan of the abdomen and pelvis showed a smooth surface cyst without septation, which was concurrent with benign ovarian cyst (Fig. 1). The cyst was measured as 20 20 30 cm. Laparoscopic excision of the cyst, after US-guided drainage, was planned. Preoperative serum alfa-fetoprotein, b-human chorionic gonadotropin, CA 125, and hormone levels were evaluated and found to be normal. Before the operation, under ultrasonographic guidance, a 9F nephrostomy catheter (Urotech, Bruckmqhl, Germany) was placed into the cyst by Seldinger technique under local anesthesia. Six liters of serous fluid was drained from the cyst. Control US examination showed that the cyst had been completely drained. After induction of general endotracheal anesthesia, a 10-mm trocar was placed through the umbilicus by the Hasson technique. A 308 scope was placed through the umbilical port after 10 mm Hg pneumoperitoneum was established. On laparoscopic examination, the cyst originating from the right ovary was seen. The cyst had been completely drained and there was no intraperitoneal fluid spread around. There was no ovarian tissue visible on the cyst wall. The right tuba was intact. The left tuba and ovary were normal. The nephrostomy catheter was removed. Two additional 5-mm trocars were placed on the lower abdominal quadrants bilaterally, and the third trocar was placed through the cyst drainage hole. The cyst was excised by preserving the right tuba and was taken out of the abdomen through infraumbilical incision (Fig. 2). The operation lasted for 60 minutes, with 10-mL blood loss, without any complication. Postoperative recovery of the patient was uneventful. The patient was discharged on the second postoperative day. The cyst was reported as follicular cyst
Fig. 1 Computed tomography scan of the abdomen; the cyst has filled both the abdomen and the pelvis.
O. AtesS et al.
Fig. 2 The thin-walled giant cyst (drained) is taken out from the abdomen through the umbilical port incision.
in pathologic examination and there was no ovarian tissue determined in the specimen.
2. Discussion Benign ovarian cysts can be detected during US examination [3]. On US examination when the cyst is determined as unilateral, unilocular, and smooth surface with a thin wall, without solid parts and ascites, malignancy risk is very low [3]. The normal levels of tumor markers, especially serum CA 125 level, support the benign characteristic of the cyst. Malignant tumors are complex soft tissue masses with ill-defined, irregular borders with central necrosis, thick septations, and papillary projections. They have external ovarian or intracystic vegetations. If such anatomic variations are seen during US evaluation, a greater concern about malignancy should be taken. When the malignancy risk is high, this technique seems inappropriate. In our patient, there were no malignancy criteria in both computed tomography and US. Therefore, we have preferred the laparoscopic approach. The main principles in the management of benign ovarian cysts are preservation of the reproductive and hormonal functions of the ovaries and preventing recurrence. However, in our patient, there was no apparent ovarian tissue seen during laparoscopic exploration once the cyst was removed; therefore, we could only spare the ipsilateral tube. Giant ovarian cysts that exceed to the umbilicus carry risk of perforation while trocar insertion during laparoscopy [4]. In addition, the cyst content can be spread intraperitoneally during laparoscopic excision of large cysts [3,5]. Therefore, laparoscopic excision is suggested only for the cysts that did not exceed to the umbilicus or that are in intrapelvic localization [6]. Giant ovarian cysts that are exceeding to the umbilicus and filling the abdomen may limit the working space during laparoscopy. On the other
Laparoscopic excision of a giant ovarian cyst hand, larger incision is needed if laparotomy is performed for excision of giant over cysts. In recent years, with the minimal invasive approach becoming a widespread practice, laparascopic excision is preferred in management of benign giant ovarian cysts that exceed to the umbilicus [6,7]. Salem operated on 15 adult patients with giant ovarian cysts laparoscopically (cyst sizes are larger than 10 cm). To prevent cyst rupture, he had inserted the trocars from the left subcostal area [6]. Although the method is successful in adults, it cannot be applied to children as there is not enough working space as the giant cyst is filling up the abdomen. However, to establish enough working space, giant ovarian cysts can be drained before the laparoscopic approach. Nagele and Magos [8] had drained a large ovarian cyst with a Veress needle under ultrasonographic guidance before laparoscopy. Cevriog˘lu et al [9] have performed laparoscopic cyst excision after US-guided drainage with a spinal needle in a patient with a giant paraovarian cyst. During US-guided cyst drainage, the needle could release from the cyst wall, and the cyst contents could spill intraperitoneally. Although there is no risk of malign cell spillage in benign cysts, the cyst content can cause chemical peritonitis [5]. Therefore, a permanent catheter to drain the cyst could be placed into the cyst before the laparoscopic excision to avoid spillage. We performed US-guided drainage of the cyst before the laparoscopic excision to achieve enough working space and also to prevent intraperitoneal spillage. We preferred to use a nephrostomy catheter during this process to drain the cyst completely. Until the cyst had drained completely, we did not move the catheter to prevent intraperitoneal spillage. Before laparoscopy, we had confirmed that the cyst has been drained completely with US examination. During laparoscopic excision, the catheter insertion hole was used for placing the third trocar to prevent to create an extra scar. The frequently seen ovarian cystic masses of childhood are the functional cysts including follicular cysts, corpus luteum cysts, and theca lutein cysts [10]. Among them, follicular cysts are the most common cysts during childhood. All follicular cysts are benign cysts and they are selflimited. Although pathologic examination revealed follicular cyst in our patient, there is no ovarian tissue found in the specimen. To the best of our knowledge, there is no
E11 information or a case reported about follicular cysts that exceed to this size during childhood. Because most of the ovarian cysts resolve during adolescence, for most patients, just follow-up will be enough rather than an intervention. Hormonal suppression, such as oral contraceptive pills, does not change the outcome in adolescent girls with ovarian cysts and it is not recommended [11]. Therefore, we prefer to follow our patient with only serial US examinations during the postoperative follow-up period. The excision of giant ovarian cysts by laparotomy requires larger incision. Laparoscopic excision of giant ovarian cysts carries a risk of perforation during trocar insertion and intraabdominal spillage of the cyst content. However, laparoscopic excision after US-guided drainage of giant ovarian cysts seems to be a safe and applicable treatment modality even in children.
References [1] Helmrath MA, Shin CE, Warner BW. Ovarian cysts in the pediatric population. Semin Pediatr Surg 1998;7:19 - 28. [2] Yuen PM, Yu KM, Yip SK, et al. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol 1997;177:109 - 14. [3] Knudsen UB, Tabor A, Mosgaard B, et al. Management of ovarian cysts. Acta Obstet Gynecol Scand 2004;83:1012 - 21. [4] Ma KK, Tsui PZY, Wong WC, et al. Laparoscopic management of large ovarian cysts: more than cosmetic considerations. Hong Kong Med J 2004;10:139 - 41. [5] Mecke H, Savvas V. Laparoscopic surgery of dermoid cysts— intraoperative spillage and complications. Eur J Obstet Gynecol Reprod Biol 2004;96:80 - 4. [6] Salem AFH. Laparoscopic excision of large ovarian cysts. J Obstet Gynaecol Res 2002;28:290 - 4. [7] Ou CS, Liu YH, Zabriskie V, et al. Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter. J Laparoendosc Adv Surg Tech 2001;11:125 - 31. [8] Nagele F, Magos AL. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol 1996;175:1377 - 8. [9] Cevriog˘lu AS, Polat C, Fenkc¸i V, et al. Laparoscopic management following ultrasonograhic-guided drainage in a patient with giant paraovarian cyst. Surg Endosc 2004;18:346. [10] Quint EH, Kozlowski K. Adnexal masses in teenagers. J Pediatr Adolesc Gynecol 2000;13:145 - 6. [11] Strickland JL. Ovarian cysts in neonates, children and adolescents. Curr Opin Obstet Gynecol 2002;14:459 - 65.