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Transumbilical management for neonatal ovarian cysts
Journal of Pediatric Surgery (2007) 42, 2136–2139
www.elsevier.com/locate/jpedsurg
Operative technique
Transumbilical management for neonatal ovarian cysts Jao-Yo Lin⁎, Zen-Fung Lee, Yu-Tang Chang Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan Received 6 June 2007; accepted 3 August 2007
Index words: Transumbilical management; Ovarian cyst
Abstract Background/Purpose: Since Tan and Bianchi (Br J Surg. 1986;73:399) reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Because of the long pedicle with good mobility and the frequent intraabdominal position of the neonatal ovarian cyst, we attempted to manage it via the transumbilical route. Methods: All patients were treated under intubation general anesthesia. Semicircular infraumbilical incision was made, and the abdomen was entered through a transverse fascial incision. The partially collapsed cyst after aspiration was exteriorized through the incision for cystectomy, partial deroofing, or adnexectomy. Results: From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. There were no complications from surgery. The operation time and duration of hospital stay were short. The cosmetic appearance after the procedure was good. Conclusions: The initial result suggests that transumbilical management for neonatal ovarian cysts may be a good alternative procedure when laparoscopic equipment is unavailable or experienced technique is lacking. © 2007 Elsevier Inc. All rights reserved.
In 1986, Tan and Bianchi reported that the umbilical incision could be used for pyloromyotomy in infantile hypertrophic pyloric stenosis. Since then, many pediatric surgeons have used this approach for a number of other procedures. The umbilical incision is large enough to allow adequate exposure and offers a good postsurgical cosmetic appearance. Considering that the neonatal ovarian cyst has a
⁎ Corresponding author. Tel.: +886 7 3121101x6304; fax: +886 7 3111482. E-mail address: [email protected] (J.-Y. Lin). 0022-3468/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.08.009
long pedicle with good mobility and frequent intraabdominal position, we attempted to ascertain the feasibility of transumbilical management of the neonatal ovarian cysts.
1. Materials and methods From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. All patients were detected by prenatal ultrasound scan and referred to our institution after birth. Postnatal ultrasound was performed in all cases, and one case with initial diagnosis of teratoma received an additional computed
Transumbilical management for the neonatal ovarian cysts
2137
3. Discussion
Fig. 1 Ovarian cyst was seen clearly under transumbilical incision.
tomographic scan. Indications for surgery are large symptomatic simple cyst and complex cyst diagnosed by ultrasound and, if necessary, computed tomographic scan. All patients were treated under intubation general anesthesia. A semicircular infraumbilical incision was made, and the peritoneal cavity was accessed through a transverse fascial incision. The upper margin of the ovarian cyst usually exceeded the umbilicus and was seen clearly under the incision (Fig. 1). If the cyst is not visible, palpation of the cyst and squeezing of the abdominal wall can allow guidance and fixation of the cyst beneath the incision. The wall of the cyst was grasped by forceps or was sucked by a suction tube using the technique described by Ferro et al [1]. Under direct vision, the content was aspirated by a large needle. The partially collapsed cyst was then delivered through the incision (Fig. 2). Cystectomy, partial deroofing, or adnexectomy was performed outside the abdominal wall; and the contralateral ovary can be exteriorized for inspection via the same route if necessary.
After the introduction of ultrasound for the routine monitoring of pregnancy, the incidence of ovarian cysts progressively increased. Thus, the natural course of ovarian cysts has become clearer. Cysts smaller than 4 to 5cm in diameter tend to regress or resolve spontaneously in 3 to 4 months [2,3]; and the incidence of torsion is low, although it has occurred in cysts as small as 2 cm [4]. According to the previous reports [2,5,6], cysts with a diameter larger than 5 cm and a volume of more than 40 cm3 are more likely to cause clinical symptoms. The most common complication is torsion. Many studies described that torsion occurred in 40% to 47% of these patients [2,7,8]. Very large cysts can lead to respiratory distress, abdominal distension, pulmonary hypoplasia, polyhydramnios [9], intestinal perforation [10], and even hepatic failure [11]. There is still controversy regarding the optimal management of the ovarian cyst. Traditionally, the surgical indications for ovarian cysts are large simple cysts and complex cysts. Warner et al [12] describe that the character and the size of the cyst could not be used to predict clinical outcome, but many reports [2,8,13] suggest that the cyst size is an effective prognostic predictor. Lower incidence of torsion by in utero or postnatal aspiration also supports the opinion [3,7,14]. Although ovarian cyst decompression has been reported with good results, cyst torsion or recurrence cannot be absolutely avoided. Periodic ultrasonic monitoring is necessary, and spillage of cystic fluid during aspiration may occur. Enríquez et al [15] compared the result of conservative vs surgical treatment of complex neonatal ovarian cysts and recommended conservative management with clinical and sonographic monitoring for complex neonatal ovarian cyst. However, twisted, infarcted cyst may cause inflammatory adhesion to the bowel loops [16,17] and lead to intestinal obstruction and/or rupture with peritonitis [10]. Another point is that ultrasound cannot precisely differentiate a hemorrhagic
2. Results All infants were full term (Table 1). The cysts were simple in 3 cases, whereas the other 3 cases were complex. Average size was 8.1 cm (range, 6.7-9.5 cm) for the simple cysts and 5.6 cm (range, 4.5-6.7 cm) for the complex cysts. Cases 1 and 3 developed respiratory distress owing to the mass effect of large cystic size after birth, and case 1 even needed emergent intubation. The average age at operation was 8.5 days (range, 2-20 days). The mean operating time was 27.6 minutes (range, 21-43 minutes). There were no complications from surgery, and all patients were discharged 24 hours after operation. The scars were hardly detectable about 2 weeks later.
Fig. 2
The partially decompressed ovarian cyst was exteriorized.
2138 Table 1
J.-Y. Lin et al. Transumbilical management for the neonatal ovarian cysts
Case no.
Preoperative diagnosis
Clinical symptom
Intervention size (cm)
Age at operation (d)
Operation findings
Operation time (min)
Procedure
1 2 3 4 5 6
Simple cyst Complex cyst Simple cyst Simple cyst Complex cyst Complex cyst
Respiratory distress No Respiratory distress Abdomen distension No No
9.5 6.5 8.2 6.7 5.8 4.5
2 5 3 6 15 20
Simple cyst Hemorrhage Simple cyst Simple cyst Torsion Torsion
28 21 24 23 27 43
Cystectomy Partial unroofing Cystectomy Partial unroofing Adnexectomy Adnexectomy
cyst from cystic torsion [17] or other causes of abdominal cysts. Waiting may delay the optimal treatment and increase the potential risk of complications. In 1986, Tan and Bianchi [18] reported using circumumbilical incision as the access for pyloromyotomy in infantile hypertrophic pyloric stenosis. Since then, the transumbilical approach have become popular in many institutions. Despite advances in laparoscopic techniques and equipment in infants and children, many pediatric surgeons still use this approach for a number of other procedures. Umbilical approach of pyloromyotomy may encounter difficulty if the pyloric mass is large. Many authors reported using a modified umbilical incision for easy exposure of the pylorus. This problem is not seen in dealing with ovarian cysts. We believe that the transumbilical management is feasible for several reasons. First, because of the small size of the neonatal pelvis and a long cyst pedicle, a completely intraabdominal location is common [8]. Second, the distance between the umbilicus to the pubic symphysis in full-term babies ranges from 3.5 to 4.0 cm. Theoretically, the upper margin of a cyst larger than 4 cm is near or beyond the umbilicus. Third, after decompression, even a large cyst can be pulled out from the umbilical incision without difficulty. Fourth, the mobility of ovarian cysts allows guidance toward the umbilical incision by manipulating the abdominal wall under general anesthesia. Laparoscopic management of ovarian cysts in newborns is a safe and reliable method [19-22], but it requires specialized equipment and a longer learning curve. Furthermore, large cysts may limit the working space and hinder the insertion of the trocar. Poor tolerance to pneumoperitoneum in some newborns is another concern. According to our initial experience, transumbilical management can be a good alternative to laparoscopy for management of neonatal ovarian cyst when laparoscopic equipment is unavailable or experienced technique is lacking. It offers the same cosmetic result and length of stay as a laparoscopic procedure.
4. Conclusions Our initial results suggest that transumbilical management for neonatal ovarian cysts is feasible. The technique is easy,
and surgical exposure is adequate. It offers a good cosmetic appearance like other minimally invasive procedures. Although no complication has been found until now, more cases are needed for further investigation.
References [1] Ferro F, Iacobelli BD, Zaccara A, et al. Exteriorization-aspiration minilaparotomy for treatment of neonatal ovarian cysts. J Pediatr Adolesc Gynecol 2002;15(4):205-7. [2] Brandt ML, Luks FI, Filiatrault D, et al. Surgical indications in antenatally diagnosed ovarian cysts. J Pediatr Surg 1991;26(3):276-81. [3] Bagolan P, Giorlandino C, Nahom A, et al. The management of fetal ovarian cysts. J Pediatr Surg 2002;37(1):25-30. [4] Grapin C, Montagne JP, Sirinelli D, et al. Diagnosis of ovarian cysts in the perinatal period and therapeutic implications (20 cases). Ann Radiol (Paris) 1987;30(7):497-502. [5] Ikeda K, Suita S, Nakano H. Management of ovarian cyst detected antenatally. J Pediatr Surg 1988;23(5):432-5. [6] Perrotin F, Potin J, Haddad G, et al. Fetal ovarian cysts: a report of three cases managed by intrauterine aspiration. Ultrasound Obstet Gynecol 2000;16(7):655-9. [7] Heling KS, Chaoui R, Kirchmair F, et al. Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome. Ultrasound Obstet Gynecol 2002;20(1):47-50. [8] Nussbaum AR, Sanders RC, Hartman DS, et al. Neonatal ovarian cysts: sonographic-pathologic correlation. Radiology 1988;168(3): 817-21. [9] Bornstein E, Barnhard Y, Ferber A, et al. Acute progression of a unilateral fetal ovarian cyst to complex bilateral cysts causing acute polyhydramnios. J Ultrasound Med 2006;25(4):523-6. [10] Scholz PM, Key L, Filston HC. Large ovarian cyst causing cecal perforation in a newborn infant. J Pediatr Surg 1982;17(1):91-2. [11] GrÜa A, KaragÜzel G, Çubuk M, et al. Hepatic failure as a result of ovarian cysts in a newborn. Turk J Med Sci 2006;26(5):315-8. [12] Warner BW, Kuhn JC, Barr LL. Conservative management of large ovarian cysts in children: the value of serial pelvic ultrasonography. Surgery 1992;112(4):749-55. [13] Giorlandino C, Bilancioni E, Bagolan P, et al. Antenatal ultrasonographic diagnosis and management of fetal ovarian cysts. Int J Gynaecol Obstet 1994;44(1):27-31. [14] Crombleholme TM, Craigo SD, Garmel S, et al. Fetal ovarian cyst decompression to prevent torsion. J Pediatr Surg 1997;32(10): 1447-9. [15] Enriquez G, Duran C, Toran N, et al. Conservative versus surgical treatment for complex neonatal ovarian cysts: outcomes study. AJR Am J Roentgenol 2005;185(2):501-8. [16] Chiaramonte C, Piscopo A, Cataliotti F. Ovarian cysts in newborns. Pediatr Surg Int 2001;17(2-3):171-4.
Transumbilical management for the neonatal ovarian cysts [17] Kuroiwa M, Hatakeyama SI, Suzuki N, et al. Neonatal ovarian cysts: management with reference to magnetic resonance imaging. Asian J Surg 2004;27(1):43-8. [18] Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg 1986;73(5):399. [19] Jawad AJ, Al-Meshari A. Laparoscopy for ovarian pathology in infancy and childhood. Pediatr Surg Int 1998;14(1-2):62-5.
2139 [20] Dobremez E, Moro A, Bondonny JM, et al. Laparoscopic treatment of ovarian cyst in the newborn. Surg Endosc 2003;17(2):328-32. [21] Tseng D, Curran TJ, Silen ML. Minimally invasive management of the prenatally torsed ovarian cyst. J Pediatr Surg 2002;37(10): 1467-9. [22] Esposito C, Garipoli V, Di Matteo G, et al. Laparoscopic management of ovarian cysts in newborns. Surg Endosc 1998;12(9):1152-4.
www.elsevier.com/locate/jpedsurg
Operative technique
Transumbilical management for neonatal ovarian cysts Jao-Yo Lin⁎, Zen-Fung Lee, Yu-Tang Chang Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan Received 6 June 2007; accepted 3 August 2007
Index words: Transumbilical management; Ovarian cyst
Abstract Background/Purpose: Since Tan and Bianchi (Br J Surg. 1986;73:399) reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Because of the long pedicle with good mobility and the frequent intraabdominal position of the neonatal ovarian cyst, we attempted to manage it via the transumbilical route. Methods: All patients were treated under intubation general anesthesia. Semicircular infraumbilical incision was made, and the abdomen was entered through a transverse fascial incision. The partially collapsed cyst after aspiration was exteriorized through the incision for cystectomy, partial deroofing, or adnexectomy. Results: From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. There were no complications from surgery. The operation time and duration of hospital stay were short. The cosmetic appearance after the procedure was good. Conclusions: The initial result suggests that transumbilical management for neonatal ovarian cysts may be a good alternative procedure when laparoscopic equipment is unavailable or experienced technique is lacking. © 2007 Elsevier Inc. All rights reserved.
In 1986, Tan and Bianchi reported that the umbilical incision could be used for pyloromyotomy in infantile hypertrophic pyloric stenosis. Since then, many pediatric surgeons have used this approach for a number of other procedures. The umbilical incision is large enough to allow adequate exposure and offers a good postsurgical cosmetic appearance. Considering that the neonatal ovarian cyst has a
⁎ Corresponding author. Tel.: +886 7 3121101x6304; fax: +886 7 3111482. E-mail address: [email protected] (J.-Y. Lin). 0022-3468/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.08.009
long pedicle with good mobility and frequent intraabdominal position, we attempted to ascertain the feasibility of transumbilical management of the neonatal ovarian cysts.
1. Materials and methods From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. All patients were detected by prenatal ultrasound scan and referred to our institution after birth. Postnatal ultrasound was performed in all cases, and one case with initial diagnosis of teratoma received an additional computed
Transumbilical management for the neonatal ovarian cysts
2137
3. Discussion
Fig. 1 Ovarian cyst was seen clearly under transumbilical incision.
tomographic scan. Indications for surgery are large symptomatic simple cyst and complex cyst diagnosed by ultrasound and, if necessary, computed tomographic scan. All patients were treated under intubation general anesthesia. A semicircular infraumbilical incision was made, and the peritoneal cavity was accessed through a transverse fascial incision. The upper margin of the ovarian cyst usually exceeded the umbilicus and was seen clearly under the incision (Fig. 1). If the cyst is not visible, palpation of the cyst and squeezing of the abdominal wall can allow guidance and fixation of the cyst beneath the incision. The wall of the cyst was grasped by forceps or was sucked by a suction tube using the technique described by Ferro et al [1]. Under direct vision, the content was aspirated by a large needle. The partially collapsed cyst was then delivered through the incision (Fig. 2). Cystectomy, partial deroofing, or adnexectomy was performed outside the abdominal wall; and the contralateral ovary can be exteriorized for inspection via the same route if necessary.
After the introduction of ultrasound for the routine monitoring of pregnancy, the incidence of ovarian cysts progressively increased. Thus, the natural course of ovarian cysts has become clearer. Cysts smaller than 4 to 5cm in diameter tend to regress or resolve spontaneously in 3 to 4 months [2,3]; and the incidence of torsion is low, although it has occurred in cysts as small as 2 cm [4]. According to the previous reports [2,5,6], cysts with a diameter larger than 5 cm and a volume of more than 40 cm3 are more likely to cause clinical symptoms. The most common complication is torsion. Many studies described that torsion occurred in 40% to 47% of these patients [2,7,8]. Very large cysts can lead to respiratory distress, abdominal distension, pulmonary hypoplasia, polyhydramnios [9], intestinal perforation [10], and even hepatic failure [11]. There is still controversy regarding the optimal management of the ovarian cyst. Traditionally, the surgical indications for ovarian cysts are large simple cysts and complex cysts. Warner et al [12] describe that the character and the size of the cyst could not be used to predict clinical outcome, but many reports [2,8,13] suggest that the cyst size is an effective prognostic predictor. Lower incidence of torsion by in utero or postnatal aspiration also supports the opinion [3,7,14]. Although ovarian cyst decompression has been reported with good results, cyst torsion or recurrence cannot be absolutely avoided. Periodic ultrasonic monitoring is necessary, and spillage of cystic fluid during aspiration may occur. Enríquez et al [15] compared the result of conservative vs surgical treatment of complex neonatal ovarian cysts and recommended conservative management with clinical and sonographic monitoring for complex neonatal ovarian cyst. However, twisted, infarcted cyst may cause inflammatory adhesion to the bowel loops [16,17] and lead to intestinal obstruction and/or rupture with peritonitis [10]. Another point is that ultrasound cannot precisely differentiate a hemorrhagic
2. Results All infants were full term (Table 1). The cysts were simple in 3 cases, whereas the other 3 cases were complex. Average size was 8.1 cm (range, 6.7-9.5 cm) for the simple cysts and 5.6 cm (range, 4.5-6.7 cm) for the complex cysts. Cases 1 and 3 developed respiratory distress owing to the mass effect of large cystic size after birth, and case 1 even needed emergent intubation. The average age at operation was 8.5 days (range, 2-20 days). The mean operating time was 27.6 minutes (range, 21-43 minutes). There were no complications from surgery, and all patients were discharged 24 hours after operation. The scars were hardly detectable about 2 weeks later.
Fig. 2
The partially decompressed ovarian cyst was exteriorized.
2138 Table 1
J.-Y. Lin et al. Transumbilical management for the neonatal ovarian cysts
Case no.
Preoperative diagnosis
Clinical symptom
Intervention size (cm)
Age at operation (d)
Operation findings
Operation time (min)
Procedure
1 2 3 4 5 6
Simple cyst Complex cyst Simple cyst Simple cyst Complex cyst Complex cyst
Respiratory distress No Respiratory distress Abdomen distension No No
9.5 6.5 8.2 6.7 5.8 4.5
2 5 3 6 15 20
Simple cyst Hemorrhage Simple cyst Simple cyst Torsion Torsion
28 21 24 23 27 43
Cystectomy Partial unroofing Cystectomy Partial unroofing Adnexectomy Adnexectomy
cyst from cystic torsion [17] or other causes of abdominal cysts. Waiting may delay the optimal treatment and increase the potential risk of complications. In 1986, Tan and Bianchi [18] reported using circumumbilical incision as the access for pyloromyotomy in infantile hypertrophic pyloric stenosis. Since then, the transumbilical approach have become popular in many institutions. Despite advances in laparoscopic techniques and equipment in infants and children, many pediatric surgeons still use this approach for a number of other procedures. Umbilical approach of pyloromyotomy may encounter difficulty if the pyloric mass is large. Many authors reported using a modified umbilical incision for easy exposure of the pylorus. This problem is not seen in dealing with ovarian cysts. We believe that the transumbilical management is feasible for several reasons. First, because of the small size of the neonatal pelvis and a long cyst pedicle, a completely intraabdominal location is common [8]. Second, the distance between the umbilicus to the pubic symphysis in full-term babies ranges from 3.5 to 4.0 cm. Theoretically, the upper margin of a cyst larger than 4 cm is near or beyond the umbilicus. Third, after decompression, even a large cyst can be pulled out from the umbilical incision without difficulty. Fourth, the mobility of ovarian cysts allows guidance toward the umbilical incision by manipulating the abdominal wall under general anesthesia. Laparoscopic management of ovarian cysts in newborns is a safe and reliable method [19-22], but it requires specialized equipment and a longer learning curve. Furthermore, large cysts may limit the working space and hinder the insertion of the trocar. Poor tolerance to pneumoperitoneum in some newborns is another concern. According to our initial experience, transumbilical management can be a good alternative to laparoscopy for management of neonatal ovarian cyst when laparoscopic equipment is unavailable or experienced technique is lacking. It offers the same cosmetic result and length of stay as a laparoscopic procedure.
4. Conclusions Our initial results suggest that transumbilical management for neonatal ovarian cysts is feasible. The technique is easy,
and surgical exposure is adequate. It offers a good cosmetic appearance like other minimally invasive procedures. Although no complication has been found until now, more cases are needed for further investigation.
References [1] Ferro F, Iacobelli BD, Zaccara A, et al. Exteriorization-aspiration minilaparotomy for treatment of neonatal ovarian cysts. J Pediatr Adolesc Gynecol 2002;15(4):205-7. [2] Brandt ML, Luks FI, Filiatrault D, et al. Surgical indications in antenatally diagnosed ovarian cysts. J Pediatr Surg 1991;26(3):276-81. [3] Bagolan P, Giorlandino C, Nahom A, et al. The management of fetal ovarian cysts. J Pediatr Surg 2002;37(1):25-30. [4] Grapin C, Montagne JP, Sirinelli D, et al. Diagnosis of ovarian cysts in the perinatal period and therapeutic implications (20 cases). Ann Radiol (Paris) 1987;30(7):497-502. [5] Ikeda K, Suita S, Nakano H. Management of ovarian cyst detected antenatally. J Pediatr Surg 1988;23(5):432-5. [6] Perrotin F, Potin J, Haddad G, et al. Fetal ovarian cysts: a report of three cases managed by intrauterine aspiration. Ultrasound Obstet Gynecol 2000;16(7):655-9. [7] Heling KS, Chaoui R, Kirchmair F, et al. Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome. Ultrasound Obstet Gynecol 2002;20(1):47-50. [8] Nussbaum AR, Sanders RC, Hartman DS, et al. Neonatal ovarian cysts: sonographic-pathologic correlation. Radiology 1988;168(3): 817-21. [9] Bornstein E, Barnhard Y, Ferber A, et al. Acute progression of a unilateral fetal ovarian cyst to complex bilateral cysts causing acute polyhydramnios. J Ultrasound Med 2006;25(4):523-6. [10] Scholz PM, Key L, Filston HC. Large ovarian cyst causing cecal perforation in a newborn infant. J Pediatr Surg 1982;17(1):91-2. [11] GrÜa A, KaragÜzel G, Çubuk M, et al. Hepatic failure as a result of ovarian cysts in a newborn. Turk J Med Sci 2006;26(5):315-8. [12] Warner BW, Kuhn JC, Barr LL. Conservative management of large ovarian cysts in children: the value of serial pelvic ultrasonography. Surgery 1992;112(4):749-55. [13] Giorlandino C, Bilancioni E, Bagolan P, et al. Antenatal ultrasonographic diagnosis and management of fetal ovarian cysts. Int J Gynaecol Obstet 1994;44(1):27-31. [14] Crombleholme TM, Craigo SD, Garmel S, et al. Fetal ovarian cyst decompression to prevent torsion. J Pediatr Surg 1997;32(10): 1447-9. [15] Enriquez G, Duran C, Toran N, et al. Conservative versus surgical treatment for complex neonatal ovarian cysts: outcomes study. AJR Am J Roentgenol 2005;185(2):501-8. [16] Chiaramonte C, Piscopo A, Cataliotti F. Ovarian cysts in newborns. Pediatr Surg Int 2001;17(2-3):171-4.
Transumbilical management for the neonatal ovarian cysts [17] Kuroiwa M, Hatakeyama SI, Suzuki N, et al. Neonatal ovarian cysts: management with reference to magnetic resonance imaging. Asian J Surg 2004;27(1):43-8. [18] Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg 1986;73(5):399. [19] Jawad AJ, Al-Meshari A. Laparoscopy for ovarian pathology in infancy and childhood. Pediatr Surg Int 1998;14(1-2):62-5.
2139 [20] Dobremez E, Moro A, Bondonny JM, et al. Laparoscopic treatment of ovarian cyst in the newborn. Surg Endosc 2003;17(2):328-32. [21] Tseng D, Curran TJ, Silen ML. Minimally invasive management of the prenatally torsed ovarian cyst. J Pediatr Surg 2002;37(10): 1467-9. [22] Esposito C, Garipoli V, Di Matteo G, et al. Laparoscopic management of ovarian cysts in newborns. Surg Endosc 1998;12(9):1152-4.