A prospective, randomized comparison of port wound and culdotomy for extracting mature teratomas laparoscopically

Ovarian Mature Cystic Teratoma: Challenges of Surgical Management

Although ovarian mature cystic teratomas are the commonest adnexal masses occurring in premenopausal women, there are many challenges faced by gynecologists on deciding upon the best surgical management. There is uncertainty, lack of consensus, and variation in surgical practices. This paper critically analyzes various surgical approaches and techniques used to treat these cysts in an attempt to outline a unified guidance. MEDLINE and EMBASE databases were searched in January 2015 with no date limit using the key words “ovarian teratoma” and “ovarian dermoid.” The search was limited to articles in English language, humans, and female. The two authors conducted the search independently. The laparoscopic approach is generally considered to be the gold standard for the management. Oophorectomy should be the standard operation except in younger women with a single small cyst. The risk of chemical peritonitis after contents spillage is extremely rare and can certainly be overcome with thorough peritoneal lavage using warmed fluid. There is a place for surveillance in some selected cases.

Transvaginal specimen extraction at laparoscopy without concomitant hysterectomy: our experience and systematic review of the literature

STUDY OBJECTIVE

The modality of surgical specimen extraction is extremely important in the setting of minimally invasive operations. To assess the feasibility, safety, and applicability of transvaginal specimen extraction through posterior colpotomy in women with uterus in situ, we present our 11-year experience with this technique and perform a systematic review of the available studies in the field of gynecologic laparoscopy.

DESIGN

A retrospective analysis and systematic review of the literature (Canadian Task Force classification II-2).

SETTING

A tertiary care center.

PATIENTS

Two hundred thirty women with uterus in situ undergoing minimally invasive surgery for gynecologic disease at our institution with transvaginal specimen removal in the period between 2001 and 2012. We then reviewed 17 studies, collecting data on a total of 899 transvaginal retrieval procedures.

INTERVENTIONS

Transvaginal specimen retrieval after operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Overall, 259 retrieval procedures were performed in the 230 patients operated on at our institution (including extraction of adnexal specimens [n = 190], uterine myomectomies [n = 36], bowel resections [n = 17], and other [n = 16]). All interventions were completed laparoscopically. Two (0.8%) women required secondary surgery because of postoperative intraperitoneal bleeding. Three additional (1.3%) minor postoperative complications were observed. No intra- and postoperative complications associated with the extraction technique occurred. In our literature review, a total of 58 (6.5%) complications were recorded. Only 1 (0.1%) adverse event was related to the transvaginal extraction procedure.

CONCLUSION

Our data suggest that transvaginal specimen retrieval after operative laparoscopy represents a safe, feasible, and applicable technique. Further research is needed to assess the real advantages of this natural orifice extraction procedure.

Poor prognosis of intraoperative rupture of mature cystic teratoma with malignant transformation

OBJECTIVE

To present the phenomenon of the postoperative rapid progression of mature cystic teratoma (MCT) with malignant transformation (MT) when intraoperative spillage occurs during operation.

CASE REPORTS

Two patients with MCT were treated, one with total hysterectomy plus bilateral salpingo-oophorectomy in an exploratory laparotomy, and the other with cystectomy with laparoscopy, respectively. Tumor spillage occurred during both operations. The postoperative pathology showed MCT with MT (squamous cell carcinoma type). Both patients were referred to our hospital and underwent treatment (3 months and 8 days, respectively, after the initial operation). At the secondary laparotomy for staging surgery, tumor dissemination was observed in both patients.

CONCLUSION

Whether or not tumor dissemination is correlated with tumor rupture during operation, we emphasize that any patient with a preoperative diagnosis of MCT should have it removed intact to avoid the possibly catastrophic event of tumor dissemination.

A prospective comparison of morcellator and culdotomy for extracting of uterine myomas laparoscopically in nullipara

We compare the removal of uterine myomas in 78 nulliparous women identified by ultrasound during laparoscopic myomectomy through culdotomy or by use of a power morcellator. Patients were divided into two groups. The culdotomy group was significantly longer. There were no significant differences in tumor size, total specimen weight, patient body weight, total operating time, blood loss, and postoperative stay between each group. Uterine myomas can be removed successfully through either port site in nullipara; however, because of reduced removal time, the power morcellator is preferred.

Comparison of laparoscopy and laparotomy in managing hemodynamically stable patients with ruptured corpus luteum with hemoperitoneum

STUDY OBJECTIVE

To compare differences between laparoscopy and laparotomy in managing women ruptured corpus luteum with hemoperitoneum.

DESIGN

Three-year, prospective, nonrandomized study (Canadian Task Force classification II-2).

SETTING

University-affiliated regional hospital.

PATIENTS

Sixty hemodynamically stable women.

INTERVENTION

Laparoscopic surgery (30 women) and laparotomy (30).

MEASUREMENTS AND MAIN RESULTS

Laparoscopic surgery had significant advantages over laparotomy, including shorter hospital stay (55.33 +/- 7.67 vs 97.77 +/- 14.45 hrs, p < 0.001) without increased adverse events. Laparoscopic surgery also showed trends of shorter operating time, improved wound care, and less postoperative pain.

CONCLUSION

Laparoscopy surgery for diagnosis and treatment of women with ruptured hemorrhagic corpus luteum appears superior to laparotomy. We suggest that surgeons try laparoscopy first as a diagnostic and probably therapeutic procedure.

Advantages of open laparoscopic surgery over exploratory laparotomy in patients with tubo-ovarian abscess

STUDY OBJECTIVE

To compare laparoscopic surgery and conventional laparotomy in managing patients with tubo-ovarian abscess (TOA).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

Regional hospital.

PATIENTS

Sixty-nine women with clinically suspicious TOA.

INTERVENTION

Operative laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Laparoscopic surgery in 19 women had significant advantages over laparotomy in 37 women. It decreased hospital stay (5.37 +/-1.38 days vs 8.92 +/- 2.59 days, p = 0.0001), had a lower percentage of wound infections, and had a shorter time for fever to subside (25.79 +/- 11.45 vs 39.46 +/- 17.47 hrs, p = 0.003).

CONCLUSION

Although management of TOA consists of conservative medical treatment with antibiotics, it is now widely accepted that surgical intervention should be pursued early after the diagnosis. Open laparoscopy seems to be a good alternative to traditional laparotomy in managing these patients.

Marsupialization of the cyst as a step in laparoscopic management of ovarian cysts

STUDY OBJECTIVE

To compare a traditional technique of ovarian cyst management with a marsupialization method (MM) developed by the authors.

DESIGN

Prospective, observational study (Canadian Task Force classification II-1).

SETTING

Central Asian city teaching hospital.

PATIENTS

Eighty-one women with benign ovarian cysts.

INTERVENTION

Traditional laparoscopic cyst management and MM. Cysts were removed through a cannula site after being placed into an endobag and marsupialization. With this technique, cysts were emptied partially or completely by aspiration and brought outside the abdominal cavity through a 1.5- to 2.5-cm cannula incision site. Some of the cyst contents may be removed during extraction. The technique allows the surgeon to interrupt cyst pedicles extracorporally or intracorporally.

MEASUREMENTS AND MAIN RESULTS

With traditional methods of laparoscopic cystectomy the spillage rate was 18% (6 patients), compared with 16% (8 patients) for MM. Operating time, blood loss, and mean hospital stay were not statistically different between groups (p >00.5).

CONCLUSION

With MM technique, cystectomy is simple, reliable, and cost effective.

Excision of mature teratoma using culdotomy, with and without laparoscopy: a prospective randomised trial

OBJECTIVE

To compare the results of removing mature teratoma with laparoscopy or without laparoscopy.

DESIGN

A prospective, randomised trial.

SETTING

Medical centre.

PARTICIPANTS

Seventy-nine women with mature teratomas identified using results of ultrasound examinations and biochemical markers.

INTERVENTION

Cystectomy with laparoscopic approach or without laparoscopic approach through a culdotomy.

METHODS

Patients were randomly assigned to have their cysts removed via vaginal cystectomy without laparoscopy (n = 37, Group A) or laparoscopic cystectomy via culdotomy opening (n = 42, Group B). Inclusion criteria were history of vaginal delivery, no previous abdominal surgery, no history of pelvic inflammatory disease, no medical illness, and no presenting symptoms. Eight women randomised to Group A withdrew before surgery. The laparoscopically resected tumours were each put into a cellulose bag, and tumours without laparoscopic-assistance were removed directly via the vagina.

RESULTS

Blood loss in Group A (88 +/- 37 ml) was significantly more than that in Group B (64 +/- 20 ml, P = 0.000). The post-operative recovery times were 20 and 17 hours, respectively (P = 0.030). The rates of successful surgery were 58.6 and 97.6%, respectively (P = 0.002). The spillage rates were 44.8% and 19.0%, respectively (P = 0.006). There were no significant differences in tumour size, patient age, and operative time between groups.

CONCLUSION

Cystectomy without assistance of laparoscopy could be applied to manage mature teratoma of the ovary; however, because of the difficulty of this technique, we had high percentages of tumour spillage and more blood loss during operation and a high percentage of patients who required conversion to laparotomy compared with laparoscopic cystectomy. We favoured laparoscopically assisted cystectomy to manage mature teratoma.