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Laparoscopic management of benign cystic teratomas during pregnancy
Laparoscopic management of benign cystic teratomas during pregnancy William H. Parker, MD," Joel M. Childers, MD, b Michel Canis, MD, c Douglas R. Phillips, MD, d and Howard Topel, MD" Los Angeles, California, Tucson, Arizona, Stony Brook, New York, Park Ridge, Illinois, and Clermont-Ferrand, France OBJECTIVE" Our purpose was to evaluate the surgical management and outcome of laparoscopic removal of benign cystic teratomas during pregnancy. STUDY DESIGN: The records of women with benign cystic teratomas who were managed with operative laparoscopy during pregnancy were reviewed. RESULTS: Twelve women had laparoscopic removal of a benign cystic teratoma during pregnancy. Gestational ages at surgery ranged from 9 to 17 weeks, with a mean of 14 weeks. Cyst size ranged from 5 to 13 cm, with a mean of 8.5 cm. Intraoperative rupture of the cyst occurred in 10 of 12 (93%) women. No patient had evidence of chemical peritonitis. The mean operating time was 87 minutes and the mean postoperative hospital stay was 44 hours. No intraoperative or postoperative matemal or fetal complications occurred. CONCLUSIONS: Laparoscopic removal of a benign cystic teratoma of the ovary may be safely accomplished during pregnancy, In spite of a significant risk of cyst rupture, careful operative technique followed by copious irrigation of the pelvis may avoid chemical peritonitis and potential adverse sequelae. (AM J OBSTETGYNECOL1996;174:1499-501 .)
Key words; Laparoscopy, pregnancy
The management of an adnexal mass by operative laparoscopy is controversial. However, recent reports have shown that laparoscopic cystectomy or oophorectomy may be safely accomplished?' ~ An adnexal mass may be discovered during pregnancy in 1:160 to 1:1300 women?' 4 Persistent tumors are often removed to rule out malignancy, avoid torsion or rupture during pregnancy, and prevent the mass from obstructing delivery. Benign cystic teratomas are the most common ovarian tumors that complicate pregnancy, composing 24% to 40% of all such masses. 5' 6 The standard approach to removal of an adnexal mass during pregnancy is by laparotomy. Management by operative laparoscopy has been approached with caution because of the high level of technical ability n e e d e d to perform laparoscopic surgery in a limited operative field and because of concern that the surgical technique might endanger the fetus. Laparoscopic removal of an ovarian cyst is more likely to result in cyst rupture than if it is From the Departments of Obstetrics and Gynecology, University of California, Los Angeles, School of Medicine,~ University of Arizona,~Polyclinique de l'Hotel Dieu,~State University of New York,d and Lutheran General Hospital. Received for publication September 5, 1995; revised October 5, 1995; accepted October10, 1995. Reprint requests: William H. Parker, MD, 1450 Tenth St., Santa Monica, CA 90401. Copyright 9 1996 by Mosby-YearBook, Inc. 0002-9378/96 ~5.00 + 0 6/1/69805
removed through a laparotomy. Furthermore, the possibility of chemical peritonitis after rupture of a benign cystic teratoma has raised concern regarding the lapar Oscopic approach. The purpose of this study was to review the records of women who had laparoscopic removal of benign cystic teratomas during pregnancy performed by experienced laparoscopic surgeons and to evaluate the surgical procedure and its effects on the pregnancy and fetus. Material and m e t h o d s
We retrospectively reviewed the hospital and office records of women in our practices who underwent laparoscopic management of a benign cystic teratoma during pregnancy between 1987 and 1995. A mass was found on pelvic examination in 5 women or incidentally during obstetric ultrasonography in 3 women. Four women were evaluated for pelvic pain during pregnancy; an adnexal mass was discovered at that time. The preoperative ultrasonographic diagnosis was benign cystic teratoma in 10 patients and a mucinous cyst in 2 women. The patient's age, gestational age at surgery, surgical technique, and operative findings were reviewed. Operative time, estimated blood loss, and postoperative hospital stay were recorded. Additionally, complications of surgery and outcome of pregnancy were evaluated. 1499
1500
Parker et al.
Results Twelve women had laparoscopic removal of a benign cystic teratoma during pregnancy. Patient ages ranged from 21 to 36 years, with a mean of 29 years. Gestational ages at surgery ranged from 9 to 17 weeks, with a mean of 14 weeks. Cyst size ranged from 5 to 13 cm, with a mean of 8.5 cm. Laparoscopy was performed with direct insertion of the Verres needle or trocar in 11 women, 2 of whom had insertion in the left upper quadrant. One patient had an open laparoscopy. Additional ports were placed, as needed, above the level of the uterus in the right and left lower quadrants. Four women had an oophorectomy performed, three for cysts >10 cm and one for torsion of the adnexa. The remaining eight women had a cystectomy performed. Intraoperative rupture of the cyst occurred in 7 of 8 (88%) women with cystectomy and in 3 of 4 (75%) women who had an oophorectomy. A laparoscopic sac was used to remove the cyst from the abdomen in 6 cases. Estimated blood loss ranged from 5 to 100 ml, with a mean of 52 ml. Operating times ranged from 60 to 130 minutes, with a mean of 87 minutes. The postoperative hospital stay ranged from 8 to 72 hours, with a mean of 44 hours. No patient had evidence of chemical peritonitis, and no intraoperative or postoperative maternal or fetal complications occurred. After surgery two women underwent elective termination of the pregnancy, one for trisomy 13 and the other for a major fetal cardiac anomaly. Ten women were delivered at term without incident. One of these women required a cesarean section, and no pelvic or adnexal adhesions were noted at surgery.
Comment Adnexal masses have been reported to occur during pregnancy in 1:160 to 1:1300 women. 3' 4 With the frequent use of early obstetric sonography, the current rate of discovery may be higher, v Current management of these masses involves observation of cysts not suspicious for malignancy until the second trimester, which allows for spontaneous resolution of nonneoplastic masses. One study of adnexal masses detected ultrasonographically during pregnancy found that all 15 masses <5 cm resolved spontaneously and 19 of 39 (49%) simple cysts >5 cm also resolved spontaneously.7 Improved ultrasonographic imaging and a better understanding of the ultrasonographic appearance of benign cystic teratomas often allows this diagnosis to be made preoperatively. One study found that 12 of 13 benign cystic teratomas contained ultrasonographic evidence of a "dermoid plug. ''s In our study the presumptive diagnosis of a benign cystic teratoma was established ultrasonographically in 10 of the 12 patients. One patient required a "one-cut" computed tomographic scan to confirm the ultrasonographic impression. The potential risks of surgery and anesthesia must be balanced with the risks of a persistent adnexal mass dur-
May 1996 AmJ ObstetGynecol
ing pregnancy. Two large studies found no increase in the risk of congenital anomalies among women operated on during pregnancy.9' io However, one of these studies found an increased risk of spontaneous abortion (risk ratio 2.0) among women subjected to general anesthesia and gynecologic surgery during the first or second trimester. 9The other study found that, for women subjected to surgery during pregnancy, the risk of delivery before 37 weeks was 7.5% compared with the expected risk of 5.1%. 1~ Birth weights were also lower in the surgical group because of both prematurity and a higher rate of intrauterine growth restriction. The authors could not determine what roles anesthesia, surgery, or the disorders that necessitated surgery played in these adverse outcomes. The effect of a carbon dioxide pneumoperitoneum on the fetus during laparoscopic surgery is not well understood. However, recent animal studies suggest that there are no deleterious effects. 11 Masses that persist after the second trimester are removed to prevent torsion or rupture during pregnancy, prevent possible obstruction of delivery by the mass, and to rule out malignancy.I2 In a large study of benign cystic teratomas during pregnancy, torsion occurred in 19%, rupture in 3%, and obstruction of labor in 14% of patients. ~An additional 22% of women required surgery in the puerperium for torsion, rupture, or infection of the mass. Furthermore, malignancy has been reported in 5% of adnexal masses discovered during pregnancy.6 Of significance, one study demonstrated that elective removal of an adnexal mass during pregnancy was less morbid than removal of a symptomatic mass in an emergency setting. 4Fifteen of 54 patients studied had an emergency laparotomy, 6 for hemorrhage from a ruptured cyst, 7 for adnexal torsion, and 1 to remove an infarcted mass without torsion. Among these 15 women, 8 (53%) had a spontaneous abortion and 3 (20%) were delivered before 37 weeks' gestation. For the 39 women undergoing elective surgery for an adnexal mass, 2 (5%) had a spontaneous abortion and none were delivered before 37 weeks. To avoid the potential risks of a surgical emergency, the authors recommended elective removal of any adnexal mass >6 cm that persists for 16 weeks, regardless of its ultrasonographic appearance. The advantages of laparoscopic management of benign cystic teratomas in nonpregnant women have been demonstrated. A retrospective case-controlled study comparing the management of benign cystic teratomas by laparotomy with those managed by laparoscopy found comparable operating times but significantlyshorter hospital stays (0.5 vs 3.5 days) for those women who had their cysts managed by laparoscopy) 3 The shorter hospital stay and faster recovery associated with laparoscopic surgery may also be of benefit to the pregnant patient; however, experience with laparoscopic surgery in pregnant women is limited] ~-17 One study of nonpregnant patients documented a higher incidence of rupture of cystic teratomas with lap-
Volume 174, Number 5 AmJ Obstet Gynecol
aroscopic m a n a g e m e n t than with those m a n a g e d by laparotomy. 1~ However, five separate studies reported only two instances of chemical peritonitis after laparoscopic m a n a g e m e n t of 168 w o m e n with b e n i g n cystic teratomas.1, 1~. 18-20I n our study n o patient had signs of peritoneal irritation, chemical peritonitis, or p r e m a t u r e labor after surgery. Copious irrigation of the peMs a n d u p p e r a b d o m e n at the time of laparoscopic surgery appears to limit the risk of chemical peritonitis. To ensure the safety of the ferns, careful operative technique is r e c o m m e n d e d d u r i n g the laparoscopic mana g e m e n t of a b e n i g n cystic teratoma d u r i n g pregnancy. Surgery should be p e r f o r m e d early in the second trimester, w h e n the risk of i n d u c i n g a s p o n t a n e o u s abortion is reported to be low a n d the uterus is small e n o u g h to allow adequate operative exposure. O p e n laparoscopy or initial p l a c e m e n t of the Verres n e e d l e a n d trocar in the left u p p e r q u a d r a n t may be c o n s i d e r e d to protect the gravid uterus from injury. 21 Exposure of the operative field may be m o r e difficult because of the size a n d position of the gravid uterus a n d because an intrauterine elevating device c a n n o t be used. Ovarian cystectomy is r e c o m m e n d e d in these reproductive-aged w o m e n to preserve ovarian tissue. Careful inspection of the peritoneal cavity, copious irrigation, a n d removal of all spilled cyst contents should be p e r f o r m e d to prevent chemical peritonitisY D u r i n g surgery the contralateral ovary should be inspected because these tumors may be bilateral in ]0% of cases. However, an ovary that appears to be n o r m a l will rarely contain a b e n i g n cystic teratoma, a n d therefore wedge resection is n o t indicated. To the contrary, wedge resection has b e e n shown to i n d u c e extensive adhesions, thus risking impaired fertility. 2~ To avoid the risks of torsion, rupture, obstruction of labor, or emergency adnexal surgery, we believe that elective removal of b e n i g n cystic teratomas d u r i n g pregnancy is appropriate. O u r preliminary experience suggests that laparoscopic removal of these masses is feasible a n d safe, a n d that further study of this approach is warranted. REFERENCES
1. Canis M, Mage G, PoulyJ, Wattiez A, Manhes H, Bruhat M. Laparoscopic diagnosis of adnexal cystic masses: a twelve year experience with long-term follow-up. Obstet Gyaaecol 1994;83:70%12. 2. Parker W, Levine R, Howard F, Sansone B, BerekJ. A multicenter study of laparoscopic management of selected cystic
Parker et al.
1501
adnexal masses in postmenopausal women. J Am Cell Surg 1994;179:733-7. 3. Sunoo C, Terada K, Kamemoto L, Hale R. Adnexal masses in pregnancy: occurrence by ethnic group. Obstet Gynecol 1990;75:38-40. 4. Hess L, Peaceman A, O'Brien W, Winkel C, Cruikshank D, Morrison J. Adnexal mass occurring with intrauterine pregnancy: report of fifty-four patients requiring laparotomy for definitive management. &~j OBSTETGYNECOL1988;158: 1029-34: 5. Peterson W, Prevost E, Edmunds E Hundley J, Morris E Benign cystic teratomas of the ovary: a clinico-statistical study of 1,007 cases with a review of the literature. AM J OBsa'~TG~COL 1955;70:368-82. 6. Tawa K Ovarian tumors in pregnancy. AMJ OSSTETG';NECOL 1964;90:511-6. 7. Thorton J, Wells M. Ovarian cysts during pregnancy: does ultrasound make traditional management inappropriate? Obstet Gynecol 1987;69:717-20. 8. Quinn S, Erickson S, Black W. Cystic ovarian teratomas: the sonogrpahic appearance of the dermoid plug. Radiology 1985;155:477-8. 9. Duncan P, Pope W, Cohen M, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986;64: 790-4. 10. Mazze R, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. AMJ OBSTETGYNJSCOL1989;61:1178-85. 11. Bernard J, Chaffin D, Droste S, Tierney A; Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 1995;85:669-74. 12. Struyk A, Treffers E Ovarian tumors in pregnancy. Acta Obstet Gynecol Scand 1984;63:421-4. 13. Albini S, Benadiva C, Haverly K, Luciano A. Management of benign cystic teratomas: laparoscopy compared with laparotomy.J Am Assoc Gynecol Laparoscop 1994;1:219-22. 14. Nezhat F, Nezhat C, Sitfen S, Fehnel S. Laparoscopic ovarian cystectomy during pregnancy. J Laproendosc Surg 1991;1: 161-4. 15. Howard E ViU M. Laparoscopic adnexal surgery during pregnancy. J Am Assoc Gynecol Laparoscop 1994;2:91-3. 16. Soper N, Hunter J, Petrie R. Laparoscopic cholecystectomy during pregnancy. Surg Endosc 1992;6:115-7. 17, Schreibner J. Laparoscopic appendectomy in pregnancy. Surg Endosc 1990;4:100-2. 18. Reich H, McGlynn F, Sekel L, Taylor R Laparoscopic management of ovarian dermoid cysts. J Reprod Med 1992;37: 6404. 19. Chen J, He E, Chen M. Operative laparoscopy in benign cystic teratomas of ovary. China MedJ 1992;50:194-7. 20. Nezhat C, Winer W, Nezhat E Laparoscopic removal of dermoid cysts. Obstet Gynecol 1989;73:278-80. 21. ChildersJ, Brzechffa P, Surwit E. Laparoscopy using the left upper quadrant as the primary trocar site. Gynecol Oncol 1993;50:221-5. 22. Parker W, BerekJ. Management of the pelvic mass by operative laparoscopy. In: Soderstrom R, editor. Operative laparoscopy: the master's techniques. New York: Raven Press, 1994:109-19. 23. ToaffR, ToaffM, Peyser M. Infertilityfollowing wedge resection of the ovaries. AMJ OBSTETG~COL 1976;124:92-6.
Key words; Laparoscopy, pregnancy
The management of an adnexal mass by operative laparoscopy is controversial. However, recent reports have shown that laparoscopic cystectomy or oophorectomy may be safely accomplished?' ~ An adnexal mass may be discovered during pregnancy in 1:160 to 1:1300 women?' 4 Persistent tumors are often removed to rule out malignancy, avoid torsion or rupture during pregnancy, and prevent the mass from obstructing delivery. Benign cystic teratomas are the most common ovarian tumors that complicate pregnancy, composing 24% to 40% of all such masses. 5' 6 The standard approach to removal of an adnexal mass during pregnancy is by laparotomy. Management by operative laparoscopy has been approached with caution because of the high level of technical ability n e e d e d to perform laparoscopic surgery in a limited operative field and because of concern that the surgical technique might endanger the fetus. Laparoscopic removal of an ovarian cyst is more likely to result in cyst rupture than if it is From the Departments of Obstetrics and Gynecology, University of California, Los Angeles, School of Medicine,~ University of Arizona,~Polyclinique de l'Hotel Dieu,~State University of New York,d and Lutheran General Hospital. Received for publication September 5, 1995; revised October 5, 1995; accepted October10, 1995. Reprint requests: William H. Parker, MD, 1450 Tenth St., Santa Monica, CA 90401. Copyright 9 1996 by Mosby-YearBook, Inc. 0002-9378/96 ~5.00 + 0 6/1/69805
removed through a laparotomy. Furthermore, the possibility of chemical peritonitis after rupture of a benign cystic teratoma has raised concern regarding the lapar Oscopic approach. The purpose of this study was to review the records of women who had laparoscopic removal of benign cystic teratomas during pregnancy performed by experienced laparoscopic surgeons and to evaluate the surgical procedure and its effects on the pregnancy and fetus. Material and m e t h o d s
We retrospectively reviewed the hospital and office records of women in our practices who underwent laparoscopic management of a benign cystic teratoma during pregnancy between 1987 and 1995. A mass was found on pelvic examination in 5 women or incidentally during obstetric ultrasonography in 3 women. Four women were evaluated for pelvic pain during pregnancy; an adnexal mass was discovered at that time. The preoperative ultrasonographic diagnosis was benign cystic teratoma in 10 patients and a mucinous cyst in 2 women. The patient's age, gestational age at surgery, surgical technique, and operative findings were reviewed. Operative time, estimated blood loss, and postoperative hospital stay were recorded. Additionally, complications of surgery and outcome of pregnancy were evaluated. 1499
1500
Parker et al.
Results Twelve women had laparoscopic removal of a benign cystic teratoma during pregnancy. Patient ages ranged from 21 to 36 years, with a mean of 29 years. Gestational ages at surgery ranged from 9 to 17 weeks, with a mean of 14 weeks. Cyst size ranged from 5 to 13 cm, with a mean of 8.5 cm. Laparoscopy was performed with direct insertion of the Verres needle or trocar in 11 women, 2 of whom had insertion in the left upper quadrant. One patient had an open laparoscopy. Additional ports were placed, as needed, above the level of the uterus in the right and left lower quadrants. Four women had an oophorectomy performed, three for cysts >10 cm and one for torsion of the adnexa. The remaining eight women had a cystectomy performed. Intraoperative rupture of the cyst occurred in 7 of 8 (88%) women with cystectomy and in 3 of 4 (75%) women who had an oophorectomy. A laparoscopic sac was used to remove the cyst from the abdomen in 6 cases. Estimated blood loss ranged from 5 to 100 ml, with a mean of 52 ml. Operating times ranged from 60 to 130 minutes, with a mean of 87 minutes. The postoperative hospital stay ranged from 8 to 72 hours, with a mean of 44 hours. No patient had evidence of chemical peritonitis, and no intraoperative or postoperative maternal or fetal complications occurred. After surgery two women underwent elective termination of the pregnancy, one for trisomy 13 and the other for a major fetal cardiac anomaly. Ten women were delivered at term without incident. One of these women required a cesarean section, and no pelvic or adnexal adhesions were noted at surgery.
Comment Adnexal masses have been reported to occur during pregnancy in 1:160 to 1:1300 women. 3' 4 With the frequent use of early obstetric sonography, the current rate of discovery may be higher, v Current management of these masses involves observation of cysts not suspicious for malignancy until the second trimester, which allows for spontaneous resolution of nonneoplastic masses. One study of adnexal masses detected ultrasonographically during pregnancy found that all 15 masses <5 cm resolved spontaneously and 19 of 39 (49%) simple cysts >5 cm also resolved spontaneously.7 Improved ultrasonographic imaging and a better understanding of the ultrasonographic appearance of benign cystic teratomas often allows this diagnosis to be made preoperatively. One study found that 12 of 13 benign cystic teratomas contained ultrasonographic evidence of a "dermoid plug. ''s In our study the presumptive diagnosis of a benign cystic teratoma was established ultrasonographically in 10 of the 12 patients. One patient required a "one-cut" computed tomographic scan to confirm the ultrasonographic impression. The potential risks of surgery and anesthesia must be balanced with the risks of a persistent adnexal mass dur-
May 1996 AmJ ObstetGynecol
ing pregnancy. Two large studies found no increase in the risk of congenital anomalies among women operated on during pregnancy.9' io However, one of these studies found an increased risk of spontaneous abortion (risk ratio 2.0) among women subjected to general anesthesia and gynecologic surgery during the first or second trimester. 9The other study found that, for women subjected to surgery during pregnancy, the risk of delivery before 37 weeks was 7.5% compared with the expected risk of 5.1%. 1~ Birth weights were also lower in the surgical group because of both prematurity and a higher rate of intrauterine growth restriction. The authors could not determine what roles anesthesia, surgery, or the disorders that necessitated surgery played in these adverse outcomes. The effect of a carbon dioxide pneumoperitoneum on the fetus during laparoscopic surgery is not well understood. However, recent animal studies suggest that there are no deleterious effects. 11 Masses that persist after the second trimester are removed to prevent torsion or rupture during pregnancy, prevent possible obstruction of delivery by the mass, and to rule out malignancy.I2 In a large study of benign cystic teratomas during pregnancy, torsion occurred in 19%, rupture in 3%, and obstruction of labor in 14% of patients. ~An additional 22% of women required surgery in the puerperium for torsion, rupture, or infection of the mass. Furthermore, malignancy has been reported in 5% of adnexal masses discovered during pregnancy.6 Of significance, one study demonstrated that elective removal of an adnexal mass during pregnancy was less morbid than removal of a symptomatic mass in an emergency setting. 4Fifteen of 54 patients studied had an emergency laparotomy, 6 for hemorrhage from a ruptured cyst, 7 for adnexal torsion, and 1 to remove an infarcted mass without torsion. Among these 15 women, 8 (53%) had a spontaneous abortion and 3 (20%) were delivered before 37 weeks' gestation. For the 39 women undergoing elective surgery for an adnexal mass, 2 (5%) had a spontaneous abortion and none were delivered before 37 weeks. To avoid the potential risks of a surgical emergency, the authors recommended elective removal of any adnexal mass >6 cm that persists for 16 weeks, regardless of its ultrasonographic appearance. The advantages of laparoscopic management of benign cystic teratomas in nonpregnant women have been demonstrated. A retrospective case-controlled study comparing the management of benign cystic teratomas by laparotomy with those managed by laparoscopy found comparable operating times but significantlyshorter hospital stays (0.5 vs 3.5 days) for those women who had their cysts managed by laparoscopy) 3 The shorter hospital stay and faster recovery associated with laparoscopic surgery may also be of benefit to the pregnant patient; however, experience with laparoscopic surgery in pregnant women is limited] ~-17 One study of nonpregnant patients documented a higher incidence of rupture of cystic teratomas with lap-
Volume 174, Number 5 AmJ Obstet Gynecol
aroscopic m a n a g e m e n t than with those m a n a g e d by laparotomy. 1~ However, five separate studies reported only two instances of chemical peritonitis after laparoscopic m a n a g e m e n t of 168 w o m e n with b e n i g n cystic teratomas.1, 1~. 18-20I n our study n o patient had signs of peritoneal irritation, chemical peritonitis, or p r e m a t u r e labor after surgery. Copious irrigation of the peMs a n d u p p e r a b d o m e n at the time of laparoscopic surgery appears to limit the risk of chemical peritonitis. To ensure the safety of the ferns, careful operative technique is r e c o m m e n d e d d u r i n g the laparoscopic mana g e m e n t of a b e n i g n cystic teratoma d u r i n g pregnancy. Surgery should be p e r f o r m e d early in the second trimester, w h e n the risk of i n d u c i n g a s p o n t a n e o u s abortion is reported to be low a n d the uterus is small e n o u g h to allow adequate operative exposure. O p e n laparoscopy or initial p l a c e m e n t of the Verres n e e d l e a n d trocar in the left u p p e r q u a d r a n t may be c o n s i d e r e d to protect the gravid uterus from injury. 21 Exposure of the operative field may be m o r e difficult because of the size a n d position of the gravid uterus a n d because an intrauterine elevating device c a n n o t be used. Ovarian cystectomy is r e c o m m e n d e d in these reproductive-aged w o m e n to preserve ovarian tissue. Careful inspection of the peritoneal cavity, copious irrigation, a n d removal of all spilled cyst contents should be p e r f o r m e d to prevent chemical peritonitisY D u r i n g surgery the contralateral ovary should be inspected because these tumors may be bilateral in ]0% of cases. However, an ovary that appears to be n o r m a l will rarely contain a b e n i g n cystic teratoma, a n d therefore wedge resection is n o t indicated. To the contrary, wedge resection has b e e n shown to i n d u c e extensive adhesions, thus risking impaired fertility. 2~ To avoid the risks of torsion, rupture, obstruction of labor, or emergency adnexal surgery, we believe that elective removal of b e n i g n cystic teratomas d u r i n g pregnancy is appropriate. O u r preliminary experience suggests that laparoscopic removal of these masses is feasible a n d safe, a n d that further study of this approach is warranted. REFERENCES
1. Canis M, Mage G, PoulyJ, Wattiez A, Manhes H, Bruhat M. Laparoscopic diagnosis of adnexal cystic masses: a twelve year experience with long-term follow-up. Obstet Gyaaecol 1994;83:70%12. 2. Parker W, Levine R, Howard F, Sansone B, BerekJ. A multicenter study of laparoscopic management of selected cystic
Parker et al.
1501
adnexal masses in postmenopausal women. J Am Cell Surg 1994;179:733-7. 3. Sunoo C, Terada K, Kamemoto L, Hale R. Adnexal masses in pregnancy: occurrence by ethnic group. Obstet Gynecol 1990;75:38-40. 4. Hess L, Peaceman A, O'Brien W, Winkel C, Cruikshank D, Morrison J. Adnexal mass occurring with intrauterine pregnancy: report of fifty-four patients requiring laparotomy for definitive management. &~j OBSTETGYNECOL1988;158: 1029-34: 5. Peterson W, Prevost E, Edmunds E Hundley J, Morris E Benign cystic teratomas of the ovary: a clinico-statistical study of 1,007 cases with a review of the literature. AM J OBsa'~TG~COL 1955;70:368-82. 6. Tawa K Ovarian tumors in pregnancy. AMJ OSSTETG';NECOL 1964;90:511-6. 7. Thorton J, Wells M. Ovarian cysts during pregnancy: does ultrasound make traditional management inappropriate? Obstet Gynecol 1987;69:717-20. 8. Quinn S, Erickson S, Black W. Cystic ovarian teratomas: the sonogrpahic appearance of the dermoid plug. Radiology 1985;155:477-8. 9. Duncan P, Pope W, Cohen M, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986;64: 790-4. 10. Mazze R, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. AMJ OBSTETGYNJSCOL1989;61:1178-85. 11. Bernard J, Chaffin D, Droste S, Tierney A; Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 1995;85:669-74. 12. Struyk A, Treffers E Ovarian tumors in pregnancy. Acta Obstet Gynecol Scand 1984;63:421-4. 13. Albini S, Benadiva C, Haverly K, Luciano A. Management of benign cystic teratomas: laparoscopy compared with laparotomy.J Am Assoc Gynecol Laparoscop 1994;1:219-22. 14. Nezhat F, Nezhat C, Sitfen S, Fehnel S. Laparoscopic ovarian cystectomy during pregnancy. J Laproendosc Surg 1991;1: 161-4. 15. Howard E ViU M. Laparoscopic adnexal surgery during pregnancy. J Am Assoc Gynecol Laparoscop 1994;2:91-3. 16. Soper N, Hunter J, Petrie R. Laparoscopic cholecystectomy during pregnancy. Surg Endosc 1992;6:115-7. 17, Schreibner J. Laparoscopic appendectomy in pregnancy. Surg Endosc 1990;4:100-2. 18. Reich H, McGlynn F, Sekel L, Taylor R Laparoscopic management of ovarian dermoid cysts. J Reprod Med 1992;37: 6404. 19. Chen J, He E, Chen M. Operative laparoscopy in benign cystic teratomas of ovary. China MedJ 1992;50:194-7. 20. Nezhat C, Winer W, Nezhat E Laparoscopic removal of dermoid cysts. Obstet Gynecol 1989;73:278-80. 21. ChildersJ, Brzechffa P, Surwit E. Laparoscopy using the left upper quadrant as the primary trocar site. Gynecol Oncol 1993;50:221-5. 22. Parker W, BerekJ. Management of the pelvic mass by operative laparoscopy. In: Soderstrom R, editor. Operative laparoscopy: the master's techniques. New York: Raven Press, 1994:109-19. 23. ToaffR, ToaffM, Peyser M. Infertilityfollowing wedge resection of the ovaries. AMJ OBSTETG~COL 1976;124:92-6.