comparative analysis of laparoscopy versus laparotomy

7182019 Comparative Analysis of Laparoscopy Versus Laparotomy

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Comparative analysis of laparoscopy versuslaparotomyin the management of ovarian cyst during

pregnancyAbstract Aim The aim of the present study was to evaluate the surgical and obstetric results oflaparoscopy versuslaparotomy in the management of ovarian cyst during pregnancyMaterial and Methods Sixty-nine eligible patients who met our criteria were randomlydivided into thelaparoscopy group (n = 33 and the laparotomy group (n = 3 The two groups werecompared for theirsurgical and obstetric outcomes and the extent of pelvic adhesion discovered in latercesarean section (CSResults The laparoscopy group had less blood loss (3 $ vs $ $3 mamp P = )shorter postoperativehospital stay () vs + days P $ and lower postoperative pain score () $) vs $P $ compared with the laparotomy group The operative time neonates pgar scoresand birthweightsbetween the two groups showed no signi0cant di1erences (P 2 Sixteen patients in thelaparoscopy groupand $ patients in the laparotomy group underwent cesarean section The 0lmy and densetype adhesion ratewas signi0cantly di1erent between the laparoscopy group and the laparotomy group ()vs 33 and vs ) respectivelyConclusions The present results suggest that laparoscopy is a better choice than

laparotomy for ovarian cystduring pregnancy with less blood loss less postoperative pain and less postoperative hospitalstay 4t o1ers afaster recovery results in less pelvic adhesion and does not a1ect the fetus5 however studiesencompassinglarger numbers of cases are neededKey words adhesion laparoscopy laparotomy ovarian cyst pregnancy

Introduction6varian cyst during pregnancy represents a wideoccurrence range from $7 to $7)3)+ deliveries$ The

studies based purely on ultrasound detection of adnexal masses in pregnancy showed a higher prevalenceof $7$8$7++$83 most of which are physiologicalovarian cyst in early pregnancy pproximately +8of ovarian cysts during pregnancy with a diameter cm will spontaneously resolve and need nosurgical intervention 9or the persistent presence of ovarian cyst of diameter 2 cm after the 0rst trimester

generally surgery would be reuired to prevent acuteabdominal symptoms caused by rupture or torsionduring pregnancy and to mae out the pathologicaldiagnosis This is especially important when malignancy

is suspected$

ampaparoscopic surgery currently is accepted as themost eltcient way to treat benign ovarian cyst because



of the reduced postoperative pain short hospitaliationand rapid recovery Since the $s laparoscopicsurgery has been successfully used in pregnantwomen gtowever there is no consensus about the bestsurgical choice for ovarian cyst during pregnancy

umerous reports attest to the feasibility of laparoscopicsurgery during pregnancy5 whereas otherscholars are concerned about the ris of laparoscopysuch as an increase in fetal deaths+ n updated searchhas not identi0ed any randomied controlled trials 4norder to select the optimum surgical procedure forovarian cysts during pregnancy we too a prospectiverandomied controlled trial to compare the surgicaland obstetric results of laparoscopy versus laparotomyin the management of ovarian cyst during pregnancy

Methods9rom September ) to ecember )$) pregnantwomen with ovarian cyst who had an indication forsurgery were selected in our hospital (Aniversity TertiaryCare Beferral Center The inclusion criteria werethat (i all patients should have normal previous menstrualhistory and had no history of abdominalsurgery5 (ii the patients were in the second trimesterwith ovarian cyst diameter D cm5 and (iii all thesurgery was elective and emergency surgery wasexcludedll patients gave their written informed consent toparticipate in the study Eatients were informed aboutthe riss associated with surgery and anesthesia suchas the possibility of abortion and we explained thatthere is no standard surgery for this condition to datepproval was also obtained from the 6bstetrics and

Fynecology gtospital of 9udan Aniversity 4nstitutionalBeview Goard The sample sie was calculated to be 3$patients in each group to test the di1erence betweenthe two groups with the power of and type 4 errorof Hach patient who met the criteria was assigneda randomiation number and then the patient was randomlyassigned to each treatment group The randomnumber table was used Sixty-nine eligible patientswere enrolled and were randomly divided into thelaparoscopy group (n = 33 and the laparotomy group(n = 3 ll patients were given physical examinationultrasonic examination and serum cancer antigen(C-$) level measurement

AnesthesiaHndotracheal general anesthesia was performed in thelaparoscopic operation group 4nduction of anesthesiawas achieved using succinylcholine 9or maintenanceenIurane fentanyl and vecuronium or rocuroniumwere used Continuous epidural combined with spinaladministration of bupivacaine and fentanyl was performedin the laparotomy group Jetamine nitrousoxide and vasopressors were not given in either groupuring the operation all patients were monitored continuouslyfor blood pressure electrocardiographicparameters transcutaneous oxygen saturation andend-tidal C6)Operation

9or the laparoscopy group gravid patients were placedin the left lateral decubitus position to minimie compression



of the vena cava Surgery was performedby 0rst bringing up the umbilicus by towel forcepsto insert a $-mm trocar through which thevideolaparoscope was inserted and the pneumoperitoneumwas generated with pressure ept at$8$) mmgtg Then two -mm trocars were inserted

about cm to the right and left of the umbilicusrespectively $-mm trocar was inserted about cmabove the umbilicus and was later used for placing thelaparoscope fter retaining abdominal Iushing Iuidin case of malignancy the ovarian wall was incised toexpose the cyst The cyst wall was then detached andexcised with the stripping techniue5 we tried to avoidcyst rupture and spilling of its contents fter strippingthe cyst we put the specimen into a retrieval bagwhich was put into the abdomen and pulled outthrough the umbilical trocar Khen necessary hemostasiswas achieved by applying the bipolar forceps tothe ovarian parenchyma after excision of the cysticwall amparge area electric coagulation was avoided to

protect ovarian function uring the operation weavoided stimulating the uterus9or the laparotomy group the longitudinal incisionwas made and surgery was performed routinely9or all patients ovarian cystectomy was performed0rst The cyst was sent to the pathologist for observation4f the froen-section pathological diagnosis wasborderline or malignant the surgery may have beenconverted5 this depended on the phase of the malignanttumor the doctor and the patients preferenceo antibiotics were administered prophylactically9or those who had postoperative uterus contractionsprogesterone and magnesium sulfate were given to

inhibit contractions until they ceased9or pain degree assessments the visual analog scale(LS was used which ranges from to $ Eatientperioperative data including operative time estimatedblood loss (HGamp postoperative pain postoperativefever and postoperative hospitaliation lengths wererecorded Eostoperative fever was de0ned as a bodytemperature D 3+MC on two consecutive occasions atleast h apart except during the 0rst ) h

ll patients obstetric outcomes were followed upeonatal pgar score and birthweight were recorded9or those who ended up with cesarean section (CSdirect inspection of the type and place of adhesionsduring CS was registered The type of adhesionincluded none 0lmy and dense

Statistical MethodsStatistical analyses were performed using spss $ata are expressed as the mean standard deviation(S The Students t -test or N)-test were used as appropriatei1erences were considered to be signi0cant atP The detailed formula for sample number calculationis as follows

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Results The detailed patient characteristics of the two groupsare shown in Table $ o signi0cant di1erences werefound in the age body mass index cystic sie (thelongest diameter of cyst or preoperative serumC-$) level between the two groups

Table ) presents the pathology of the ovarian cysts inthe two groups 9or the two borderline cysts unilateral

oophorectomy was carried out 6ne patient whosepathological diagnosis was adenocarcinoma (4c stagereceived unilateral salpingo-oophorectomy Cystectomywas given for the other benign cystsll surgeries were done successfully without complicationduring operation one was complicated byinOury to the gravid uterus or pregnancy loss 4n onepatient laparoscopy was converted to laparotomybecause the pelvis was too densely adhered to exposethe operative 0eld

The laparoscopy group had less HGamp fewer postoperativeuterus contractions less postoperative painshorter hospital stays and less postoperative fever than

the laparotomy group These di1erences were signi0cant(Table 3 gtowever there were no signi0cant di1erencesin operation time and cyst-rupture rate

There were no signi0cant di1erences between thegroups for mean gestational age mean birthweightmean pgar score (Table 3 rates of preterm deliverylow birthweight or miscarriage s for the means of delivery the incidence of CS in the laparoscopy andlaparotomy group was 33 ($73 and ($73) respectively and no signi0cant di1erence wasobserved 9or those who underwent CS pelvic adhesionwas evaluated Ke found the adhesion rate extent

of adhesion and position of adhesion di1ered signi0cantly



between the two groups Eatients who underwentlaparoscopy showed signi0cantly less adhesionthan those who underwent laparotomy (Table 3

Discussion There is still great dispute about the management of ovarian cyst during pregnancy Some studies support

the safety of close observation in these patients whenultrasound 0ndings do not indicate malignancy tumormarers (C-$) lactate dehydrogenase are normaland the patient is asymptomatic$8$) everthelesssome studies have suggested surgical intervention forconcerns of ovarian malignancy tumor torsion tumorrupture or obstruction of labor$38$ 4t was also shownthat pregnant patients may undergo surgery safelyduring any trimester without any increased ris to themother or fetus$$8$+

Since the $s there have been many studies indicatingthat laparoscopic surgery for ovarian cyst duringpregnancy is feasible and safe and several studiesdemonstrating that laparoscopic surgery can achievebetter maternal outcome such as shorter hospital stayfaster recovery and a lower rate of postoperativecomplications (such as pulmonary embolus$ thanlaparotomic surgery in the management of ovarian cystduring pregnancy)8)) gtowever these were all caseseries studies Therefore the evidence for the magnitudeof these bene0ts was associated with potentialbias and the results and conclusions of these studiesmust be interpreted with caution 6ur study is the 0rstprospective randomied control trial in this 0eld Kevalidated the better results of laparoscopic surgery

than laparotomic surgery with less HGamp shorter postoperative

hospital stay less maternal fever and lesspostoperative pain as reported 4n a retrospectivestudy including $ laparotomies and ++laparoscopies Joo et al reported that laparoscopy hada shorter mean operative time than laparotomy foradnexal masses Ke demonstrated no signi0cant di1erencefor mean operative time between the twogroups This may be due to di1erences amongst individualsurgeons and their levels of experience Jooet al also found that postoperative declines in hemoglobinlevels were similar between groups which isinconsistent with our results 6ur result similar toanother study)3 showed that HGamp and hemoglobin

decline were lower in laparoscopy cases than in laparotomy4n spite of such di1erences there is a consensusthat the laparoscopic approach appears to o1er asuitable alternative to laparotomy and that it is associatedwith shorter recovery The improved visualiationin laparoscopy may also reduce the ris of uterineirritability by decreasing the need for uterinemanipulation9urthermore we followed the enrolled patients whounderwent CS and evaluated the extent of adhesion inthese patients Ke found less pelvic adhesion in thelaparoscopy group than in the laparotomy group Tothe best of our nowledge this is the 0rst study tocompare pelvic adhesion for the gravid patients who

underwent laparoscopic and laparotomic surgeryrespectively lthough the sample number is limited



we can speculate that laparoscopy is also associatedwith less pelvic adhesionespite these advantages controversy about thelaparoscopic approach still exists for several reasons

The most signi0cant of these is C6) pneumoperitoneumused in laparoscopic surgery Theoretically the

absorption of C6)

insuPated into the abdomen maycause hypercarbia and possible acid-based disturbancesin the fetus lso increased maternal intraperitonealpressure may impact the uteruss blood Iowcausing the reduction of placental blood Iow to thefetus Some animal studies have con0rmed fetalacidosis with associated tachycardia hypertensionand hypercapnia during C6) pneumoperitoneum))

though no long-term e1ects from these changes havebeen identi0ed while other animal studies contradictthese 0ndings Garnard et al) studied this condition inpregnant ewes and found that the sheep fetus has sultcientplacental Iow reserves or compensatoryresponses to maintain adeuate gas exchange during a

$-h )-mmgtg maternal C6) pneumoperitoneumBecently another study showed that laparoscopic techniuesdo not modify uteroplacental perfusion evaluatedusing non-invasive ultrasonography in humanpregnancy)

Khen approaching from the umbilicus we carriedout the surgery very carefully so as not to have contactwith nor stimulate the uterus in order to avoid miscarriagelthough the miscarriage rate was not signi0cantlydi1erent between the two groups this approachreuires a sophisticated techniue and silled training6ne case report)+ described how after aspiration of itscontents the tumor was extracted and cystectomy was

performed extracorporeally 4t seems safer to remove acyst from the body cavity5 and it may be possible tominimie pneumoperitoneum in this waynother potential danger is the ris of fetal exposureto intra-abdominal smoe generated by laparoscopicinstruments which result in increased levels of poisonousgases mostly carbon monoxide though no evidencehas con0rmed this Beedy et al) found that therewas no di1erence in intrauterine growth restriction orstillbirth between laparoscopy and laparotomy in their)-year study 4n this study we found that there was nosigni0cant di1erence between the laparoscopy andlaparotomy group regarding perinatal outcomes suchas birthweight pgar scores delivery gestation congenital

malformations or perinatal mortality 4n thisregard we may infer that laparoscopy is safe for fetusoutcome5 however we did not study the long-terme1ects on the children 6ne study followed up $$ childrenaged $8+ years and found no growth or developmentaldelay3 The comparison of laparotomy andlaparoscopy performed in pregnancy in over ) millionpregnancies in Sweden over ) years found no di1erencein fetal outcome between the two techniues3$

Begarding the pressure of pneumoamnios somereports suggested intra-abdominal insuPation pressuresbe maintained at less than $) mmgtg to avoidworsening pulmonary physiology in gravid women3)

while some argued that insuPation less than$) mmgtg may not provide adeuate visualiation of the intra-abdominal cavity Eressures of $ mmgtg have



been used during laparoscopy in pregnant patientswithout increasing adverse outcomes to the patient orthe fetus$ Ke set the pressure at $)8$ mmgtg andfound it could provide adeuate visualiation for thesurgeryBecently one study demonstrated that the incidence

of cyst rupture was signi0cantly higher in ovariantumorectomy by laparoscopy than by laparotomy33

Conversely our rupture incidence is and 33 for

laparoscopy and laparotomy respectively without signi0cantdi1erencesKe succeeded in applying laparoscopyin a huge cyst with a diameter of )) cm withoutrupture at )) wees gestation indicating that laparoscopyis a feasible and safe treatment for women withlarge ovarian cysts and that tumor sie does not havean e1ect on laparoscopic management3 ue to thelimited sample we did not carry out multivariate

analysis evertheless it seems ovarian cyst is moreapt to rupture in endometrial cyst borderline cyst andmalignant cyst This may be because these cysts aremore adhered than others in the pelvic region Thesurgeons sill experience and carefulness are alsoimportant factors 4n our study cyst rupture occurredin the patient with adenocarcinoma and in the twopatients with borderline cysts Anilateral oophorectomywas given for the two borderline cysts to preventrecurrence The patient with pathologically diagnosedadenocarcinoma (4c underwent unilateral salpingooophorectomy

This adenocarcinoma had noobvious malignant-appearing 0ndings on preoperative

sonography with normal C-$) level and slightlyincreased C$- uring the laparoscopic cystectomythe tumor ruptured because it was closely adheredwith ovarian tissue fter appropriate counselingregarding the methods as well as possible complicationsthe patients agents decided to chose unilateralsalpingo-oophorectomy chemotherapy during pregnancywith preservation of the fetus and debulingsurgery during CS gtowever after the surgery thepatient decided to undergo abortion and she thenunderwent debuling surgery and chemotherapy Sheis still alive now about $ year after chemotherapy Theother two patients with borderline cyst are also alivewith no recurrence 4t is reported that the maOority of cases of ovarian cancer in pregnancy were incidentallydetected by ultrasound at an early stage resulting ingood prognosis for the mother and the neonate3 Thereare some studies suggesting that laparoscopic comprehensivesurgical staging of early ovarian cancer is assafe and adeuate as the standard surgical staging performedvia laparotomy So we believe that anxietyabout laparoscopic rupture and potential ris of malignancyis unnecessary

There were some limitations to our study 9irst oursample was small Second all our surgeries were electivenot including the emergency situations such asovarian cyst torsion and rupture This may explain why

the incidence of postoperative abortion and pretermlabor in our study is much less than that reported inother studies Third our follow-up of the fetuses is not



long enough 9inally we cannot rule out the e1ect of di1erent anesthesias Fiven the considerations of avoiding fetal exposure to unnecessary medicationregional anesthesia was used in the laparotomy group

The same anesthesia method in laparoscopy wouldhave been diltcult to tolerate for patients because of

pneumoperitoneum so general anesthesia was used inthe laparoscopy group 4t has been reported thatpatients undergoing laparotomy with regional anesthesiafor adnexal mass in pregnancy may have higher risof preterm labor than those given general inhalationalanesthesia3 gtowever there was no di1erence in therate of preterm labor between the two groups and weare unable to explain this precisely nother point isthat our follow-up of neonates with di1erent anesthesiatechniues is short-term and long-term follow-upis reuired4n conclusion our data showed that in treatingovarian cyst during pregnancy laparoscopy has abetter clinical outcome than laparotomy with less

blood loss faster recovery less postoperative painshorter hospital stay and less postoperative pelvicadhesion 4t also provides good cosmetic results ampaparoscopyreuires general anesthesia which costs morethan regional anesthesia such as spinal bloc or epiduralbloc 4t also reuires a sophisticated techniueeuipment and special training The present study islimited by its relatively small sample 4n the futurelarge randomied trials with long-term follow-up arewarranted to obtain more consistent data

Disclosure The authors declare that they have no conIict of interest



of the reduced postoperative pain short hospitaliationand rapid recovery Since the $s laparoscopicsurgery has been successfully used in pregnantwomen gtowever there is no consensus about the bestsurgical choice for ovarian cyst during pregnancy

umerous reports attest to the feasibility of laparoscopicsurgery during pregnancy5 whereas otherscholars are concerned about the ris of laparoscopysuch as an increase in fetal deaths+ n updated searchhas not identi0ed any randomied controlled trials 4norder to select the optimum surgical procedure forovarian cysts during pregnancy we too a prospectiverandomied controlled trial to compare the surgicaland obstetric results of laparoscopy versus laparotomyin the management of ovarian cyst during pregnancy

Methods9rom September ) to ecember )$) pregnantwomen with ovarian cyst who had an indication forsurgery were selected in our hospital (Aniversity TertiaryCare Beferral Center The inclusion criteria werethat (i all patients should have normal previous menstrualhistory and had no history of abdominalsurgery5 (ii the patients were in the second trimesterwith ovarian cyst diameter D cm5 and (iii all thesurgery was elective and emergency surgery wasexcludedll patients gave their written informed consent toparticipate in the study Eatients were informed aboutthe riss associated with surgery and anesthesia suchas the possibility of abortion and we explained thatthere is no standard surgery for this condition to datepproval was also obtained from the 6bstetrics and

Fynecology gtospital of 9udan Aniversity 4nstitutionalBeview Goard The sample sie was calculated to be 3$patients in each group to test the di1erence betweenthe two groups with the power of and type 4 errorof Hach patient who met the criteria was assigneda randomiation number and then the patient was randomlyassigned to each treatment group The randomnumber table was used Sixty-nine eligible patientswere enrolled and were randomly divided into thelaparoscopy group (n = 33 and the laparotomy group(n = 3 ll patients were given physical examinationultrasonic examination and serum cancer antigen(C-$) level measurement

AnesthesiaHndotracheal general anesthesia was performed in thelaparoscopic operation group 4nduction of anesthesiawas achieved using succinylcholine 9or maintenanceenIurane fentanyl and vecuronium or rocuroniumwere used Continuous epidural combined with spinaladministration of bupivacaine and fentanyl was performedin the laparotomy group Jetamine nitrousoxide and vasopressors were not given in either groupuring the operation all patients were monitored continuouslyfor blood pressure electrocardiographicparameters transcutaneous oxygen saturation andend-tidal C6)Operation

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comparative analysis of laparoscopy versus laparotomy

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