clinical study laparoscopic cystectomy in-a-bag of an...

Clinical StudyLaparoscopic Cystectomy In-a-Bag of an Intact CystIs It Feasible and Spillage-Free After All

Stelios Detorakis Dimitrios Vlachos Stavros Athanasiou Themistoklis GrigoriadisAikaterini Domali Ioannis Chatzipapas Emmanuel Stamatakis Athanasios MousiolisApostolos Patrikios Aris Antsaklis Dimitrios Loutradis and Athanasios Protopapas

1st Department of Obstetrics and Gynecology of the University of Athens Alexandra Hospital80 Queen Sophie Avenue and Lourou Street 11528 Athens Greece

Correspondence should be addressed to Athanasios Protopapas protothaotenetgr

Received 22 May 2015 Accepted 10 January 2016

Academic Editor Peng Hui Wang

Copyright copy 2016 Stelios Detorakis et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

This prospective studywas conducted to assess the feasibility of laparoscopic cystectomy of an intact adnexal cyst performed inside awater proof endoscopic bag aiming to avoid intraperitoneal spillage in case of cyst rupture 102 patients were recruited Two of themwere pregnant In 8 of the patients the lesions were bilateral adding up to a total of 110 cysts involved in our study The endoscopicsac did not rupture in any case Mean diameter of the cysts was 57 cm (range 23ndash105 cm) In 75110 (682) cases cystectomywas completed without rupture whereas in the remaining 35110 (318) cases the cyst ruptured Minimal small spillage occurreddespite every effort only in 8110 (72) cases with large (gt8 cm) cystic teratomas There were no intraoperative or postoperativecomplications We concluded that laparoscopic cystectomy in-a-bag of an intact cyst is feasible and oncologically safe for cystictumors with a diameter lt 8 cmManipulation of larger tumors with the adnexa into the sac may be more difficult and in such casesprevious puncture and evacuation of the cyst contents should be considered

1 Introduction

Advances in laparoscopic surgery over the past 3 decades havemade the removal of most benign ovarian masses that previ-ously required laparotomy technically possible Laparoscopicsurgery is less invasive requires shorter hospitalization andrecovery times and is usually favored by young patients dueto its better aesthetic results [1 2] However its role in themanagement of adnexal masses has become controversial interms of the oncological safety of such a procedureThemainconcern is that iatrogenic rupture and spillage of contentsof a malignant adnexal mass would upgrade the diseasestage resulting in a need for adjuvant chemotherapy andpossibly compromising the overall survival of the patient[3 4] These concerns have led to several guidelines andrestrictions concerning laparoscopic management of adnexalmasses throughout the years which are not generally adoptedand change quite often [5 6]

Laparoscopic cystectomy in-a-bag is a technique pro-posed for the management of suspicious adnexal cysticmasses and has been described in the early rsquo90s [7 8]Nevertheless its real value in preventing spillage of contentsin case of intraoperative rupture of a cyst has not beenproperly assessed in a prospective manner Furthermoreunder the preoperative term ldquosuspicious adnexal massesrdquo avariety of pathologies will be included with the majorityrepresenting benign ovarian swellings [9 10]

Our study was designed to investigate prospectively thetrue value of a large waterproof and handle-free endoscopicsac in preventing spillage of contents after rupture of laparo-scopically managed cystic adnexal massesWe also attemptedto determine the probabilities of rupture for each of theseveral histologically different cystic masses encountered in agroup of young patients inwhoman effort to excise the lesionintact was made Our purpose was to recognize preoperativeand intraoperative risk factors for rupture and spillage after

Hindawi Publishing CorporationMinimally Invasive SurgeryVolume 2016 Article ID 8640871 6 pageshttpdxdoiorg10115520168640871

2 Minimally Invasive Surgery

rupture and set the limits for attempting excision of anintact cyst versus performing puncture and evacuation of itscontents

2 Materials and Methods

Patients with cystic adnexal masses referred for laparoscopicmanagement to the Gynecological Endoscopy Unit of the 1stDepartment of Obstetrics amp Gynecology of the University ofAthens ldquoAlexandrardquo Hospital Athens Greece from January2009 to September 2013 were recruited for this prospectivecohort study The study was approved by our institutionrsquosscientific committee and a detailed informed consent wasobtained from all patients

The standard preoperative triage included a completeclinical and gynecological examination and tumor markers(CEA CA-125 CA19-9 a-fetoprotein and 120573-hCG) plus adetailed pelvic transvaginal (TVS) andor transabdominal(TAS) ultrasound scan During ultrasonographic examina-tion the following characteristics of the adnexal mass werelooked for and recorded size appearance of fluid contentpresence of a solid component septations papillary projec-tions into the cyst or surface excrescences the thickness of thecyst wall presence of neovascularization and the cystrsquos uni-or bilateral localization An abdominal CT scan or MRI wasoccasionally performed to assist in the differential diagnosisWomen gt 45 years old those with a preoperative diagnosis ofan endometrioma and those with probable invasive ovariancancer were excluded from this study Cases with possiblefunctional cysts were reexamined after 3-4 months and werescheduled for laparoscopy were the lesion persisted

Ovarian masses included in our sample were allocatedinto four groups regarding their sonographic characteristicsfluid filled structures anechoic or of low echogenicity possi-ble teratomas paraovarian cysts andmasses that could not beclassified as benign or malignant based on their sonographicappearance Fluid filled ovarian lesions were subgroupedinto unilocular and multilocular Ovarian lesions presentingwith mixed echogenicity consisting of longitudinal whitelines or a Rokitansky nodule and showing acoustic shadowswere categorized as teratomas Unilocular anechoic cysticmasses observed nearby the ovarywere allocated in a separategroup Finally ovarian cystic lesions that could not be pre-operatively reported as definitely benign were characterizedas suspicious Presence of papillary projections meaninginner irregularities of cystic wall gt 3mm and presence ofa solid component were taken into account Solid partsin particular were differentiated from Rokitansky nodulesbased on the presence or not of acoustic shadows Because ofthe expected high prevalence of benign masses in our groupof patients size per se was not considered a single criterionto characterize the mass as suspicious or not despite the factthat lesion size may affect preoperative diagnosis [11ndash13]

Laparoscopic surgery was performed using the techniqueof 4 trocars one primary trocar was placed through a verticalintraumbilical incision allowing the use of a 10mm 0-degree laparoscope Another two accessory trocars (5mm)were inserted in the lower abdomen lateral to the inferior

Figure 1 Cyst-harboring adnexa inside handle-free endoscopic sac

epigastric vessels and a fourth accessory trocar (5mm) wasinserted above the pubic hairline

After insertion of the laparoscope a careful and thoroughinspection of the pelvis and abdomen was performed andperitoneal washings or free peritoneal fluid was taken forcytological examination The waterproof endoscopic bag(Unimax Medical Technology Promedt Consulting GmBH510158401015840 times 710158401015840) was inserted blindly into the peritoneal cavitywrapped tightly into its plastic applicator through the umbil-ical trocar and opened by unrolling it with atraumaticforceps after replacing the laparoscopeThe lesion-harboringadnexa was placed and kept inside the bag throughout itsdissection (Figure 1) The endoscopic bag used in our studywas not attached to an external manipulator instead it wassupplied with a lasso at its rim made of a memory wireaimed to be tightened in the end of the procedure to allowfor safe specimen extraction Laparoscopic cystectomy wasperformed without previous evacuation of the cyst makingan effort to keep the adnexa inside the sac throughout theprocedure and excise the cyst intact In case of inadvertentrupture even minimal leakage was recorded In cases withbilateral cysts the side harboring the smaller cyst was treatedfirst

The ovarian capsule was incised with scissors and thecleavage plane between cyst and ovary was identified Thecyst was enucleated from the surrounding ovarian tissuemainly by means of blunt dissection andor aqua dissectionDense adhesions between the cyst and ovarian stroma weredivided sharply with scissors after bipolar coagulation closerto the surface of the cyst In cases with suspicious massesthe technique was slightly modified and the adhesions weredivided closer to the ovary than the cyst to allow for asafety margin In case of rupture during cyst dissection theinstrument tips were washed with normal saline while insidethe bag before removing them from the peritoneal cavity

After excision of the cyst the left 5mm accessory trocarwas replaced by a 10mm trocar The end of the wire waspulled outside the peritoneal cavity through this trocar whichwas removed and the closed mouth of the bag was retrievedthrough the skin incision and opened extracorporeally Thecyst was deflated inside the bag using a needle or anothercutting instrument and a suction pump in order to reduce itsvolume andmake the extraction of the bag and the remainingcyst possible without contamination of the abdominal wall

Minimally Invasive Surgery 3

Table 1 Distribution of our cases according to the final histological diagnosis

Final histologyRupture Spillage MCD

Total119873

No119873 ()

Yes119873 ()

No119873 ()

Yes119873 ()

Meancm

Rangecm

Serous cystadenoma 10 (625) 6 (375) 14 (875) 2 (125) 698 48ndash95 16Mucinous cystadenoma 3 (188) 13 (813) 11 (688) 5 (313) 761 43ndash105 16Serous cystadenofibroma 5 (833) 1 (167) 6 (1000) 0 (00) 643 50ndash100 6Simple serous cyst 11 (917) 1 (83) 12 (1000) 0 (00) 447 32ndash61 12Benign cystic teratoma 33 (733) 12 (267) 44 (978) 1 (22) 517 23ndash82 45Borderline ovarian tumor 2 (500) 2 (500) 0 (00) 0 (00) 740 52ndash86 4Paraovarian cyst 11 (1000) 0 (00) 11 (1000) 0 (00) 625 40ndash90 11Total 75 (682) 35 (318) 102 (927) 8 (73) 570 23ndash105 110

Whenever a solid component was prominent the incisionwasenlarged to allow for easier and safer extraction

Based on final histology the following histological groupsemerged and are used for analysis serous cystadenomamucinous cystadenoma benign cystadenofibroma simpleserous cyst benign mature cystic teratoma paraovarian cystand borderline ovarian tumor

3 Statistics

Statistical analysis was performed with the Statistics Pack-age for Social Sciences (SPSS) version 15 An independentsamples 119905-test and the nonparametric Mann-Whitney 119880 testwere used to compareMCDs between cases with and withoutrupture and between cases with and without spillage TheChi-square and Fisherrsquos exact tests were used to determinethe statistical significance during comparisons of categoricaldata

The logistic regression model provided the estimatedprobability of rupture and spillage for any particular case Inthis model the MCD was used as an independent variableA 119901 value of less than 005 was considered as statisticallysignificant

4 Results

All 102 cases included in this study were operated on bya single senior surgeon (AP) to ensure consistency in theoperative technique In 8 cases the lesions were bilateralwhich made a total of 110 cysts available for analysis Twopatients were pregnant and their procedure was performedduring the second trimester of pregnancy Another 6 cases4 with endometriomas and 2 with functional cysts with anerroneous preoperative diagnosis discovered during surgerywere excluded from this study

Patients and maximum cyst diameters per group of finalhistology are summarized in Table 1 Mean patient age was289 years (range 12ndash44) Mean maximum diameter of thecysts (MCD)was 57 cm (range 23ndash105 cm)The endoscopicsac did not rupture in any case In 75110 (682) casescystectomy was completed without rupture whereas in theremaining 35110 (318) cases the cyst ruptured Spillage

occurred despite every effort in 8110 (72) cases all withlarge (gt8 cm) cystic teratomas Rupture occurred in 321(1753) of the cysts with sonolucent fluid content whereasin 264 (1453) of those with mixed solid and sonolucentcontents and in 100 (44) of those with internal echos thecyst ruptured

The mean MCD of the cysts that ruptured independentof spillage was 675 cm and the mean MCD of those withoutrupture was 560 cm This difference was statistically signif-icant (119901 lt 0001) In the group of patients with rupturebut no spillage the MCD was 610 cm and did not differsignificantly compared with that of the no-rupture groupWhen attempting to determine a cutoff point of the MCDabove which the probability of rupture (with or withoutspillage) increases significantly this was set at 73 cm Amongovarian cysts with a MCD ge 73 cm 577 (1526) rupturedcompared with 238 (2084) of those with a MCD lt 73 cm(119901 = 0003) The relative risk (RR) of rupture was 436 timesgreater for cysts withMCD ge 73 cm than for those withMCDlt 73 cm (Figure 2)

Combining the final histological diagnosis and the MCDof the cyst with the probability of rupture we found thatovarian cysts with a MCD ge 73 cm had an almost threefold(times294) higher RR of rupture than those with aMCD lt 73 cmfor a given histological type (119901 = 0040) Mucinous cys-tadenomas in particular were more likely to rupture duringtheir excision compared with other histological types of thesame diameter 813 (1316) of the mucinous cystadenomasruptured whereas only 234 of the other histological types(2294) did so during their excision (119901 lt 00001) The RRof rupture for mucinous cystadenomas was 107 times highercompared with other histological types for the same MCD(Figures 3 and 4)

In our study 318 of the ovarian cysts (35110) rupturedduring their excision with the previously described tech-nique In 229 (835) of these spillage of their contentsinto the peritoneal cavity was recorded and therefore thepercentage of rupture and spillage in our study was 72(8110) The mean MCD of the ovarian cysts with spillage oftheir contents was 894 cm which was significantly higherthan the mean MCD of 574 cm of those without spillage(independent of rupture) and the mean MCD of 610 cm


RuptureRupture without spillageSpillage

00

02

04

06

08

10

12

Logi

stic p

roba

bilit

y

2 4 6 8 10 12 140MCD (cm)

Figure 2 Probabilities of rupture with and without spillage inrelation to MCD (cm)

01020304050607080

()

other histologyMCD gt 8 and

typesother histologyMCD lt 8 and

typesand

MCD lt 8

mucinous

MCD ge 8

andmucinous

749

50

250

06

cystadenoma cystadenoma

Figure 3 Probabilities of rupture in relation to MCD (cm) and cysthistology

of those with rupture but no spillage (119901 lt 00001 eachcomparison) In the groupwith rupture and spillage 5 of the 8(625) cases had mucinous cystadenomas Moreover 313(516) of mucinous cystadenomas sustained spillage of theircontent The percentage of spillage in all other histologicaltypes grouped together was significantly lower (119901 = 0002)

We also tried to determine a cutoff point of statisticalsignificance (according towhat we did for cyst rupture) abovewhich the probability of spillage of contents of a rupturedovarian cyst into the peritoneal cavity increases significantlyThis cutoff point was set at 8 cm Among ovarian cysts withMCD ge 8 cm 438 (716) sustained spillage compared withonly 11 (194) of those with MCD lt 8 cm (119901 lt 00001) Inother words the RR of spillage was 72 times higher for cystsge 8 cm than for those lt 8 cm In the group of 35 cysts thatruptured during their excision and in relation to the cutoffpoint of 8 cm in only 36 (128) of those with aMCD lt 8 cmtheir contents were spilled after rupture comparedwith 100(77) of those with MCD ge 8 cm (119901 lt 0001)

Regarding the relation between the histological diagnosisof the cyst and the probability of spillage we found that cystswith MCD ge 8 cm had a RR for spillage 56 times higherthan those with MCD lt 8 cm among cysts with the samefinal histology (FH) (119901 = 0001) Mucinous cystadenomas in

Series 1 194

0102030405060708090

100

()

MCD ge 73 andother histology

types

MCD lt 73 andother histology

types

MCD lt 73

andmucinous

MCD ge 73

andmucinous

884

721

414


Figure 4 Probabilities of spillage in relation to MCD (cm) and cysthistology

particular for the same MCD had a RR for spillage 89 timeshigher than other histological types (119901 = 0033) Borderlinetumors in particular ruptured in 24 (50) cases includinga pregnant patient but without any spillage whereas in noneof the 11 paraovarian cysts ruptured

Another interesting aspect in our study was to investigatehow the increase of theMCDaffects the probability of ruptureand spillage In order to determine that aspect we developedthree statistical models using as an independent variable theMCD and as a dependent variable the event of rupture withor without spillage (model 1) rupture without spillage (model2) and finally rupture with spillage (model 3) For every 1 cmincrease of the MCD there is an average increase of the RRof rupture by 148 times (119901 = 002) For every 1 cm increaseof the MCD there is an average increase of the RR of rupturewith spillage by 38 times (119901 = 0001) (Figure 2)

5 Discussion

This prospective study was conducted to determine safetycriteria for attempting the laparoscopic excision of an intactadnexal cyst using a handle-free endoscopic sac as protectionfrom spillage Our study population consisted exclusively ofyoung patients desiring preservation of their full reproduc-tive capacity We believe that avoidance of spillage duringcystectomy is of great importance not only for malignantcysts (because of disease upstaging) but also for benign onesbecause of the possibility that the spilled content might causechemical peritonitis and result in future periadnexal andintraperitoneal adhesions even in the absence of symptoms[14 15]

The operative management of adnexal cystic swellings(ACS) represents one of the commonest indications forlaparoscopic gynecological surgery Such a preoperative diag-nosis may include several pathological entities ovarian andnonovarian lesions nonneoplastic and neoplastic massesand among these benign borderline and even invasive neo-plasms Accurate preoperative andor intraoperative diagno-sis may be feasible on many occasions and impossible inothers for the reason that different pathologies may share avariety of similar morphological features [16ndash18]

ldquoSuspicious adnexal massrdquo is a term used to describea lesion that does not appear to be overt cancer but


possesses several sonographic ormorphologic characteristicsthat increase its likelihood of proving malignant at finalhistology [7 19] Despite the fact that even today manyauthorities consider laparoscopy an inappropriate tool totreat invasive ovarian cancer the laparoscopic approach hasbeen established over the years as the first-line operativemodality to evaluate suspicious adnexal masses [19ndash21]

The prevalence of invasive ovarian cancer is highly vari-able in groups of patients with ovarian cystic swellings treatedwith laparoscopy It depends on the studied population andis lowest in young patients lt 40 years old [19 22] Inthis reproductive age group laparoscopic cystectomy withovarian preservation represents the treatment of choice for allbenign lesionsAfter careful patient selection even suspiciouscystic masses may be treated conservatively providing thatall measures are taken to avoid intraoperative spillage in caseof rupture Obviously removal from the peritoneal cavity ofan intact cyst with extraperitoneal evacuation inside a water-proof endoscopic sac has the lowest risk of intraperitonealspillage and contamination

The main parameter that should be considered whenchoosing the right method to excise a cyst (with or withoutprevious evacuation of its contents) is its maximal diameterRupture of a cyst does not necessarily lead to spillage ofits contents into the peritoneal cavity providing that itis always being excised in a waterproof laparoscopic sacwhereas rupture is obviously a prerequisite for spillage Ourstudy showed that the RR for rupture increases by 48for every 1 cm rise in cyst diameter whereas the RR forspillage quadruples respectively From a clinical perspectivethemain concern is not somuch to avoid rupture of a cyst butto avoid spillage Therefore the cutoff point in cyst diameterwith a major clinical significance was set at 8 cm Based onour results showing that 438 of the cysts withMCD ge 8 cmsustained spillage of their contents compared with only 11of thoselt 8 cm (in otherwords the RRof spillagewas 72 timeshigher for cysts ge 8 cm) we can conclude that the techniqueof excision of an intact cyst without previous evacuation ofits contents is effective and oncologically safe for lesions le8 cm For larger ovarian cystic masses it is recommended topuncture and evacuate the cyst inside the sac and then removeits residual wall from the ovary

Mucinous cystadenomas (the majority of which weremultilocular) were associated with an almost 10-fold higherRR for rupture compared with other histological types (forthe same MCD) It can be safely concluded that for cyststhat give us morphologically the impression of a mucinouscystadenoma it is safer to previously evacuate their content(always in a laparoscopic bag in order to avoid microspillage)and then excise the remaining cystic wall This may requiremore than a single puncture

An interesting finding of our study was the low rate ofrupture for those cystic masses that were characterized assuspicious Overall only 314 (214) cysts in this group(4 borderlines 5 cystadenofibromas 2 serous cystadenomasand 3 teratomas) ruptured with 0 spillage For this group ofpatients the cystectomy technique as it wasmentioned abovewas slightly different With the modified technique even inthe group of patients with borderline ovarian tumors (119873 = 4)

the rupture rate was 50 (one in a pregnant patient) with0 spillage This indicates (a) that laparoscopic cystectomymay be performed safely in a BOT without spillage and (b)that oophorectomy should not be the obligatory treatment ofchoice for suspicious cystic masses

In conclusion taking into account two major parametersin an adnexal cyst to be treated with laparoscopic cystectomy(maximum diameter and morphological profile) we wereable to come up with a guideline concerning choice of theproper technique for its safe excision without spillage of itscontents into the peritoneal cavity Similarly with properpatient selection rupture could be avoided in a significantpercentage of cases In any case the adnexa harboring thelesion should be placed inside a waterproof laparoscopic sacand particular attention must be paid to keep it inside thesac throughout the procedure In the unfortunate event thatspillage occurs cyst contents must be immediately removedby repeated washing and aspiration Vigorous irrigation ofthe peritoneal cavity with saline solution combined withpositioning of the patient in the anti-Trendelenburg positionby the end of the surgery minimizes the risk of chemicalperitonitis and possibly implantation of malignant cells

Competing Interests

Drs Stelios Detorakis Dimitrios Vlachos Stavros Athana-siou Themistoklis Grigoriadis Aikaterini Domali IoannisChatzipapas Emmanuel Stamatakis Athanasios MousiolisApostolos Patrikios Aris Antsaklis Dimitrios Loutradisand Athanasios Protopapas have no competing interests orfinancial ties to disclose

References

[1] L Mettler K Semm and K Shive ldquoEndoscopic managementof adnexal massesrdquo Journal of the Society of LaparoendoscopicSurgeons vol 1 no 2 pp 103ndash112 1997

[2] M Canis B Rabischong C Houlle et al ldquoLaparoscopicmanagement of adnexal masses a gold standardrdquo CurrentOpinion in Obstetrics and Gynecology vol 14 no 4 pp 423ndash428 2002

[3] A J Dembo M Davy A E Stenwig E J Berle R S Bushand K Kjorstad ldquoPrognostic factors in patients with stage Iepithelial ovarian cancerrdquoObstetrics andGynecology vol 75 no2 pp 263ndash273 1990

[4] I Vergote J De Brabanter A Fyles et al ldquoPrognostic impor-tance of degree of differentiation and cyst rupture in stage Iinvasive epithelial ovarian carcinomardquoThe Lancet vol 357 no9251 pp 176ndash182 2001

[5] American College of Obstetricians and Gynecologists ldquoACOGPractice Bulletin (2007) Management of adnexal massesrdquoObstetrics amp Gynecology vol 110 no 1 pp 201ndash214 2007

[6] French College of Gynecologists and Obstetricians ldquoRecom-mendations for clinical practice presumed benign ovariantumorsrdquo Journal de Gynecologie Obstetrique et Biologie de laReproduction vol 42 no 8 pp 856ndash866 2013

[7] A Shushan A Protopapas and A L Magos ldquoLaparoscopicldquooophorectomy-in-a bagrdquo-an alternative to laparotomy for theevaluation of suspicious ovarian massesrdquo Journal of Obstetricsand Gynaecology vol 21 no 4 pp 399ndash401 2001


[8] A Zanatta M M S Rosin and L Gibran ldquoLaparoscopy as themost effective tool formanagement of postmenopausal complexadnexal masses when expectancy is not advisablerdquo Journal ofMinimally Invasive Gynecology vol 19 no 5 pp 554ndash561 2012

[9] T Slangen P Beretta G Catalano R Marana and B vanHerendael ldquoBag surgery as part of a protocol to treat ovarianmasses by laparoscopyrdquoThe Journal of the American Associationof Gynecologic Laparoscopists vol 1 no 4 part 2 article S341994

[10] P M Yuen and M S Rogers ldquoLaparoscopic removal ofovarian cysts using a zipper storage bagrdquo Acta Obstetricia etGynecologica Scandinavica vol 73 no 10 pp 829ndash831 1994

[11] D Timmerman L Valentin T H Bourne W P Collins HVerrelst and I Vergote ldquoTerms definitions and measurementsto describe the sonographic features of adnexal tumors a con-sensus opinion from the International Ovarian Tumor Analysis(IOTA) grouprdquoUltrasound inObstetrics andGynecology vol 16no 5 pp 500ndash505 2000

[12] L Savelli A C Testa D Timmerman D Paladini O Ljung-berg and L Valentin ldquoImaging of gynecological disease (4)clinical and ultrasound characteristics of struma ovariirdquo Ultra-sound in Obstetrics and Gynecology vol 32 no 2 pp 210ndash2192008

[13] A Di Legge A C Testa L Ameye et al ldquoLesion size affectsdiagnostic performance of IOTA logistic regression modelsIOTA simple rules and risk of malignancy index in discriminat-ing between benign andmalignant adnexal massesrdquoUltrasoundin Obstetrics and Gynecology vol 40 no 3 pp 345ndash354 2012

[14] S Milingos A Protopapas P Drakakis et al ldquoLaparoscopictreatment of ovarian dermoid cysts eleven yearsrsquo experiencerdquoJournal of the American Association of Gynecologic Laparo-scopists vol 11 no 4 pp 478ndash485 2004

[15] W Kondo N Bourdel B Cotte et al ldquoDoes prevention ofintraperitoneal spillage when removing a dermoid cyst preventgranulomatous peritonitisrdquo BJOGmdashAn International Journal ofObstetrics and Gynaecology vol 117 no 8 pp 1027ndash1030 2010

[16] S Takemoto K Ushijima R Kawano et al ldquoValidity ofintraoperative diagnosis at laparoscopic surgery for ovariantumorsrdquo Journal of Minimally Invasive Gynecology vol 21 no4 pp 576ndash579 2014

[17] A L Covens J E Dodge C Lacchetti et al ldquoSurgical man-agement of a suspicious adnexal mass a systematic reviewrdquoGynecologic Oncology vol 126 no 1 pp 149ndash156 2012

[18] M Canis R Mashiach A Wattiez et al ldquoFrozen section inlaparoscopic management of macroscopically suspicious ovar-ian massesrdquo Journal of the American Association of GynecologicLaparoscopists vol 11 no 3 pp 365ndash369 2004

[19] M Canis G Mage J L Pouly A Wattiez H Manhes and MA Bruhat ldquoLaparoscopic diagnosis of adnexal cystic massesa 12-year experience with long-term follow-uprdquo Obstetrics andGynecology vol 83 no 5 pp 707ndash712 1994

[20] R H Demir and G J Marchand ldquoAdnexal masses suspectedto be benign treated with laparoscopyrdquo Journal of the Society ofLaparoendoscopic Surgeons vol 16 no 1 pp 71ndash84 2012

[21] D J Quinlan D E Townsend and G H Johnson ldquoSafe andcost effective laparoscopic removal of adnexal massesrdquo Journalof the American Association of Gynecologic Laparoscopists vol4 no 2 pp 215ndash218 1997

[22] A Mahdavi B Berker C Nezhat F Nezhat and C NezhatldquoLaparoscopic management of ovarian cystsrdquo Obstetrics andGynecology Clinics of North America vol 31 no 3 pp 581ndash5922004

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rupture and set the limits for attempting excision of anintact cyst versus performing puncture and evacuation of itscontents

2 Materials and Methods

Patients with cystic adnexal masses referred for laparoscopicmanagement to the Gynecological Endoscopy Unit of the 1stDepartment of Obstetrics amp Gynecology of the University ofAthens ldquoAlexandrardquo Hospital Athens Greece from January2009 to September 2013 were recruited for this prospectivecohort study The study was approved by our institutionrsquosscientific committee and a detailed informed consent wasobtained from all patients

The standard preoperative triage included a completeclinical and gynecological examination and tumor markers(CEA CA-125 CA19-9 a-fetoprotein and 120573-hCG) plus adetailed pelvic transvaginal (TVS) andor transabdominal(TAS) ultrasound scan During ultrasonographic examina-tion the following characteristics of the adnexal mass werelooked for and recorded size appearance of fluid contentpresence of a solid component septations papillary projec-tions into the cyst or surface excrescences the thickness of thecyst wall presence of neovascularization and the cystrsquos uni-or bilateral localization An abdominal CT scan or MRI wasoccasionally performed to assist in the differential diagnosisWomen gt 45 years old those with a preoperative diagnosis ofan endometrioma and those with probable invasive ovariancancer were excluded from this study Cases with possiblefunctional cysts were reexamined after 3-4 months and werescheduled for laparoscopy were the lesion persisted

Ovarian masses included in our sample were allocatedinto four groups regarding their sonographic characteristicsfluid filled structures anechoic or of low echogenicity possi-ble teratomas paraovarian cysts andmasses that could not beclassified as benign or malignant based on their sonographicappearance Fluid filled ovarian lesions were subgroupedinto unilocular and multilocular Ovarian lesions presentingwith mixed echogenicity consisting of longitudinal whitelines or a Rokitansky nodule and showing acoustic shadowswere categorized as teratomas Unilocular anechoic cysticmasses observed nearby the ovarywere allocated in a separategroup Finally ovarian cystic lesions that could not be pre-operatively reported as definitely benign were characterizedas suspicious Presence of papillary projections meaninginner irregularities of cystic wall gt 3mm and presence ofa solid component were taken into account Solid partsin particular were differentiated from Rokitansky nodulesbased on the presence or not of acoustic shadows Because ofthe expected high prevalence of benign masses in our groupof patients size per se was not considered a single criterionto characterize the mass as suspicious or not despite the factthat lesion size may affect preoperative diagnosis [11ndash13]

Laparoscopic surgery was performed using the techniqueof 4 trocars one primary trocar was placed through a verticalintraumbilical incision allowing the use of a 10mm 0-degree laparoscope Another two accessory trocars (5mm)were inserted in the lower abdomen lateral to the inferior

Figure 1 Cyst-harboring adnexa inside handle-free endoscopic sac

epigastric vessels and a fourth accessory trocar (5mm) wasinserted above the pubic hairline

After insertion of the laparoscope a careful and thoroughinspection of the pelvis and abdomen was performed andperitoneal washings or free peritoneal fluid was taken forcytological examination The waterproof endoscopic bag(Unimax Medical Technology Promedt Consulting GmBH510158401015840 times 710158401015840) was inserted blindly into the peritoneal cavitywrapped tightly into its plastic applicator through the umbil-ical trocar and opened by unrolling it with atraumaticforceps after replacing the laparoscopeThe lesion-harboringadnexa was placed and kept inside the bag throughout itsdissection (Figure 1) The endoscopic bag used in our studywas not attached to an external manipulator instead it wassupplied with a lasso at its rim made of a memory wireaimed to be tightened in the end of the procedure to allowfor safe specimen extraction Laparoscopic cystectomy wasperformed without previous evacuation of the cyst makingan effort to keep the adnexa inside the sac throughout theprocedure and excise the cyst intact In case of inadvertentrupture even minimal leakage was recorded In cases withbilateral cysts the side harboring the smaller cyst was treatedfirst

The ovarian capsule was incised with scissors and thecleavage plane between cyst and ovary was identified Thecyst was enucleated from the surrounding ovarian tissuemainly by means of blunt dissection andor aqua dissectionDense adhesions between the cyst and ovarian stroma weredivided sharply with scissors after bipolar coagulation closerto the surface of the cyst In cases with suspicious massesthe technique was slightly modified and the adhesions weredivided closer to the ovary than the cyst to allow for asafety margin In case of rupture during cyst dissection theinstrument tips were washed with normal saline while insidethe bag before removing them from the peritoneal cavity

After excision of the cyst the left 5mm accessory trocarwas replaced by a 10mm trocar The end of the wire waspulled outside the peritoneal cavity through this trocar whichwas removed and the closed mouth of the bag was retrievedthrough the skin incision and opened extracorporeally Thecyst was deflated inside the bag using a needle or anothercutting instrument and a suction pump in order to reduce itsvolume andmake the extraction of the bag and the remainingcyst possible without contamination of the abdominal wall




Total119873

No119873 ()

Yes119873 ()

No119873 ()

Yes119873 ()

Meancm

Rangecm




3 Statistics



4 Results









00

02

04

06

08

10

12

Logi

stic p

roba

bilit

y

2 4 6 8 10 12 140MCD (cm)


01020304050607080

()



typesand

MCD lt 8

mucinous

MCD ge 8

andmucinous

749

50

250

06






Series 1 194

0102030405060708090

100

()


types


types

MCD lt 73

andmucinous

MCD ge 73

andmucinous

884

721

414





5 Discussion












Competing Interests


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















Total119873

No119873 ()

Yes119873 ()

No119873 ()

Yes119873 ()

Meancm

Rangecm




3 Statistics



4 Results









00

02

04

06

08

10

12

Logi

stic p

roba

bilit

y

2 4 6 8 10 12 140MCD (cm)


01020304050607080

()



typesand

MCD lt 8

mucinous

MCD ge 8

andmucinous

749

50

250

06






Series 1 194

0102030405060708090

100

()


types


types

MCD lt 73

andmucinous

MCD ge 73

andmucinous

884

721

414





5 Discussion












Competing Interests


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















00

02

04

06

08

10

12

Logi

stic p

roba

bilit

y

2 4 6 8 10 12 140MCD (cm)


01020304050607080

()



typesand

MCD lt 8

mucinous

MCD ge 8

andmucinous

749

50

250

06






Series 1 194

0102030405060708090

100

()


types


types

MCD lt 73

andmucinous

MCD ge 73

andmucinous

884

721

414





5 Discussion












Competing Interests


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
























Competing Interests


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















clinical study laparoscopic cystectomy in-a-bag of an...

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