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Transumbilical 1-port laparoscopic resection of benign ovarian tumor
Journal of Pediatric Surgery (2012) 47, 1340–1344
www.elsevier.com/locate/jpedsurg
Transumbilical 1-port laparoscopic resection of benign ovarian tumor Shin-Yi Lee, Hui-Ming Lee, Chun-Yu Kao, Jiin-Haur Chuang ⁎ From the Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan Received 27 April 2011; revised 6 December 2011; accepted 8 December 2011
Key words: Children; Laparoscopy; Ovarian tumor; Tumor marker
Abstract Background/Purpose: We evaluated the effectiveness of transumbilical 1-port laparoscopic resection of benign ovarian tumors in children with limited working space. Methods: This study involved 15 children and adolescents with benign ovarian tumors treated from January 2006 to December 2010. Preoperative evaluation included physical findings, tumor markers, and imaging studies. A single surgeon performed the procedure using a 10-mm 0° operative laparoscope with a 5-mm working channel. The fallopian tube was suspended with transabdominal suspensory sutures passing through the mesosalpinx to expose the tumor and remove it after aspiration of the contents. The tumor was contained in the endobag and chopped into pieces before removal through the small umbilical wound. Results: The patients' age ranged from 2 to 17 years (mean, 9.7 years). Tumor size ranged from 3.6 to 23 cm. Tumor markers including α-fetoprotein, β-human chorionic gonadotropin, cancer antigen 125, and carcinoembryonic antigen were negative. The average operating time was 134 minutes. Except for 1 patient with associated encephalomyelitis, all patients were discharged within 3 days after surgery. Pathologic examination and follow-up studies revealed benign tumors, with no residual lesions in the abdomen or recurrence. Conclusions: Transumbilical 1-port laparoscopic resection is effective for resection of benign ovarian tumors in children, with a satisfactory cosmetic outcome. However, to prevent inadequate resection of a potential malignant lesion, thorough preoperative evaluation with physical signs, tumor markers, and imaging studies, as well as flexible intraoperative tactics, should be adopted. © 2012 Elsevier Inc. All rights reserved.
More than 90% of ovarian masses in infants, children, and adolescents are benign, of which simple or hemorrhagic cysts make up the largest group, followed by mature cystic
⁎ Corresponding author. Tel.: +886 7 7317123x8811; fax: +886 7 7311696. E-mail address: [email protected] (J.-H. Chuang). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.12.005
teratomas [1,2]. A laparoscopic approach to the latter in children and adolescents has already become a standard form of therapy [3], despite limited working space, which has delayed the spread of laparoscopic surgery in the pediatric population compared with adults [4]. Recent advances in laparoscopic surgery have changed the conventional 3-trocar approach and introduced transumbilical single-site surgery for excision of borderline ovarian tumors [5]. The findings of
TOPLR of benign ovarian tumor
1341
short hospital stays and satisfactory cosmetic outcomes with no increase in postoperative complications indicate that the procedure is not only feasible but a beneficial alternative in female patients. We studied the feasibility and effectiveness of transumbilical 1-port laparoscopic resection (TOPLR) of benign ovarian tumors in patients younger than 18 years.
1. Patients and methods This study involved 15 children and adolescents with ovarian tumors and no signs of precocious puberty, ranging in age from 2 to 17 years, who were consecutively treated from January 2006 to December 2010. All of them were treated with TOPLR. The patients presented with abdominal pain or fullness or an abdominal mass. Preoperative evaluation included tumor markers and imaging studies. α-Fetoprotein (AFP), β-human chorionic gonadotropin (β-HCG), cancer antigen 125 (CA125), and carcinoembryonic antigen (CEA) levels were checked to evaluate the risk of malignancy, unless emergency surgery was needed. Imaging studies consisted of abdominal ultrasonography, computed tomography (CT), or both. The procedure was performed by placing one 10-mm trocar through the umbilicus with the patient in the Trendelenburg position and rotating it to the left or right, depending on the location of the tumor. A 10-mm 0° operative laparoscope (Karl Storz, Tuttlingen, Germany) with a 5-mm working channel was used. Through the 5-mm working channel, a 5-mm laparoscopic forceps was used to identify and expose the tumor. The cystic content was aspirated with laparoscopic suction if the tumor was large (Fig. 1A). If ovarian torsion was found, detorsion was performed before aspiration and resection. Using a straight needle, a 3-0 polyglactin suspensory suture was made percutaneously. After the peritoneal cavity had been entered, the needle was passed through the mesosalpinx, and the suture was then made to exit the abdomen using a different penetrating wound. The procedure is similar to that described in our previous publication on transumbilical 1-port laparoscopic appendectomy [6]. The fallopian tube was suspended, and the mesosalpinx was exposed. The mesosalpinx and proper ovarian ligament was divided by bipolar or Ligasure (Valleylab, Boulder, CO) forceps. One suspensory suture was usually sufficient for adequate exposure of the mesosalpinx, but 2 sutures were sometimes required. The suspensory ligament and the vessels of the diseased ovary were ligated with extracorporeal fisherman's knots. Ovary-sparing resection of the tumor was performed whenever possible. Oophorectomy was performed when the ovarian parenchyma was hard to separate from the tumor or when there was torsion and gangrenous change of the ovarian tumor, including the ovarian parenchyma. During the ovary-preserving procedure, we used Ligasure to resect the tumor without ligation or resection of the ovarian vessels.
Fig. 1 A, CT scan of the abdomen reveals a huge cyst, later proven to be serous cystadenoma, with septum and a diameter of 23 × 12 cm. B, Postoperative view of the patient's abdomen reveals that the scar is hidden in the umbilicus (arrow).
We followed the procedures described by Karpelowsky et al [7] to gently enlarge the incision by blunt and sharp dissection to locate the cleavage plane between the tumor wall and the ovarian cortex. The cyst was removed, and the ovarian tissue was left open without suture. When oophorectomy was performed, the ovarian vessels were divided using bipolar scissors or Ligasure. The tumor was removed and placed into an endobag. Because most of the tumors were large enough to preclude extraction from the small umbilical wound, the tumor was chopped into small pieces in the endobag. Then the tumor was removed from the endobag piece by piece. Because the tumor was contained in the endobag, spillage was avoided. However, we still irrigated the peritoneal cavity with a large amount of normal saline to avoid any leftover tissues, and the fluid was aspirated. Before removal of the
1342
S.-Y. Lee et al.
laparoscope, we checked for possible enlarged lymph nodes in the iliac and aortocaval area, as well as any abnormal findings in the contralateral ovary. The incised umbilical fascia was closed with 5-0 polydioxanone sutures, and the skin was closed with subcuticular 5-0 polydioxanone sutures. The patients and their family are satisfied with the immediate postoperative cosmetic outcome. After the operation, the patient was encouraged to eat and to walk as soon as possible. Oral acetaminophen was routinely used for postoperative pain control.
2. Results The patients had a mean age of 9.7 years. The tumor size was evaluated initially by imaging studies and then during surgery and was ranged from 3.6 to 23 cm. Tumor markers including AFP, β-HCG, CA-125, and CEA were within the reference ranges. One patient had no preoperative evaluation with ultrasonography and CT or tumor markers because of the need for emergency management after a preoperative diagnosis of acute appendicitis. All patients received TOPLR without conversion to laparotomy or to 3-port laparoscopy. Oophorectomy was performed in 9 patients, and ovarysparing tumor resection was done in 6 patients. The operative time ranged from 42 to 240 minutes, with a mean of 134 minutes. One advantage of the procedure is that it can
be performed by a single surgeon (mainly, S.Y. Lee) without assistance. Oral acetaminophen was sufficient to relieve postoperative pain in 14 patients, with only 1 patient requiring intramuscular administration of meperidine hydrochloride. The patients were advised to eat immediately after recovery from surgery and anesthesia. The hospital stay was relatively short, ranging from 1 to 3 days, with a mean of 2 days. The only exception was a patient with acute disseminated encephalomyelitis that developed before surgery; this patient was hospitalized for 70 days until full recovery from this condition. For comparison, the hospital stay of the 7 patients receiving laparotomy for resection of benign ovarian tumors at the same period was found to range from 2 to 14 days, with a mean of 4.75 days. No patients experienced chemical peritonitis. Pathologic findings included mature (cystic) teratomas in 12 patients, simple cyst with torsion in 1 patient, and mucinous and serous cystadenoma in 1 patient each (Table 1). Ultrasonography was used for postoperative follow-up, and no recurrence was detected during a follow-up period ranging from 3 months to 4 years (medium, 1 year 8 months). In our last 3 patients receiving ovary-sparing tumor resection, the size of their ovaries can be accurately measured with the use of a better abdominal ultrasound. The size of the preserved ovary on the lesion site was 1.9 × 1.1, 0.9 × 0.6, and 0.8 × 0.7 cm, whereas the size of the contralateral normal ovary was 2.7 × 2.3, 1.2 × 0.9, and 0.9 × 0.8 cm,
Table 1
Demographic data of the patients
Age (y)
Tumor marker
Image
10 8
CEA: 1.7 HCG: b0.5 AFP: b3 AFP: 0.63 CEA: 1.3 CA-125: 29.9 HCG: b5 AFP: b3 Nil AFP: 1.44 CA-125: 30.5 HCG: b5 AFP: b3 HCG: b5 AFP: b3 Nil HCG: b5; AFP: b3 HCG: b5; AFP: b3; CEA: b0.5; CA-125: 15.3 AFP: 1; CEA: 0.93; CA-125: 12.5 HCG: b5; AFP: b3 Nil Nil
CT CT
8 × 10 6×7
161 86
CT
9 × 10
13
11 7 17 14 7 8 15 13 4 12 2 4
Size (cm)
Operation time (min)
Postoperative stay (d)
Diagnosis
Right or left
2 2
MCT with torsion MCT
Right Left
125
2
MT with torsion
Left
CT
11 × 7
124
1
MT with torsion
Left
Ultrasound CT
5×6 23 × 12
42 240
1 2
MCT Serous cystadenoma
Right Left
CT
4 × 2.8
115
70
MCT
Left
CT
15 × 13
171
3
MCT
Left
Nil CT CT
3.6 × 1.8 21 × 18.5 20 × 12
119 182 225
1 2 2
MT Mucinous cystadenoma MT
Right Right Right
CT CT Ultrasound CT
4.9 × 4.4 11 × 11 6×6 6.5 × 4.7
80 167 57 119
3 2 2 3
Simple cyst with torsion MCT MCT MCT
Left Left Right Right
Normal values for AFP, b20 ng/mL; CA-125, b35 U/L; CEA, b5 ng/mL; and HCG, b10 IU/L. MCT indicates mature cystic teratoma; MT, mature teratoma.
TOPLR of benign ovarian tumor respectively, when followed 12, 11, and 22 months after the operation. The results suggest that the preserved ovary was still present with discernible parenchyma despite being smaller than the contralateral normal ovary.
3. Discussion Ovarian masses in children and adolescents lie on a spectrum ranging from simple cyst to complex malignancies including yolk sac tumors and primary carcinomas of the ovary [1,8]. Luckily, most ovarian masses are benign, of which simple and hemorrhagic cysts are most frequently found, followed by mature cystic teratomas [1,2]. Borderline ovarian tumors, which include mucinous or serous cystadenomas and, rarely, carcinoma, are uncommon in children and can be successfully treated with less aggressive procedures [9]. Excluding ovarian malignancy, for which the safety of laparoscopic management has not been confirmed, most ovarian tumors are amenable to minimally invasive surgery [1]. The results of our study support the use of transumbilical single-port surgery for resection of most benign ovarian tumors including borderline ovarian tumors [5]. Its benefits include a hospital stay averaging 2 days, reduced need for narcotic analgesics, and the cosmetic result of an inconspicuous scar hidden within the umbilicus, which is especially beneficial to patients who do not want a visible scar on the abdomen (Fig. 1B). Our mean operative time for this procedure was 134 minutes, which is longer than the 79 minutes previously reported for single-port surgery [4] and 82 minutes reported elsewhere for laparoscopic removal of large ovarian cysts by the open technique [10]. Several factors may account for the difference, including our health care system's calculation of operative time starting from the completion of anesthesia instead of the time of actual surgical intervention, our meticulous chopping of the tumor into pieces within the endobag before removal of the tumor tissues through the small umbilical wound, and our repeated cleansing of the abdominal cavity with a large amount of normal saline after resection of the tumor. It is worthwhile to spend extra time during surgery to reduce the risk of postoperative complications such as chemical peritonitis and residual tumor tissues. Because of a lack of reliable preoperative indicators of ovarian malignancy in children, several markers including β-HCG, AFP, CA-125, and CEA are included in preoperative evaluation. Elevated levels of tumor markers may not conclusively demonstrate malignancy but indicate that possibility, particularly when a mass larger than 8 cm or with solid imaging characteristics is found, or when there are signs of precocious puberty [8]. Unless emergency surgery was needed, tumor markers, particularly β-HCG and AFP, were checked in most cases before operation in this study. Negative findings for these tumor markers, and lack of solid
1343 imaging characteristics and physical signs of precocious puberty support the use of TOPLR for benign ovarian tumors. One exceptional case with preoperative diagnosis of acute appendicitis did not have preoperative evaluation with ultrasonography and CT or tumor markers. However, the cyst was small, and the whole mass could be removed and contained in the endobag without spillage. The pathologic findings and follow-up studies using abdominal ultrasonography confirmed the benign nature of all of the tumors treated through the minimally invasive procedure. Preservation of the ovary by removal of the tumor alone has been attempted by surgeons using a multiaccess laparoscopic approach [7,11]. Torsion of the ovary is not a contraindication to that procedure. In this study, we also confirmed the feasibility of preserving as much ovarian tissues as possible. This was accomplished in 6 patients (40%), including 1 with ovarian torsion and 2 with ovarian tumors exceeding 10 cm. The ovary could not be preserved when torsion caused gangrenous change of the ovary and the tumor or when the ovarian parenchyma was too thin or unable to be separated from the tumor without risking tumor rupture and spillage of the contents. There is no consensus as to the rate of cystectomy with ovarian preservation. Karpelowsky et al reported a preservation rate of 100%. However, in their series of 12 cases, a second operation is required in 3 patients 7 to 10 days after detorsion of the ovaries. In the other series, ovarian preservation was successful in 48% [11]. The relatively lower rate of ovary preservation in our study may reflect one limitation of our procedure, which is needed to improve in the future. Finally, aspiration of the cystic contents in a large ovarian tumor is almost inevitable when choosing laparoscopy [10,11]. One report showed that intraoperative tumour spillage occurred in 27 (52%) patients, but there were no cases of chemical peritonitis as well as tumor recurrence [11]. In this study, we also aspirated the cyst under a direct laparoscopic view, which is reported to be safer because it allows the assessment of the abdominal cavity and ovarian cyst, thus limiting the risk of spillage [12]. Despite no gross intraoperative spillage, we did not prevent minor, inconspicuous leakage. We, therefore, followed other's experience to use a copious amount of normal saline for irrigation of the abdominal cavity and to aspirate fluid as much as possible [10]. In this study, we used the single-port single-instrument technique, which is quite different from current singleincision/single-site surgery that uses multiple instruments through 1 port. In performing a single-port single-instrument technique, the operative laparoscope has to move at the same time and direction when the forceps or other instrument is used. It needs a short period of adaptation, but the learning curve is expected to be as short as we have for appendectomy [6]. In summary, the TOPLR procedure is feasible and effective in resection of benign ovarian tumors in children with limited working space in the abdomen and also has satisfactory cosmetic outcomes. Although the risk for malignancy is so low in these cases that the cosmetic benefit for a
1344 single-port surgery is worth achieving, we still warn against the possibility of malignancy in a small number of cases with normal tumor markers, and this technique would upstage the tumor.
References [1] Michelotti B, Segura BJ, Sau I, et al. Surgical management of ovarian disease in infants, children, and adolescents: a 15-year review. J Laparoendosc Adv Surg Tech A 2010;20:261-4. [2] Vaysse C, Delsol M, Carfagna L, et al. Ovarian germ cell tumors in children. Management, survival and ovarian prognosis. A report of 75 cases. J Pediatric Surg 2010;45:1484-90. [3] Mayer JP, Bettolli M, Kolberg-Schwerdt A, et al. Laparoscopic approach to ovarian mass in children and adolescents: already a standard in therapy. J Laparoendosc Adv Surg Tech A 2009;19(Suppl 1):S111-5. [4] Ateş O, Karakaya E, Hakgüder G, et al. Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage. J Pediatr Surg 2006;41:E9-11.
S.-Y. Lee et al. [5] Marocco F, Fanfani F, Rossitto C, et al. Laparoendoscopic single-site surgery for fertility-sparing staging of border line ovarian tumors: initial experience. Surg Laparosc Endosc Percutan Tech 2010;20: e172-5. [6] Lee SY, Lee HM, Hsieh CS, et al. Transumbilical laparoscopic appendectomy for acute appendicitis: a reliable one-port procedure. Surg Endosc 2011;25:1115-20. [7] Karpelowsky JS, Hei ER, Matthews K. Laparoscopic resection of benign ovarian tumours in children with gonadal preservation. Pediatr Surg Int 2009;25:251-4. [8] Oltmann SC, Garcia N, Barber R, et al. Can we preoperatively risk stratify ovarian masses for malignancy? J Pediatr Surg 2010;45:130-4. [9] Song T, Choi CH, Lee YY, et al. Pediatric borderline ovarian tumors: a retrospective analysis. J Pediatr Surg 2010;45:1955-60. [10] Eltabbakh GH, Charboneau AM, Eltabbakh NG. Laparoscopic surgery for large benign ovarian cysts. Gynecol Oncol 2008;108:72-6. [11] Templeman CL, Hertweck SP, Scheetz JP, et al. The management of mature cystic teratomas in children and adolescents: a retrospective analysis. Hum Reprod 2000;15:2669-72. [12] Coccia ME, Rizzello F, Bracco GL. Seven-liter ovarian cyst in an adolescent treated by minimal access surgery: laparoscopy and open cystectomy. J Pediatr Surg 2009;44:E5-8.
www.elsevier.com/locate/jpedsurg
Transumbilical 1-port laparoscopic resection of benign ovarian tumor Shin-Yi Lee, Hui-Ming Lee, Chun-Yu Kao, Jiin-Haur Chuang ⁎ From the Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan Received 27 April 2011; revised 6 December 2011; accepted 8 December 2011
Key words: Children; Laparoscopy; Ovarian tumor; Tumor marker
Abstract Background/Purpose: We evaluated the effectiveness of transumbilical 1-port laparoscopic resection of benign ovarian tumors in children with limited working space. Methods: This study involved 15 children and adolescents with benign ovarian tumors treated from January 2006 to December 2010. Preoperative evaluation included physical findings, tumor markers, and imaging studies. A single surgeon performed the procedure using a 10-mm 0° operative laparoscope with a 5-mm working channel. The fallopian tube was suspended with transabdominal suspensory sutures passing through the mesosalpinx to expose the tumor and remove it after aspiration of the contents. The tumor was contained in the endobag and chopped into pieces before removal through the small umbilical wound. Results: The patients' age ranged from 2 to 17 years (mean, 9.7 years). Tumor size ranged from 3.6 to 23 cm. Tumor markers including α-fetoprotein, β-human chorionic gonadotropin, cancer antigen 125, and carcinoembryonic antigen were negative. The average operating time was 134 minutes. Except for 1 patient with associated encephalomyelitis, all patients were discharged within 3 days after surgery. Pathologic examination and follow-up studies revealed benign tumors, with no residual lesions in the abdomen or recurrence. Conclusions: Transumbilical 1-port laparoscopic resection is effective for resection of benign ovarian tumors in children, with a satisfactory cosmetic outcome. However, to prevent inadequate resection of a potential malignant lesion, thorough preoperative evaluation with physical signs, tumor markers, and imaging studies, as well as flexible intraoperative tactics, should be adopted. © 2012 Elsevier Inc. All rights reserved.
More than 90% of ovarian masses in infants, children, and adolescents are benign, of which simple or hemorrhagic cysts make up the largest group, followed by mature cystic
⁎ Corresponding author. Tel.: +886 7 7317123x8811; fax: +886 7 7311696. E-mail address: [email protected] (J.-H. Chuang). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.12.005
teratomas [1,2]. A laparoscopic approach to the latter in children and adolescents has already become a standard form of therapy [3], despite limited working space, which has delayed the spread of laparoscopic surgery in the pediatric population compared with adults [4]. Recent advances in laparoscopic surgery have changed the conventional 3-trocar approach and introduced transumbilical single-site surgery for excision of borderline ovarian tumors [5]. The findings of
TOPLR of benign ovarian tumor
1341
short hospital stays and satisfactory cosmetic outcomes with no increase in postoperative complications indicate that the procedure is not only feasible but a beneficial alternative in female patients. We studied the feasibility and effectiveness of transumbilical 1-port laparoscopic resection (TOPLR) of benign ovarian tumors in patients younger than 18 years.
1. Patients and methods This study involved 15 children and adolescents with ovarian tumors and no signs of precocious puberty, ranging in age from 2 to 17 years, who were consecutively treated from January 2006 to December 2010. All of them were treated with TOPLR. The patients presented with abdominal pain or fullness or an abdominal mass. Preoperative evaluation included tumor markers and imaging studies. α-Fetoprotein (AFP), β-human chorionic gonadotropin (β-HCG), cancer antigen 125 (CA125), and carcinoembryonic antigen (CEA) levels were checked to evaluate the risk of malignancy, unless emergency surgery was needed. Imaging studies consisted of abdominal ultrasonography, computed tomography (CT), or both. The procedure was performed by placing one 10-mm trocar through the umbilicus with the patient in the Trendelenburg position and rotating it to the left or right, depending on the location of the tumor. A 10-mm 0° operative laparoscope (Karl Storz, Tuttlingen, Germany) with a 5-mm working channel was used. Through the 5-mm working channel, a 5-mm laparoscopic forceps was used to identify and expose the tumor. The cystic content was aspirated with laparoscopic suction if the tumor was large (Fig. 1A). If ovarian torsion was found, detorsion was performed before aspiration and resection. Using a straight needle, a 3-0 polyglactin suspensory suture was made percutaneously. After the peritoneal cavity had been entered, the needle was passed through the mesosalpinx, and the suture was then made to exit the abdomen using a different penetrating wound. The procedure is similar to that described in our previous publication on transumbilical 1-port laparoscopic appendectomy [6]. The fallopian tube was suspended, and the mesosalpinx was exposed. The mesosalpinx and proper ovarian ligament was divided by bipolar or Ligasure (Valleylab, Boulder, CO) forceps. One suspensory suture was usually sufficient for adequate exposure of the mesosalpinx, but 2 sutures were sometimes required. The suspensory ligament and the vessels of the diseased ovary were ligated with extracorporeal fisherman's knots. Ovary-sparing resection of the tumor was performed whenever possible. Oophorectomy was performed when the ovarian parenchyma was hard to separate from the tumor or when there was torsion and gangrenous change of the ovarian tumor, including the ovarian parenchyma. During the ovary-preserving procedure, we used Ligasure to resect the tumor without ligation or resection of the ovarian vessels.
Fig. 1 A, CT scan of the abdomen reveals a huge cyst, later proven to be serous cystadenoma, with septum and a diameter of 23 × 12 cm. B, Postoperative view of the patient's abdomen reveals that the scar is hidden in the umbilicus (arrow).
We followed the procedures described by Karpelowsky et al [7] to gently enlarge the incision by blunt and sharp dissection to locate the cleavage plane between the tumor wall and the ovarian cortex. The cyst was removed, and the ovarian tissue was left open without suture. When oophorectomy was performed, the ovarian vessels were divided using bipolar scissors or Ligasure. The tumor was removed and placed into an endobag. Because most of the tumors were large enough to preclude extraction from the small umbilical wound, the tumor was chopped into small pieces in the endobag. Then the tumor was removed from the endobag piece by piece. Because the tumor was contained in the endobag, spillage was avoided. However, we still irrigated the peritoneal cavity with a large amount of normal saline to avoid any leftover tissues, and the fluid was aspirated. Before removal of the
1342
S.-Y. Lee et al.
laparoscope, we checked for possible enlarged lymph nodes in the iliac and aortocaval area, as well as any abnormal findings in the contralateral ovary. The incised umbilical fascia was closed with 5-0 polydioxanone sutures, and the skin was closed with subcuticular 5-0 polydioxanone sutures. The patients and their family are satisfied with the immediate postoperative cosmetic outcome. After the operation, the patient was encouraged to eat and to walk as soon as possible. Oral acetaminophen was routinely used for postoperative pain control.
2. Results The patients had a mean age of 9.7 years. The tumor size was evaluated initially by imaging studies and then during surgery and was ranged from 3.6 to 23 cm. Tumor markers including AFP, β-HCG, CA-125, and CEA were within the reference ranges. One patient had no preoperative evaluation with ultrasonography and CT or tumor markers because of the need for emergency management after a preoperative diagnosis of acute appendicitis. All patients received TOPLR without conversion to laparotomy or to 3-port laparoscopy. Oophorectomy was performed in 9 patients, and ovarysparing tumor resection was done in 6 patients. The operative time ranged from 42 to 240 minutes, with a mean of 134 minutes. One advantage of the procedure is that it can
be performed by a single surgeon (mainly, S.Y. Lee) without assistance. Oral acetaminophen was sufficient to relieve postoperative pain in 14 patients, with only 1 patient requiring intramuscular administration of meperidine hydrochloride. The patients were advised to eat immediately after recovery from surgery and anesthesia. The hospital stay was relatively short, ranging from 1 to 3 days, with a mean of 2 days. The only exception was a patient with acute disseminated encephalomyelitis that developed before surgery; this patient was hospitalized for 70 days until full recovery from this condition. For comparison, the hospital stay of the 7 patients receiving laparotomy for resection of benign ovarian tumors at the same period was found to range from 2 to 14 days, with a mean of 4.75 days. No patients experienced chemical peritonitis. Pathologic findings included mature (cystic) teratomas in 12 patients, simple cyst with torsion in 1 patient, and mucinous and serous cystadenoma in 1 patient each (Table 1). Ultrasonography was used for postoperative follow-up, and no recurrence was detected during a follow-up period ranging from 3 months to 4 years (medium, 1 year 8 months). In our last 3 patients receiving ovary-sparing tumor resection, the size of their ovaries can be accurately measured with the use of a better abdominal ultrasound. The size of the preserved ovary on the lesion site was 1.9 × 1.1, 0.9 × 0.6, and 0.8 × 0.7 cm, whereas the size of the contralateral normal ovary was 2.7 × 2.3, 1.2 × 0.9, and 0.9 × 0.8 cm,
Table 1
Demographic data of the patients
Age (y)
Tumor marker
Image
10 8
CEA: 1.7 HCG: b0.5 AFP: b3 AFP: 0.63 CEA: 1.3 CA-125: 29.9 HCG: b5 AFP: b3 Nil AFP: 1.44 CA-125: 30.5 HCG: b5 AFP: b3 HCG: b5 AFP: b3 Nil HCG: b5; AFP: b3 HCG: b5; AFP: b3; CEA: b0.5; CA-125: 15.3 AFP: 1; CEA: 0.93; CA-125: 12.5 HCG: b5; AFP: b3 Nil Nil
CT CT
8 × 10 6×7
161 86
CT
9 × 10
13
11 7 17 14 7 8 15 13 4 12 2 4
Size (cm)
Operation time (min)
Postoperative stay (d)
Diagnosis
Right or left
2 2
MCT with torsion MCT
Right Left
125
2
MT with torsion
Left
CT
11 × 7
124
1
MT with torsion
Left
Ultrasound CT
5×6 23 × 12
42 240
1 2
MCT Serous cystadenoma
Right Left
CT
4 × 2.8
115
70
MCT
Left
CT
15 × 13
171
3
MCT
Left
Nil CT CT
3.6 × 1.8 21 × 18.5 20 × 12
119 182 225
1 2 2
MT Mucinous cystadenoma MT
Right Right Right
CT CT Ultrasound CT
4.9 × 4.4 11 × 11 6×6 6.5 × 4.7
80 167 57 119
3 2 2 3
Simple cyst with torsion MCT MCT MCT
Left Left Right Right
Normal values for AFP, b20 ng/mL; CA-125, b35 U/L; CEA, b5 ng/mL; and HCG, b10 IU/L. MCT indicates mature cystic teratoma; MT, mature teratoma.
TOPLR of benign ovarian tumor respectively, when followed 12, 11, and 22 months after the operation. The results suggest that the preserved ovary was still present with discernible parenchyma despite being smaller than the contralateral normal ovary.
3. Discussion Ovarian masses in children and adolescents lie on a spectrum ranging from simple cyst to complex malignancies including yolk sac tumors and primary carcinomas of the ovary [1,8]. Luckily, most ovarian masses are benign, of which simple and hemorrhagic cysts are most frequently found, followed by mature cystic teratomas [1,2]. Borderline ovarian tumors, which include mucinous or serous cystadenomas and, rarely, carcinoma, are uncommon in children and can be successfully treated with less aggressive procedures [9]. Excluding ovarian malignancy, for which the safety of laparoscopic management has not been confirmed, most ovarian tumors are amenable to minimally invasive surgery [1]. The results of our study support the use of transumbilical single-port surgery for resection of most benign ovarian tumors including borderline ovarian tumors [5]. Its benefits include a hospital stay averaging 2 days, reduced need for narcotic analgesics, and the cosmetic result of an inconspicuous scar hidden within the umbilicus, which is especially beneficial to patients who do not want a visible scar on the abdomen (Fig. 1B). Our mean operative time for this procedure was 134 minutes, which is longer than the 79 minutes previously reported for single-port surgery [4] and 82 minutes reported elsewhere for laparoscopic removal of large ovarian cysts by the open technique [10]. Several factors may account for the difference, including our health care system's calculation of operative time starting from the completion of anesthesia instead of the time of actual surgical intervention, our meticulous chopping of the tumor into pieces within the endobag before removal of the tumor tissues through the small umbilical wound, and our repeated cleansing of the abdominal cavity with a large amount of normal saline after resection of the tumor. It is worthwhile to spend extra time during surgery to reduce the risk of postoperative complications such as chemical peritonitis and residual tumor tissues. Because of a lack of reliable preoperative indicators of ovarian malignancy in children, several markers including β-HCG, AFP, CA-125, and CEA are included in preoperative evaluation. Elevated levels of tumor markers may not conclusively demonstrate malignancy but indicate that possibility, particularly when a mass larger than 8 cm or with solid imaging characteristics is found, or when there are signs of precocious puberty [8]. Unless emergency surgery was needed, tumor markers, particularly β-HCG and AFP, were checked in most cases before operation in this study. Negative findings for these tumor markers, and lack of solid
1343 imaging characteristics and physical signs of precocious puberty support the use of TOPLR for benign ovarian tumors. One exceptional case with preoperative diagnosis of acute appendicitis did not have preoperative evaluation with ultrasonography and CT or tumor markers. However, the cyst was small, and the whole mass could be removed and contained in the endobag without spillage. The pathologic findings and follow-up studies using abdominal ultrasonography confirmed the benign nature of all of the tumors treated through the minimally invasive procedure. Preservation of the ovary by removal of the tumor alone has been attempted by surgeons using a multiaccess laparoscopic approach [7,11]. Torsion of the ovary is not a contraindication to that procedure. In this study, we also confirmed the feasibility of preserving as much ovarian tissues as possible. This was accomplished in 6 patients (40%), including 1 with ovarian torsion and 2 with ovarian tumors exceeding 10 cm. The ovary could not be preserved when torsion caused gangrenous change of the ovary and the tumor or when the ovarian parenchyma was too thin or unable to be separated from the tumor without risking tumor rupture and spillage of the contents. There is no consensus as to the rate of cystectomy with ovarian preservation. Karpelowsky et al reported a preservation rate of 100%. However, in their series of 12 cases, a second operation is required in 3 patients 7 to 10 days after detorsion of the ovaries. In the other series, ovarian preservation was successful in 48% [11]. The relatively lower rate of ovary preservation in our study may reflect one limitation of our procedure, which is needed to improve in the future. Finally, aspiration of the cystic contents in a large ovarian tumor is almost inevitable when choosing laparoscopy [10,11]. One report showed that intraoperative tumour spillage occurred in 27 (52%) patients, but there were no cases of chemical peritonitis as well as tumor recurrence [11]. In this study, we also aspirated the cyst under a direct laparoscopic view, which is reported to be safer because it allows the assessment of the abdominal cavity and ovarian cyst, thus limiting the risk of spillage [12]. Despite no gross intraoperative spillage, we did not prevent minor, inconspicuous leakage. We, therefore, followed other's experience to use a copious amount of normal saline for irrigation of the abdominal cavity and to aspirate fluid as much as possible [10]. In this study, we used the single-port single-instrument technique, which is quite different from current singleincision/single-site surgery that uses multiple instruments through 1 port. In performing a single-port single-instrument technique, the operative laparoscope has to move at the same time and direction when the forceps or other instrument is used. It needs a short period of adaptation, but the learning curve is expected to be as short as we have for appendectomy [6]. In summary, the TOPLR procedure is feasible and effective in resection of benign ovarian tumors in children with limited working space in the abdomen and also has satisfactory cosmetic outcomes. Although the risk for malignancy is so low in these cases that the cosmetic benefit for a
1344 single-port surgery is worth achieving, we still warn against the possibility of malignancy in a small number of cases with normal tumor markers, and this technique would upstage the tumor.
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