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Surgical treatment of ovarian dermoid cysts
European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47–50
Surgical treatment of ovarian dermoid cysts Giuseppe Morgante*, Antonino Ditto, Antonio la Marca, Valeria Trotta, Vincenzo De Leo Siena University, Department of Gynecology and Obstetrics, 53100 Siena, Italy Received 25 May 1998; received in revised form 15 June 1998; accepted 18 June 1998
Abstract Objective: To evaluate the efficacy of laparoscopic ovarian cystectomy and to compare the surgical course, post-surgical course and particularly post-surgical pain of the laparoscopic and laparotomic methods. Study design: We conducted a surgical study on dermoid cysts at the Gynecology Department of Siena University between 1 January 1992 and 31 December 1996. The selected cases were randomized into two groups based on surgical approach: via laparotomy (n522) or laparoscopy (n522). Surgical times, estimated blood loss, post-surgical pain, time in hospital, speed of recovery and complications were compared. Results: Mean blood loss was significantly less for laparoscopy (58.64630.17 ml versus 103.84638.45 ml, P,0.05). Mean hospitalization was 6.3261.09 days for laparotomy and 3.1860.39 days for laparoscopy (P,0.05). Post-surgical pain was significantly less in laparoscopy patients (P,0.05). The laparoscopic technique had fewer post-surgical complications. Conclusions: The laparoscopic approach had many advantages. Laparoscopy should be the elective treatment for women with dermoid cysts, because it has many advantages for the patient and lower costs for the national health system. 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Laparotomy; Laparoscopy; Dermoid cysts; Ovary
1. Introduction Dermoid cysts of the ovary are often diagnosed in women of reproductive age and account for 5–25% of all ovarian tumours [1]. Ninety-nine percent of teratomas are benign. The period of maximum incidence of these tumors is between 30 and 40 years of age [2]. Neoplastic transformation is rare and generally begins from epithelial elements; the most common form of transformation is squamous cell carcinoma; adenocarcinoma and the carcinoid form are much less frequent [3]. The clinical course of dermoid cysts of the ovary is asymptomatic and torsion or spontaneous rupture (followed by acute chemical peritonitis) only occur in 16% and 3–7% of patients, respectively [4]. Diagnosis is based *Corresponding author. Tel.: 139 577 331160; Fax: 139 577 263464; e-mail:[email protected]
on clinical examination and ultrasonographic indications, confirmed by radiological evidence of solid cystic residues in the ovaries [5]. The standard treatment for benign cystic teratoma is laparotomy with surgical removal of the ovarian cysts or oophorectomy and salpingectomy in postmenopausal women. The advent of new, much less invasive techniques, such as laparoscopy, has revolutionized this sector of gynecological surgery. Many studies have shown that laparoscopic treatment of ovarian masses is satisfactory [6] and that laparoscopic diagnosis of malignant tumours of the ovaries has good sensitivity in expert hands [7]. The risk of spillage or inadvertent puncturing of a malignant neoplasm is very low. Laparoscopic treatment of benign ovarian cysts does not prejudice fertility. In this paper we report our experience in the treatment of ovarian cystic teratomas by laparotomy and laparoscopy. Our purpose is to evaluate the two techniques in
0301-2115 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 98 )00139-0
48
G. Morgante et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47 – 50
terms of duration of operation, blood loss, post-surgical pain, mean stay in hospital, complications and recovery in a group of 44 patients with the suspicion of dermoid cyst.
2. Materials and methods We analyzed 44 cases of dermoid cysts treated in the Department of Obstetrics and Gynecology of the University of Siena between 1 January 1992 and 31 December 1996. The parameters considered were type of surgery, duration of operation, blood loss, complications, histology, length of hospitalization and post-surgical pain. After informed consent the patients were assigned to laparoscopy (n522) or laparotomy (n522) by means of a random number table. All women were of reproductive age (14–42 years), without acute pelvic symptoms and with ultrasound diagnosis of dermoid cyst (range 4–12 cm). All patients, except four young women who had never had sexual intercourse, underwent transabdominal and transvaginal ultrasound examinations before surgery. A Siemens Sonoline SL 2 was used with a 3.5 MHz transabdominal sectorial probe and a 5.0–7.5 MHz transvaginal probe. For laparoscopy, the patients underwent general anesthesia with tracheal intubation and the peritoneum was inflated with CO 2 . A 10 / 12 mm trocar for the endoscope was inserted through the navel. Two 5-mm trocars and, when necessary, a 10 / 12-mm trocar for surgical instruments were inserted through the security abdominal triangle. With both procedures, the pelvic cavity was examined with great care for signs of neoplasm. Peritoneal fluid from the Douglas cavity and pre-surgical wash-out were obtained for cytological examination. In eight cases, after aspiration of the cysts, the capsule was removed in such a way as to avoid spillage of cyst fluid into the abdominal cavity. When the capsule broke or fluid spilt, the cavity was washed with saline solution. Bipolar cautery was used for hemostasis. Once the cyst was removed, the ovary was left open. In fourteen other cases the intact dermoid cyst was removed from the ovary, placed in the endo-bag, emptied of fluid and extracted through the 12 mm trocar. When the empty cyst was too large to extract through the trocar, we enlarged the incision and removed the bag directly. Careful follow-up of the laparoscopic cases in which spillage occurred (six cases) and those in which it did not (16 cases) failed to reveal any differences. No patient contracted chemical peritonitis. Blood loss was evaluated during laparotomy by counting and weighing the swabs used. During laparoscopy, blood loss was measured as the difference between the liquid aspirated and that used to wash out the pelvic cavity. The intensity of post-surgical pain was scored using a numerical point scale [8] and considering patient requests
for analgesics. The women filled in the scales in the morning and before taking any analgesic for 3 days after the operation. The patients were contacted by phone 2 weeks after the operation to enquire about recovery. Statistical analysis was performed only on randomized patients using the Fisher exact test and analysis of variance for repeated measures (Anova) and t-test as appropriate. The Bonferroni correction factor was used in the case of multiple testing. Statistical significance was taken as P, 0.05. Values are reported as mean6standard deviation.
3. Results The mean age of patients undergoing laparotomy was 30.28 years (68.32; range 14–42); the mean age of patients undergoing laparoscopy was 29.45 years (66.84; range 15–40). Most of the women sought medical advice because of chronic pelvic pain (25%) or menstrual irregularity (12.8%). In 58.5% of the cases the cysts were discovered by chance during gynecological and / or ultrasonographic examination. In all cases, histological examination of the cysts confirmed the diagnosis of benign dermoid cyst. The mean diameter of the cysts was 6.9 cm (62.7; range 4–12 cm). Dermoid cysts was bilateral in 7.9% of cases, and associated with cysts of other histotypes homolaterally in 8.1% and contralaterally in 15.7%. The associated cysts were of a functional nature (17.2%), endometriosic (4.5%), serous cystadenomas (5.3%), mucinous cystadenoma (1.2%). The mean duration of the operation was 56.87 min for laparotomy (614.52; range 25–110 min) and 79.32 min for laparoscopy (626.61; range 30–130 min). Mean cyst size was 6.74 cm for those removed by laparotomy (62.32; range 4–12 cm) and 6.46 cm for those removed by laparoscopy (62.26; range 4–12 cm); the difference was not significant (Table 1). Cytological examination of the peritoneal fluid recovered from the Douglas cavity and pre-surgical wash-out with saline solution were negative for tumors. Routine assay of CA125 was normal (,35 mIU / l) in all patients, confirming the benignity of the ovarian masses. Mean blood loss for laparotomy was 103.84 ml (638.45 range 70–230 ml) compared to 58.64 ml for laparoscopy (630.17, range 10–110 ml); the difference was statistically significant (P,0.05) (Table 1). There was a statistically significant difference in the means of the total number of days spent in hospital including the period of preoperative examination (generally 2 days). Mean hospitalization was 6.32 days for laparotomy (61.09; range 5–8 days) and 3.18 days for laparoscopy (60.39; range 3–4 days) (P,0.05) (Table 1). In all 44 women enucleations of the cystic wall were performed. All patients underwent antibiotic therapy to prevent post-surgical infection. The laparoscopy did not have any post-surgical complications. After laparotomy,
G. Morgante et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47 – 50
49
Table 1 Comparison of surgical and post-surgical parameters in women operated for dermoid cysts by laparotomy and laparoscopy
No. of patients (total544) Operation time (min) range Mean size (cm) range Free of pain on 2nd day Mean stay in hospital (days) range Out of the hospital on 3rd day after surgery Complications Yes No Blood loss during operation (ml) range Back to work on 14th day
Laparotomy
(%)
Laparoscopy
22 56.87 25–110 6.74 4–12 3 6.32 5–8 0
50
22 79.32 30–130 6.46 4–12 15 3.18 3–4 22
50
2 20 103.84 70–230 13
9.1 90.9
0 22 58.64 10–110 22
0 100
there was a case of fever (38.28C) and another of intestinal sub-occlusion, both resolved by medical therapy. Postsurgical pain was significantly less in laparoscopy patients (P,0.05) (Fig. 1), 18 / 22 of whom did not require analgesics after the first day. While of the 22 patients operated on by laparotomy, only three did not require analgesics on the second day (P#0.05). All women who had undergone laparoscopy were back to normal life 7 days after discharge from the hospital, as compared to only 12 / 22 of the women who had undergone laparotomy (P,0.05) (Table 1).
4. Discussion Removal of dermoid cysts of the ovary by laparoscopy has increased in the last few years. In our department these cases were treated only by laparotomy, until several years
13.6
59.1
(%)
P NS NS
68.2
,0.05 ,0.05 ,0.05 NS
,0.05 100
,0.05
ago, but with the advent of minimally invasive surgical techniques and improvements in laparoscopic instruments, our current orientation is to treat patients by laparoscopy when possible. Clinical studies in large patient populations show that most ovarian masses can be successfully treated by laparoscopy [9]. The risk of unexpected malignancy of the mass is reduced by accurate pre-surgical staging [10] and an absence of spillage in expert hands [7]. However, it has been demonstrated that inadvertent surgical rupturing of a stage I ovarian epithelial neoplasm does not affect prognosis [11]. Excision of ovarian cysts found to be malignant is not uncommon and is associated with problems such as inappropriate preparation of the patient for major surgery, incomplete staging by laparoscopy and hence delay in beginning therapy. It has been reported that women with bilateral or multiple dermoid cysts have a relatively higher risk of
Fig. 1. Post-surgical pain in patients operated for dermoid cysts by laparotomy and laparoscopy.
50
G. Morgante et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47 – 50
developing ovarian neoplasms and should therefore undergo careful follow-up [12]. Among our patients, no such cases have ever been observed. Physicians therefore need to use strict criteria for selecting patients for the laparoscopic approach. Patients over 40 years of age with uncertain ultrasonographic parameters and high tumor marker levels must be evaluated with great care. In these cases it is important to make a frozen section. The removal of ovarian cysts is one of the main indications for endoscopic surgery, together with endometriosis and lysis of entero–genito–pelvic adhesions. It is extremely important to screen patients before endoscopic examination. Careful clinical and ultrasonographic tests help to identify the type of ovarian pathology. The reliability of transvaginal ultrasonographic diagnosis associated with negative CA125 and clinical oncological examination provide a highly certain diagnosis of benign ovarian swelling and hence dermoid cysts [13]. Transvaginal ultrasonography has improved the sensitivity of ultrasound examination for identifying ovarian neoplasms. However, Benacerraf et al. [14] report a 15% failure rate in the ultrasonographic diagnosis of malignant cysts. They maintain that ultrasound identification criteria such as size of the mass, irregular margins, thickness of septa and solid areas in the cysts can impart high specificity in the diagnosis of malignancy. Maiman et al. [10] however, maintain that ultrasonographic criteria do not provide certainty of benignity; in fact 31% of malignant tumors in their sample had similar features to benign ones. Although spillage occurred in some of our cases, no complications resulted. The risk of chemical peritonitis after surgical spillage seems to be low and is more likely if a patient is neglected after spontaneous rupture of dermoid cyst in the abdominal cavity [15]. To avoid peritonitis in cases of spillage we suggest use of the endo-catch and wash-out with quantities of normal saline or Ringer’s lactate at body temperature. The ovary is one of the most common sites of adhesion formation after surgery. Adhesions can impair reproductive function and cause post-surgical pain. The suture of ovarian tissue may increase adhesion formation [16]. It is important to leave the ovary open without suturing or to isolate it by barrier methods to significantly reduce adhesion formation after ovarian cystectomy. Further studies are required to compare the efficacy of these systems in reducing adhesion formation after laparoscopy and laparotomy [17]. Our evaluation of laparoscopy and laparotomy showed that they have similar therapeutic efficacy but the former is less traumatic, requires less hospitalization and is more economical for the national health system. Comparison of blood loss, pain, need for analgesics and level of recovery after a week gave results that were clearly in favour of laparoscopy. Most ovarian cysts are benign and a recent study showed that even post-menopausal women can be
operated by laparoscopy [18]. In conclusion, laparoscopy should also be the elective treatment for women with suspected dermoid cyst, in view of the clear advantages for the patient and the lower costs for the national health system.
References [1] Peterson WF, Prevost EC, Edmunds FT, Hundley JM, Morris FK. Benign cystic teratomas of the ovary. A clinico–statistical study of 1007 cases with a review of the literature. Am J Obstet Gynecol 1955;70:368–82. [2] Bennington J, Ferguson B. Incidence and relative frequency of benign and malignant ovarian neoplasms. Obstet Gynecol 1968;32:627–31. [3] Peterson WF. Malignant degeneration of benign cystic teratomas of the ovary. Collective review of literature. Obstet Gynecol Surv 1957;12:793–830. [4] Caruso PA, Marsh MR, Minicowitz S, Karten G. An intense clinicopathologic study of 305 teratomas of the ovary. Cancer 1971;27:343–8. [5] Westhoff C, Pike M, Vessey M. Benign ovarian teratomas: a population-based case– control study. Br J Cancer 1988;58:93–8. [6] Gerber B, Scheunemann P, Kulz T, Rohde E, Schwarz R. Changes in surgical treatment of cystic teratoma-620 cases. Zentralbl Gynakol 1994;116(12):670–4. [7] Canis M, Mage G, Pouly JL, Wattiez A, Manhes H, Bruhat MA. Laparoscopic diagnosis of adnexal cystic masses. A 12 year experience with long term follow up. Obstet Gynecol 1994;83:707– 12. [8] Dixon JS, Bird HA. Reproducibility along a 10 cm vertical visual analogue scale. Ann Rheumatic Dis 1981;40:87–9. [9] Chapron C, Dubuisson JB, Samouh N, Foulot H, Aubriot FX, Amsquer Y, et al. Treatment of ovarian dermoid cysts. Place and modalities of operative laparoscopy. Surg Endosc 1994;8(9):1092– 5. [10] Maiman M, Seltzer V, Boyce J. Laparoscopic excision of ovarian neoplasm subsequently found to be malignant. Obstet Gynecol 1991;77:563–5. [11] Dembo AJ, Davy M, Stenwig AE, Berle EJ, Bush RS, Kjorstad K. Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol 1990;75:263–73. [12] Anteby EY, Ron M, Revel A, Shimonovitz S, Ariel I, Hurwitz A. Germ cell tumors of the ovary arising after dermoid cyst resection: a long-term follow-up study. Obstet Gynecol 1994;83(4):605–8. [13] O’Connell GJ, Ryan E, Murphy KJ, Prefontaine M. Predictive value of CA125 for ovarian carcinoma in patients presenting with pelvic masses. Obstet Gynecol 1987;70:930–2. [14] Benacerraf B, Finkler N, Wojciechowski C, Knapp R. Sonografic accuracy in the diagnosis of ovarian masses. J Reprod Med 1990;35:491–5. [15] Bollen N, Camus M, Tournaye H, Demunk L, Devroey P. Laparoscopic removal of benign mature teratoma. Human Reprod 1992;7:1429–32. [16] Curtin JP. Management of the adnexal mass. Gynecol Oncol 1994;55:S42–46. [17] Lundorff P, Hahlin M, Kallfelt B, Thorburn J, Lindblom B. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 1991;55:911–5. [18] Parker W, Berek J. Management of selected cystic adnexal masses in postmenopausal women by operative laparoscopy: a pilot study. Am J Obstet Gynecol 1990;163:1574–7.
Surgical treatment of ovarian dermoid cysts Giuseppe Morgante*, Antonino Ditto, Antonio la Marca, Valeria Trotta, Vincenzo De Leo Siena University, Department of Gynecology and Obstetrics, 53100 Siena, Italy Received 25 May 1998; received in revised form 15 June 1998; accepted 18 June 1998
Abstract Objective: To evaluate the efficacy of laparoscopic ovarian cystectomy and to compare the surgical course, post-surgical course and particularly post-surgical pain of the laparoscopic and laparotomic methods. Study design: We conducted a surgical study on dermoid cysts at the Gynecology Department of Siena University between 1 January 1992 and 31 December 1996. The selected cases were randomized into two groups based on surgical approach: via laparotomy (n522) or laparoscopy (n522). Surgical times, estimated blood loss, post-surgical pain, time in hospital, speed of recovery and complications were compared. Results: Mean blood loss was significantly less for laparoscopy (58.64630.17 ml versus 103.84638.45 ml, P,0.05). Mean hospitalization was 6.3261.09 days for laparotomy and 3.1860.39 days for laparoscopy (P,0.05). Post-surgical pain was significantly less in laparoscopy patients (P,0.05). The laparoscopic technique had fewer post-surgical complications. Conclusions: The laparoscopic approach had many advantages. Laparoscopy should be the elective treatment for women with dermoid cysts, because it has many advantages for the patient and lower costs for the national health system. 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Laparotomy; Laparoscopy; Dermoid cysts; Ovary
1. Introduction Dermoid cysts of the ovary are often diagnosed in women of reproductive age and account for 5–25% of all ovarian tumours [1]. Ninety-nine percent of teratomas are benign. The period of maximum incidence of these tumors is between 30 and 40 years of age [2]. Neoplastic transformation is rare and generally begins from epithelial elements; the most common form of transformation is squamous cell carcinoma; adenocarcinoma and the carcinoid form are much less frequent [3]. The clinical course of dermoid cysts of the ovary is asymptomatic and torsion or spontaneous rupture (followed by acute chemical peritonitis) only occur in 16% and 3–7% of patients, respectively [4]. Diagnosis is based *Corresponding author. Tel.: 139 577 331160; Fax: 139 577 263464; e-mail:[email protected]
on clinical examination and ultrasonographic indications, confirmed by radiological evidence of solid cystic residues in the ovaries [5]. The standard treatment for benign cystic teratoma is laparotomy with surgical removal of the ovarian cysts or oophorectomy and salpingectomy in postmenopausal women. The advent of new, much less invasive techniques, such as laparoscopy, has revolutionized this sector of gynecological surgery. Many studies have shown that laparoscopic treatment of ovarian masses is satisfactory [6] and that laparoscopic diagnosis of malignant tumours of the ovaries has good sensitivity in expert hands [7]. The risk of spillage or inadvertent puncturing of a malignant neoplasm is very low. Laparoscopic treatment of benign ovarian cysts does not prejudice fertility. In this paper we report our experience in the treatment of ovarian cystic teratomas by laparotomy and laparoscopy. Our purpose is to evaluate the two techniques in
0301-2115 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 98 )00139-0
48
G. Morgante et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47 – 50
terms of duration of operation, blood loss, post-surgical pain, mean stay in hospital, complications and recovery in a group of 44 patients with the suspicion of dermoid cyst.
2. Materials and methods We analyzed 44 cases of dermoid cysts treated in the Department of Obstetrics and Gynecology of the University of Siena between 1 January 1992 and 31 December 1996. The parameters considered were type of surgery, duration of operation, blood loss, complications, histology, length of hospitalization and post-surgical pain. After informed consent the patients were assigned to laparoscopy (n522) or laparotomy (n522) by means of a random number table. All women were of reproductive age (14–42 years), without acute pelvic symptoms and with ultrasound diagnosis of dermoid cyst (range 4–12 cm). All patients, except four young women who had never had sexual intercourse, underwent transabdominal and transvaginal ultrasound examinations before surgery. A Siemens Sonoline SL 2 was used with a 3.5 MHz transabdominal sectorial probe and a 5.0–7.5 MHz transvaginal probe. For laparoscopy, the patients underwent general anesthesia with tracheal intubation and the peritoneum was inflated with CO 2 . A 10 / 12 mm trocar for the endoscope was inserted through the navel. Two 5-mm trocars and, when necessary, a 10 / 12-mm trocar for surgical instruments were inserted through the security abdominal triangle. With both procedures, the pelvic cavity was examined with great care for signs of neoplasm. Peritoneal fluid from the Douglas cavity and pre-surgical wash-out were obtained for cytological examination. In eight cases, after aspiration of the cysts, the capsule was removed in such a way as to avoid spillage of cyst fluid into the abdominal cavity. When the capsule broke or fluid spilt, the cavity was washed with saline solution. Bipolar cautery was used for hemostasis. Once the cyst was removed, the ovary was left open. In fourteen other cases the intact dermoid cyst was removed from the ovary, placed in the endo-bag, emptied of fluid and extracted through the 12 mm trocar. When the empty cyst was too large to extract through the trocar, we enlarged the incision and removed the bag directly. Careful follow-up of the laparoscopic cases in which spillage occurred (six cases) and those in which it did not (16 cases) failed to reveal any differences. No patient contracted chemical peritonitis. Blood loss was evaluated during laparotomy by counting and weighing the swabs used. During laparoscopy, blood loss was measured as the difference between the liquid aspirated and that used to wash out the pelvic cavity. The intensity of post-surgical pain was scored using a numerical point scale [8] and considering patient requests
for analgesics. The women filled in the scales in the morning and before taking any analgesic for 3 days after the operation. The patients were contacted by phone 2 weeks after the operation to enquire about recovery. Statistical analysis was performed only on randomized patients using the Fisher exact test and analysis of variance for repeated measures (Anova) and t-test as appropriate. The Bonferroni correction factor was used in the case of multiple testing. Statistical significance was taken as P, 0.05. Values are reported as mean6standard deviation.
3. Results The mean age of patients undergoing laparotomy was 30.28 years (68.32; range 14–42); the mean age of patients undergoing laparoscopy was 29.45 years (66.84; range 15–40). Most of the women sought medical advice because of chronic pelvic pain (25%) or menstrual irregularity (12.8%). In 58.5% of the cases the cysts were discovered by chance during gynecological and / or ultrasonographic examination. In all cases, histological examination of the cysts confirmed the diagnosis of benign dermoid cyst. The mean diameter of the cysts was 6.9 cm (62.7; range 4–12 cm). Dermoid cysts was bilateral in 7.9% of cases, and associated with cysts of other histotypes homolaterally in 8.1% and contralaterally in 15.7%. The associated cysts were of a functional nature (17.2%), endometriosic (4.5%), serous cystadenomas (5.3%), mucinous cystadenoma (1.2%). The mean duration of the operation was 56.87 min for laparotomy (614.52; range 25–110 min) and 79.32 min for laparoscopy (626.61; range 30–130 min). Mean cyst size was 6.74 cm for those removed by laparotomy (62.32; range 4–12 cm) and 6.46 cm for those removed by laparoscopy (62.26; range 4–12 cm); the difference was not significant (Table 1). Cytological examination of the peritoneal fluid recovered from the Douglas cavity and pre-surgical wash-out with saline solution were negative for tumors. Routine assay of CA125 was normal (,35 mIU / l) in all patients, confirming the benignity of the ovarian masses. Mean blood loss for laparotomy was 103.84 ml (638.45 range 70–230 ml) compared to 58.64 ml for laparoscopy (630.17, range 10–110 ml); the difference was statistically significant (P,0.05) (Table 1). There was a statistically significant difference in the means of the total number of days spent in hospital including the period of preoperative examination (generally 2 days). Mean hospitalization was 6.32 days for laparotomy (61.09; range 5–8 days) and 3.18 days for laparoscopy (60.39; range 3–4 days) (P,0.05) (Table 1). In all 44 women enucleations of the cystic wall were performed. All patients underwent antibiotic therapy to prevent post-surgical infection. The laparoscopy did not have any post-surgical complications. After laparotomy,
G. Morgante et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47 – 50
49
Table 1 Comparison of surgical and post-surgical parameters in women operated for dermoid cysts by laparotomy and laparoscopy
No. of patients (total544) Operation time (min) range Mean size (cm) range Free of pain on 2nd day Mean stay in hospital (days) range Out of the hospital on 3rd day after surgery Complications Yes No Blood loss during operation (ml) range Back to work on 14th day
Laparotomy
(%)
Laparoscopy
22 56.87 25–110 6.74 4–12 3 6.32 5–8 0
50
22 79.32 30–130 6.46 4–12 15 3.18 3–4 22
50
2 20 103.84 70–230 13
9.1 90.9
0 22 58.64 10–110 22
0 100
there was a case of fever (38.28C) and another of intestinal sub-occlusion, both resolved by medical therapy. Postsurgical pain was significantly less in laparoscopy patients (P,0.05) (Fig. 1), 18 / 22 of whom did not require analgesics after the first day. While of the 22 patients operated on by laparotomy, only three did not require analgesics on the second day (P#0.05). All women who had undergone laparoscopy were back to normal life 7 days after discharge from the hospital, as compared to only 12 / 22 of the women who had undergone laparotomy (P,0.05) (Table 1).
4. Discussion Removal of dermoid cysts of the ovary by laparoscopy has increased in the last few years. In our department these cases were treated only by laparotomy, until several years
13.6
59.1
(%)
P NS NS
68.2
,0.05 ,0.05 ,0.05 NS
,0.05 100
,0.05
ago, but with the advent of minimally invasive surgical techniques and improvements in laparoscopic instruments, our current orientation is to treat patients by laparoscopy when possible. Clinical studies in large patient populations show that most ovarian masses can be successfully treated by laparoscopy [9]. The risk of unexpected malignancy of the mass is reduced by accurate pre-surgical staging [10] and an absence of spillage in expert hands [7]. However, it has been demonstrated that inadvertent surgical rupturing of a stage I ovarian epithelial neoplasm does not affect prognosis [11]. Excision of ovarian cysts found to be malignant is not uncommon and is associated with problems such as inappropriate preparation of the patient for major surgery, incomplete staging by laparoscopy and hence delay in beginning therapy. It has been reported that women with bilateral or multiple dermoid cysts have a relatively higher risk of
Fig. 1. Post-surgical pain in patients operated for dermoid cysts by laparotomy and laparoscopy.
50
G. Morgante et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 47 – 50
developing ovarian neoplasms and should therefore undergo careful follow-up [12]. Among our patients, no such cases have ever been observed. Physicians therefore need to use strict criteria for selecting patients for the laparoscopic approach. Patients over 40 years of age with uncertain ultrasonographic parameters and high tumor marker levels must be evaluated with great care. In these cases it is important to make a frozen section. The removal of ovarian cysts is one of the main indications for endoscopic surgery, together with endometriosis and lysis of entero–genito–pelvic adhesions. It is extremely important to screen patients before endoscopic examination. Careful clinical and ultrasonographic tests help to identify the type of ovarian pathology. The reliability of transvaginal ultrasonographic diagnosis associated with negative CA125 and clinical oncological examination provide a highly certain diagnosis of benign ovarian swelling and hence dermoid cysts [13]. Transvaginal ultrasonography has improved the sensitivity of ultrasound examination for identifying ovarian neoplasms. However, Benacerraf et al. [14] report a 15% failure rate in the ultrasonographic diagnosis of malignant cysts. They maintain that ultrasound identification criteria such as size of the mass, irregular margins, thickness of septa and solid areas in the cysts can impart high specificity in the diagnosis of malignancy. Maiman et al. [10] however, maintain that ultrasonographic criteria do not provide certainty of benignity; in fact 31% of malignant tumors in their sample had similar features to benign ones. Although spillage occurred in some of our cases, no complications resulted. The risk of chemical peritonitis after surgical spillage seems to be low and is more likely if a patient is neglected after spontaneous rupture of dermoid cyst in the abdominal cavity [15]. To avoid peritonitis in cases of spillage we suggest use of the endo-catch and wash-out with quantities of normal saline or Ringer’s lactate at body temperature. The ovary is one of the most common sites of adhesion formation after surgery. Adhesions can impair reproductive function and cause post-surgical pain. The suture of ovarian tissue may increase adhesion formation [16]. It is important to leave the ovary open without suturing or to isolate it by barrier methods to significantly reduce adhesion formation after ovarian cystectomy. Further studies are required to compare the efficacy of these systems in reducing adhesion formation after laparoscopy and laparotomy [17]. Our evaluation of laparoscopy and laparotomy showed that they have similar therapeutic efficacy but the former is less traumatic, requires less hospitalization and is more economical for the national health system. Comparison of blood loss, pain, need for analgesics and level of recovery after a week gave results that were clearly in favour of laparoscopy. Most ovarian cysts are benign and a recent study showed that even post-menopausal women can be
operated by laparoscopy [18]. In conclusion, laparoscopy should also be the elective treatment for women with suspected dermoid cyst, in view of the clear advantages for the patient and the lower costs for the national health system.
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