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Marsupialization of the Cyst as a Step in Laparoscopic Management of Ovarian Cysts
Marsupialization of Ovarian Cysts Kalegyn and Sadykova
Marsupialization of the Cyst as a Step in Laparoscopic Management of Ovarian Cysts Alexander V. Kalegyn, M.D., and Mayram H. Sadykova, M.D.
Abstract Study Objective. To compare a traditional technique of ovarian cyst management with a marsupialization method (MM) developed by the authors. Design. Prospective, observational study (Canadian Task Force classification II–1). Setting. Central Asian city teaching hospital. Patients. Eighty-one women with benign ovarian cysts. Intervention. Traditional laparoscopic cyst management and MM. Cysts were removed through a cannula site after being placed into an endobag and marsupialization. With this technique, cysts were emptied partially or completely by aspiration and brought outside the abdominal cavity through a 1.5- to 2.5-cm cannula incision site. Some of the cyst contents may be removed during extraction. The technique allows the surgeon to interrupt cyst pedicles extracorporally or intracorporally. Measurements and Main Results. With traditional methods of laparoscopic cystectomy the spillage rate was 18% (6 patients), compared with 16% (8 patients) for MM. Operating time, blood loss, and mean hospital stay were not statistically different between groups (p >00.5). Conclusion. With MM technique, cystectomy is simple, reliable, and cost effective. (J Am Assoc Gynecol Laparosc 8(4):568–572, 2001)
Materials and Methods
Laparoscopic surgery is effective in managing benign ovarian tumors, but cyst removal is associated with some difficulties, which led to development of different approaches.1,2 One difficulty is the method of cyst removal. Traditional laparoscopic technique consists of intracorporeal interruption or dissection of all anatomic structures that connect a tumor to undamaged ovarian tissue and removing the cyst or entire ovary. Bringing the tumor outside the abdominal cavity is accomplished in several ways: large cannula, port site, culdotomy, and enlarged port incision.1,2 We suggest a marsupialization method (MM) that, based on our results, would be a good alternative to traditional technique. We prospectively compared the traditional method of using a bag for cyst removal with MM.
Patients with dermoid cysts, serous and mucinous cystadenomas, and endometriomas were randomly and equally distributed between two groups. Group A had 18 patients (54%) with serous cysts, 8 (25%) with dermoid cysts, 6 (18%) with endometriomas, and 1 (3%) with mucous cytoadenoma. Respective figures in group B were 21 (44%), 11 (23%), 14 (29%), and 2 (4%). Women underwent standard preoperative evaluation including physical and ultrasound examinations. No tumor markers or other facultative diagnostic tests were performed. Frozen section was not available at the time of this study. Routine pathology examinations were performed on all specimens. Two
From the Regional 10th Obstetrical-Gynecological Hospital, Tashkent, Uzbekistan (both authors). Address reprint request to Alexander V. Kalegyn, M.D., Regional 10th Obstetrical-Gynecological Hospital, Tashkent City Health Care System, Buyuk Yupak Yulli III-9 Tashkent 700077, Uzbekistan; fax 998 712 684983. Accepted for publication May 22, 2001. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, November 2001, Vol. 8 No. 4 © 2001 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
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November 2001, Vol. 8, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
patients with malignancy identified at laparoscopy were treated by laparotomy; they are excluded from data analysis. Thirty-three women (group A, age range 17–42 yrs) underwent conventional cystectomy, oophorectomy, or salpingo-oophorectomy, with specimens placed in bags and extracted through the port site. Forty-eight women (group B, age range 17–45 yrs) were treated by MM. Body weight was a criterion for selecting patients, because MM cannot be performed in obese women. The procedure is preferable in women with normal or lean habitus.
and 115.5 ± 24.8 ml, respectively (p >0.05). There were no significant differences in tumor size and postoperative recovery (Table 1). Although we tried to follow all women for a substantial length of time, some were lost to follow-up. In the two groups combined, only two women had recurrent ovarian tumor. Both had recurrent endometriosis. Pregnancy rate was not intentionally investigated in this study, but three women did conceive. No second-look operations were performed in patients of either group.
Operative Techniques All patients were given spinal anesthesia. In threeport method, one 11-mm cannula was placed in the periumbilical area, a 5-mm cannula in the lateral abdominal incision, and a 12- to 14-mm cannula in the suprapubic area. In group A, cysts were enucleated or ovarian excision was done with scissors attached to a unipolar circuit combined with bipolar coagulation. In some cases, to ensure hemostasis, endoloop technique was employed. Once enucleated or removed, the specimen was put inside the bag to be removed through the 12to 14-mm port site. In group B, after grasping the cyst, puncturing it, and aspirating the contents, the edges of the puncture were drawn out and the contents were emptied outside the patient’s body. The empty cyst was removed by bringing it through the same cannula incision outside the abdominal cavity. Then the surgeon treated cyst pedicles extracorporeally with conventional instruments. After restoring pneumoperitoneum, which was stopped for the extracorporeal step, laparoscopic evaluation of the operative site was performed (Figures 1 through 4).
Laparoscopic surgery for benign cyst removal is advantageous compared with laparotomy.3,4 Controversy exists, however, with regard to method of removing specimens from the abdominal cavity.5,6 Putting a specimen into a bag and removing it though a port site or culdotomy is the latest, most reliable approach, and confirms the surgical principle that all ovarian cysts should be removed intact.7 Surgical efforts are directed at preventing cyst rupture and spillage. But even when spillage happens, thorough irrigation with large amounts of water gives good results.8 In an attempt to simplify and make the procedure economically more efficient and attractive for hospitals, which are forced to implement advanced procedures simultaneously with cost-saving methods, we developed MM. The method is based on the principle that the bag to be removed is the cyst wall itself. It can be brought outside of the patient’s body by drawing the apex of the cyst through a port wound. After the cyst is drained through the apex incision, it can be extracted empty to outside of the abdominal cavity. Then the procedure—cystectomy or ovariectomy—is continued with conventional surgical instruments. Advantages of MM are avoidance of electrical energy and complicated steps of endoscopic technique, and cost containment. Four basic techniques may be
Discussion
Results All tumors were removed successfully by traditional laparoscopic surgery and MM. Spillage rates were similar, 18% for traditional method and 16% for MM. Only one case of abdomen wall contamination took place in group A (3%). In group B six wounds (12.5%) were contaminated by cyst contents during extraction. Operating times were 45.5 ± 6.9 minutes for traditional cystectomy and 39.5 ± 6.7 minutes for MM (p >0.05). Blood loss was similar, 80.4 ± 25.3 ml
TABLE 1. Characteristics of Two Methods of Laparoscopic Cystectomy Variable Tumor size (mm) Operating time (min) Blood loss (ml) Time to discharge (hrs)
569
Group A
Group B
59.1 ± 0.5 45.5 ± 6.9 80.4 ± 25.3 24.1 ± 1.9
57.5 ± 1.4 39.5 ± 6.7 115.5 ± 24.8 25.7 ± 1.4
Marsupialization of Ovarian Cysts Kalegyn and Sadykova
FIGURE 1. The cyst is punctured.
FIGURE 2. The cyst is pulled out.
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November 2001, Vol. 8, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 3. Extracting the cyst with its contents.
FIGURE 4. Removal of cyst pedicles.
571
Marsupialization of Ovarian Cysts Kalegyn and Sadykova
applied to management of ovarian cyst—stripping the cyst wall and extraction; removing intact in a bag through port site or culdotomy; puncture; and irrigation and extraction.2,7 The procedure is chosen based on clinical situation. We believe that our modification combines simplicity of earliest methods of cyst fragmentation with reliability regarding spillage with most recent bag procedures. Spillage rates and other characteristics of bag removal are no better with other techniques than with MM.
2. Loffer FD, Parker WH, Hasson HM, et al: Management of ovarian cysts. In Endoscopy in Gynecology, Proceedings of the 20th Annual Meeting of the AAGL. Edited by RB Hunt, DC Martin. Baltimore, Port City Press, 1993, pp 29–33 3. Quinlan DJ, Townsend DE, Johnson GH: Safe and costeffective laparoscopic removal of adnexal masses. J Am Assoc Gynecol Laparosc 4(2):215–218, 1997 4. Shalev E, Bustan M, Romano S, et al: Laparoscopic resection of ovarian benign cyst teratomas: Experience with 84 cases. Hum. Reprod 13(7):1810–1812, 1998
Conclusion Management of ovarian benign tumors by MM provides technical alternatives for surgeons and economic savings for health care institutions. It would be suitable and helpful for hospitals that combine innovation with cost containment. Simplification of the procedure would promote performance of minimally invasive approaches in greater numbers of surgical facilities.
5. Wang PH, Lee WL, Yuan CC, et al: A prospective, randomized comparison of port wound and culdotomy for extracting mature teratomas laparoscopically. J Am Assoc Gynecol Laparosc 6(4):483–486, 1999 6. Nezhat WH, Kalyoncu S, Nezhat CH, et al: Laparoscopic management of ovarian dermoid cysts [abstr]. J Am Assoc Gynecol Laparosc 6(3):S41, 1999 7. Lee YS, Lee TH, Kang IK, et al: Laparoscopic management of dermoid cysts by four extraction methods [abstr]. J Am Assoc Gynecol Laparosc 6(3):S28, 1999
References 1. Adamyan LV, Beloglazova SE: Laparoscopy and laparotomy in the diagnosis and treatment of benign ovarian masses. In Endoscopy in Gynecology. Edited by VI Kulakov, LV Adamyan. Moscow, Victoria Print, 1999, pp 375–388
8. Vignali M, Renzini MM, Ferrari L, et al: Laparoscopic management of ovarian dermoid cysts [abstr]. J Am Assoc Gynecol Laparosc 6(3):S60, 1999
572
Marsupialization of the Cyst as a Step in Laparoscopic Management of Ovarian Cysts Alexander V. Kalegyn, M.D., and Mayram H. Sadykova, M.D.
Abstract Study Objective. To compare a traditional technique of ovarian cyst management with a marsupialization method (MM) developed by the authors. Design. Prospective, observational study (Canadian Task Force classification II–1). Setting. Central Asian city teaching hospital. Patients. Eighty-one women with benign ovarian cysts. Intervention. Traditional laparoscopic cyst management and MM. Cysts were removed through a cannula site after being placed into an endobag and marsupialization. With this technique, cysts were emptied partially or completely by aspiration and brought outside the abdominal cavity through a 1.5- to 2.5-cm cannula incision site. Some of the cyst contents may be removed during extraction. The technique allows the surgeon to interrupt cyst pedicles extracorporally or intracorporally. Measurements and Main Results. With traditional methods of laparoscopic cystectomy the spillage rate was 18% (6 patients), compared with 16% (8 patients) for MM. Operating time, blood loss, and mean hospital stay were not statistically different between groups (p >00.5). Conclusion. With MM technique, cystectomy is simple, reliable, and cost effective. (J Am Assoc Gynecol Laparosc 8(4):568–572, 2001)
Materials and Methods
Laparoscopic surgery is effective in managing benign ovarian tumors, but cyst removal is associated with some difficulties, which led to development of different approaches.1,2 One difficulty is the method of cyst removal. Traditional laparoscopic technique consists of intracorporeal interruption or dissection of all anatomic structures that connect a tumor to undamaged ovarian tissue and removing the cyst or entire ovary. Bringing the tumor outside the abdominal cavity is accomplished in several ways: large cannula, port site, culdotomy, and enlarged port incision.1,2 We suggest a marsupialization method (MM) that, based on our results, would be a good alternative to traditional technique. We prospectively compared the traditional method of using a bag for cyst removal with MM.
Patients with dermoid cysts, serous and mucinous cystadenomas, and endometriomas were randomly and equally distributed between two groups. Group A had 18 patients (54%) with serous cysts, 8 (25%) with dermoid cysts, 6 (18%) with endometriomas, and 1 (3%) with mucous cytoadenoma. Respective figures in group B were 21 (44%), 11 (23%), 14 (29%), and 2 (4%). Women underwent standard preoperative evaluation including physical and ultrasound examinations. No tumor markers or other facultative diagnostic tests were performed. Frozen section was not available at the time of this study. Routine pathology examinations were performed on all specimens. Two
From the Regional 10th Obstetrical-Gynecological Hospital, Tashkent, Uzbekistan (both authors). Address reprint request to Alexander V. Kalegyn, M.D., Regional 10th Obstetrical-Gynecological Hospital, Tashkent City Health Care System, Buyuk Yupak Yulli III-9 Tashkent 700077, Uzbekistan; fax 998 712 684983. Accepted for publication May 22, 2001. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, November 2001, Vol. 8 No. 4 © 2001 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
568
November 2001, Vol. 8, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
patients with malignancy identified at laparoscopy were treated by laparotomy; they are excluded from data analysis. Thirty-three women (group A, age range 17–42 yrs) underwent conventional cystectomy, oophorectomy, or salpingo-oophorectomy, with specimens placed in bags and extracted through the port site. Forty-eight women (group B, age range 17–45 yrs) were treated by MM. Body weight was a criterion for selecting patients, because MM cannot be performed in obese women. The procedure is preferable in women with normal or lean habitus.
and 115.5 ± 24.8 ml, respectively (p >0.05). There were no significant differences in tumor size and postoperative recovery (Table 1). Although we tried to follow all women for a substantial length of time, some were lost to follow-up. In the two groups combined, only two women had recurrent ovarian tumor. Both had recurrent endometriosis. Pregnancy rate was not intentionally investigated in this study, but three women did conceive. No second-look operations were performed in patients of either group.
Operative Techniques All patients were given spinal anesthesia. In threeport method, one 11-mm cannula was placed in the periumbilical area, a 5-mm cannula in the lateral abdominal incision, and a 12- to 14-mm cannula in the suprapubic area. In group A, cysts were enucleated or ovarian excision was done with scissors attached to a unipolar circuit combined with bipolar coagulation. In some cases, to ensure hemostasis, endoloop technique was employed. Once enucleated or removed, the specimen was put inside the bag to be removed through the 12to 14-mm port site. In group B, after grasping the cyst, puncturing it, and aspirating the contents, the edges of the puncture were drawn out and the contents were emptied outside the patient’s body. The empty cyst was removed by bringing it through the same cannula incision outside the abdominal cavity. Then the surgeon treated cyst pedicles extracorporeally with conventional instruments. After restoring pneumoperitoneum, which was stopped for the extracorporeal step, laparoscopic evaluation of the operative site was performed (Figures 1 through 4).
Laparoscopic surgery for benign cyst removal is advantageous compared with laparotomy.3,4 Controversy exists, however, with regard to method of removing specimens from the abdominal cavity.5,6 Putting a specimen into a bag and removing it though a port site or culdotomy is the latest, most reliable approach, and confirms the surgical principle that all ovarian cysts should be removed intact.7 Surgical efforts are directed at preventing cyst rupture and spillage. But even when spillage happens, thorough irrigation with large amounts of water gives good results.8 In an attempt to simplify and make the procedure economically more efficient and attractive for hospitals, which are forced to implement advanced procedures simultaneously with cost-saving methods, we developed MM. The method is based on the principle that the bag to be removed is the cyst wall itself. It can be brought outside of the patient’s body by drawing the apex of the cyst through a port wound. After the cyst is drained through the apex incision, it can be extracted empty to outside of the abdominal cavity. Then the procedure—cystectomy or ovariectomy—is continued with conventional surgical instruments. Advantages of MM are avoidance of electrical energy and complicated steps of endoscopic technique, and cost containment. Four basic techniques may be
Discussion
Results All tumors were removed successfully by traditional laparoscopic surgery and MM. Spillage rates were similar, 18% for traditional method and 16% for MM. Only one case of abdomen wall contamination took place in group A (3%). In group B six wounds (12.5%) were contaminated by cyst contents during extraction. Operating times were 45.5 ± 6.9 minutes for traditional cystectomy and 39.5 ± 6.7 minutes for MM (p >0.05). Blood loss was similar, 80.4 ± 25.3 ml
TABLE 1. Characteristics of Two Methods of Laparoscopic Cystectomy Variable Tumor size (mm) Operating time (min) Blood loss (ml) Time to discharge (hrs)
569
Group A
Group B
59.1 ± 0.5 45.5 ± 6.9 80.4 ± 25.3 24.1 ± 1.9
57.5 ± 1.4 39.5 ± 6.7 115.5 ± 24.8 25.7 ± 1.4
Marsupialization of Ovarian Cysts Kalegyn and Sadykova
FIGURE 1. The cyst is punctured.
FIGURE 2. The cyst is pulled out.
570
November 2001, Vol. 8, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 3. Extracting the cyst with its contents.
FIGURE 4. Removal of cyst pedicles.
571
Marsupialization of Ovarian Cysts Kalegyn and Sadykova
applied to management of ovarian cyst—stripping the cyst wall and extraction; removing intact in a bag through port site or culdotomy; puncture; and irrigation and extraction.2,7 The procedure is chosen based on clinical situation. We believe that our modification combines simplicity of earliest methods of cyst fragmentation with reliability regarding spillage with most recent bag procedures. Spillage rates and other characteristics of bag removal are no better with other techniques than with MM.
2. Loffer FD, Parker WH, Hasson HM, et al: Management of ovarian cysts. In Endoscopy in Gynecology, Proceedings of the 20th Annual Meeting of the AAGL. Edited by RB Hunt, DC Martin. Baltimore, Port City Press, 1993, pp 29–33 3. Quinlan DJ, Townsend DE, Johnson GH: Safe and costeffective laparoscopic removal of adnexal masses. J Am Assoc Gynecol Laparosc 4(2):215–218, 1997 4. Shalev E, Bustan M, Romano S, et al: Laparoscopic resection of ovarian benign cyst teratomas: Experience with 84 cases. Hum. Reprod 13(7):1810–1812, 1998
Conclusion Management of ovarian benign tumors by MM provides technical alternatives for surgeons and economic savings for health care institutions. It would be suitable and helpful for hospitals that combine innovation with cost containment. Simplification of the procedure would promote performance of minimally invasive approaches in greater numbers of surgical facilities.
5. Wang PH, Lee WL, Yuan CC, et al: A prospective, randomized comparison of port wound and culdotomy for extracting mature teratomas laparoscopically. J Am Assoc Gynecol Laparosc 6(4):483–486, 1999 6. Nezhat WH, Kalyoncu S, Nezhat CH, et al: Laparoscopic management of ovarian dermoid cysts [abstr]. J Am Assoc Gynecol Laparosc 6(3):S41, 1999 7. Lee YS, Lee TH, Kang IK, et al: Laparoscopic management of dermoid cysts by four extraction methods [abstr]. J Am Assoc Gynecol Laparosc 6(3):S28, 1999
References 1. Adamyan LV, Beloglazova SE: Laparoscopy and laparotomy in the diagnosis and treatment of benign ovarian masses. In Endoscopy in Gynecology. Edited by VI Kulakov, LV Adamyan. Moscow, Victoria Print, 1999, pp 375–388
8. Vignali M, Renzini MM, Ferrari L, et al: Laparoscopic management of ovarian dermoid cysts [abstr]. J Am Assoc Gynecol Laparosc 6(3):S60, 1999
572