Single-port laparoscopic surgery for benign salpingo-ovarian pathology: a single-center experience from Saudi Arabia

Operative complications of open and minimally invasive adnexal surgery compared with cases with hysterectomy: A narrative review

The decision to add hysterectomy to planned adnexectomy is often nuanced and likely increases the complexity of the planned procedure; however, these risks are not well characterized in practice. We conducted a comprehensive search in the PubMed database for English-language articles from 1997 to 2022, identifying studies reporting complication rates for open and minimally invasive surgery (MIS) hysterectomy and adnexal surgeries. We calculated medians and first and third quartiles for each complication and used a Mann-Whitney U test to calculate differences between complications for minimally invasive hysterectomy and adnexal case data. We identified 135 appropriate studies for inclusion. There were higher prevalences of blood loss requiring transfusion (1.70% versus 0.13%, P = 0.01) and urinary tract injury (0.80% versus 0.20%, P = 0.001) in MIS hysterectomy cases compared with MIS adnexal surgery, respectively. MIS hysterectomy cases were similar to MIS adnexal surgery cases in the risk of surgical site infection (1.20% versus 1.49%, P = 0.74), bowel injury (0.50% versus 0.35%, P = 0.45), vascular injury (0.20% versus 0.9%, P = 0.82), and conversion to laparotomy (1.95% versus 3.84%, P = 0.49). There were not enough data on open adnexal surgery complications to make a meaningful comparison between complications of open hysterectomy and adnexal-only cases. Patients should be counseled that the addition of hysterectomy to planned MIS adnexal surgery likely increases the risk of blood loss requiring transfusion and urinary tract injury. The increased comorbidity associated with adding hysterectomy to planned open adnexal removal is less clear.

Laparoscopic surgery of large adnexal masses (>12 cm): Single port or conventional?

INTRODUCTION

We aimed to compare single-port laparoscopic surgery (SPLS) and conventional multiport laparoscopic surgery (CMLS) for large adnexal mass (AM).

METHODS

Patients undergoing laparoscopy (LS) due to huge AMs (≥12 cm) between 2016 and 2021 were evaluated retrospectively. The SPLS procedure was applied in 25 cases, and CMLS was performed in 32 cases. The premier result was the grade of the postoperative improvement according to the Quality of Recovery (QoR)-40 questionnaire score (24 h after the surgical procedure; postoperative day 1). Observer Scar Assessment Scale (OSAS) and Patient Observer Scar Assessment Scale (PSAS) were also evaluated.

RESULTS

A total of 57 cases undergoing SPLS (n = 25) or CMLS (n = 32) due to a large AM (≥12 cm) were analyzed. No meaningful distinctions in age, menopausal status, body mass index, or mass size were observed between the two cohorts. The operation time was shorter in the SPLS than CPLS cohort (42.2 ± 3.3 vs. 47.6 ± 6.2; p < 0.001). Unilateral salpingo-oophorectomy was performed in 84.0% of cases in the SPLS cohort and 90.6% of patients in the CMLS cohort (p = 0.360). The QoR-40 points were significantly higher in the SPLS than the CMLS group (154.9 ± 12.0 vs. 146.2 ± 17.1; p = 0.035). The OSAS and PSAS scores were lower in the SPLS than the CMLS group.

CONCLUSION

LS can be used for large cysts that are not considered to be at risk of malignancy. The postoperative recovery time was shorter in patients undergoing SPLS compared to CMLS.

Early return to work: Single-port vs. multiport laparoscopic surgery for benign ovarian tumor

Objective

To compare the return to work (RTW) time between single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for benign ovarian tumors.

Methods

A cross-sectional cohort study was conducted, which consisted of 335 women of reproductive age with benign ovarian tumors and who were keen on returning to work as early as possible. Surgical outcomes, postoperative pain score, postoperative satisfaction with the cosmesis score (CS), and the RTW time of the SPLS group were compared with those of the MPLS group. Besides, the RTW time and CS were calculated from the questionnaire survey by a single specialized gynecologist.

Results

Women who met the inclusion criteria were included in the SPLS (n = 106) and MPLS groups (n = 229). The RTW time in the SPLS group (22.13 ± 27. 06 days) was significantly shorter than that in the MPLS group (46.08 ± 57.86 days) (P &lt; 0.001). The multivariate Cox analysis results showed that age (HR = 0.984, 95% CI, 0.971−0.997, P = 0.020), SPLS (HR = 3.491, 95% CI, 2.422−5. 032, P &lt; 0.001), and return to normal activity time (HR = 0.980, 95% CI, 0.961−0.998, P = 0.029) were independent factors of the RTW time.

Conclusions

SPLS may be advantageous in terms of shortening the RTW time for women with benign ovarian tumors.

Surgical management of ovarian teratomas in childhood: a multicentric study on 110 cases and a literature review

AIM OF THE STUDY

To compare a multicentric surgical experience on ovarian teratomas in childhood with the current management trends.

DESIGN

A retrospective multicentric pediatric ovarian teratomas surgically treated between January 2000 and August 2020 at four Italian institutions. PubMed database was used to search for Reviews and Systematic Reviews published between January 2010 and August 2020: 15 manuscripts reported 3633 ovarian neoplasms in pediatric age, 1219 (33,5%) of which were ovarian teratomas.

RESULTS

A hundred-ten patients with a mean age at diagnosis of 11.8 years were enrolled. Mature cystic teratomas accounted for the 90% of the masses. At surgery, 78 were oophorectomies and 32 were ovary sparing surgeries. Laparoscopy occurred in 16.3% of the surgeries.As regarding the current management trends, the mean age at diagnosis was 11.9 years and 80.5% of the cases were represented by mature teratomas. Of 430 procedures, 331 were oophorectomies while 99 were ovary sparing surgeries and laparoscopy was performed in 23.8% of cases.

CONCLUSIONS

Ovary-sparing surgery with laparoscopic approach is increasingly offered as standard treatment for benign masses that fit the criteria for mature teratomas, in the attempt to achieve the best compromise between the preservation of fertility and the prevention of recurrences. Awareness should be raised among pediatric surgeons to reduce unnecessary radical surgery.

Single incision laparoscopic surgery using conventional laparoscopic instruments versus two-port laparoscopic surgery for adnexal lesions

Single incision laparoscopic surgery (SILS) has emerged as least invasive interventions for gynecologic disease. However, SILS is slow to gain in popularity due to difficulties in triangulation and instrument crowding. Besides, the costly instruments may influence patients' will to have this procedure, and limit other medical expense as well. To optimize outcome and reduce cost, the objective of this study is to evaluate the feasibility and safety for patients undergoing adnexal surgeries using conventional laparoscopic instruments with SILS (SILS-C), and to compare with those of patients subject to TP using conventional laparoscopic instruments (TP-C). This is a retrospective case-control study. The data dated from April 2011 to April 2018. Patients who received concomitant multiple surgeries, were diagnosed with suspected advanced stage ovarian malignancy, or required frozen sections for intraoperative pathologic diagnosis were excluded. Demographic data, including the age, body weight, height, previous abdominal surgery were obtained. The surgical outcomes were compared using conventional statistical methods. 259 patients received SILS-C. The operating time was 63.83 ± 25.31 min. Blood loss was 2.38 ± 6.09 c.c. 58 patients (24.38%) needed addition of port to complete surgery. 384 patients received TP-C. Compared with SILS-C, the operating time was shorter (57.32 ± 26.38 min, OR = 0.984, CI = 0.975-0.992). The patients were further divided into unilateral or bilateral adnexectomy, and unilateral or bilateral cystectomy. Other than the operating time in unilateral cystectomy (66.12 ± 19.5 vs. 58.27 ± 23.92 min, p = .002), no statistical differences were observed in the subgroup analysis. Single incision laparoscopic surgery using conventional laparoscopic instruments is feasible and safe as initial approach to adnexal lesions. In complex setting as unilateral cystectomy or pelvic adhesions, two-port access may be considered.

The role of preoperative imaging and tumor markers in predicting malignant ovarian masses in children

PURPOSE

To investigate the clinicopathololgic characteristics and the predicting value of preoperative imaging and tumor markers in children with ovarian masses.

METHODS

Patients admitted in Shanghai children's hospital with ovary neoplasms between 2010.01 and 2015.12 were retrospectively analyzed. The medical records including age at operation, presentation of symptoms and signs, tumor marker, imaging, pathology, tumor diameter and surgical choice were reviewed. All data were analyzed using SPSS 17.0 RESULTS: A total of 139 patients were included, among which 116 were benign neoplasms and 23 malignant tumors. There was significance difference relation with the tumor diameter, character, torsion and tumor markers, but not the age, position, calculi, and symptoms. The risk factors include tumor diameters ≥ 10 cm, the odds ratio (OR) was 11, 95% confidence interval (CI) was 3-36, solid/complex tumor (OR 6, 95% CI 2, 14) and positive in tumor markers (OR 84, 95% CI 20, 345). Among the patients with benign neoplasms, 77 of them had laparoscopic ovarian cystectomy while 23 patients with malignant tumors had salpingo-oophorectomy and omentum resection.

CONCLUSION

Preoperative imaging and tumor markers could help identifying the malignant ovarian masses in children. If tumor diameter ≥ 10 cm, solid/complex in imaging and tumor markers abnormal, a radical resection is mandatory; otherwise, an ovarian-sparing surgery is recommended.

Single-incision laparoscopic surgery in gynecologic surgery: a single-institutional experience from Saudi Arabia

Background: Laparoscopy is rapidly replacing laparotomy in the field of gynecologic surgery. Generally, there are limited data concerning the utility of single-incision laparoscopic surgery (SILS) in gynecologic surgery. Specifically, in Saudi Arabia, a third-world country, data are further limited; only one related study has been conducted so far. The purpose of this study is to retrospectively report our single-institutional experience of SILS in terms of feasibility, safety and perioperative outcomes in the management of various gynecologic conditions.

Methods: The study took place at the Women’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia. From January 2012 to May 2016, all gynecologic patients who underwent SILS procedures were analyzed for pre-, intra- and post-operative details. SILS was performed using a single multi-port trocar and standard laparoscopic instruments.

Results: A total of 54 patients underwent 66 SILS procedures. The median age and body mass index (BMI) were 36 years and 28.2 kg/m ², respectively. Fourteen patients (26%) had ≥ 1 previous abdominal and/or pelvic surgeries. Twenty-four patients (44.4%) were nulliparous. The three most commonly performed SILS procedures were unilateral salpingo-oophorectomy (45.5%) and unilateral ovarian cystectomy (27.3%) and adhesiolysis (6.1%). The median operative time, estimated blood loss and hospital stay were 74 min, 50 ml and 1 day, respectively. Three patients required conversion to laparotomy, as follows: unidentified non-stopping bleeding source (n=1) and endometriosis stage IV resulting in difficult dissection (n=2). One patient developed post-operative incisional hernia that was treated surgically. The median patients’ post-operative pain (according to Wong-Baker FACES Foundation pain rating scale) within 4 hours was 2. At 4-week post-operatively, the median wound scar length (measured at outpatient clinic) was 2 cm.

Conclusions: SILS is feasible, safe and associated with acceptable clinical and surgical outcomes.

Postoperative Outcomes after Single-port Laparoscopic Removal of Adnexal Masses in Patients Referred to Gynecologic Oncology at a Large Academic Center

STUDY OBJECTIVE

To report surgical and pathologic outcomes after single-port laparoscopy (SPL) for adnexal masses in patients referred to a gynecologic oncology practice at a single academic institution.

DESIGN

A retrospective analysis (Canadian Task Force Classification II.2).

SETTING

A single academic institution with multiple hospital centers.

PATIENTS

Women who underwent at least 1 single-port laparoscopic surgery for the treatment of an adnexal mass from 2009 to 2015 after referral to a gynecologic oncology practice.

INTERVENTION

Data were collected on the surgical procedure, patient demographic variables, 30-day surgical outcomes, and hernia development.

MEASUREMENTS AND MAIN RESULTS

Three hundred twenty-five surgeries were performed in 322 patients with a median follow-up of 42.7 months. The median age was 54.5 years, and the median body mass index was 28.1 kg/m². All patients underwent unilateral or bilateral salpingectomy or oophorectomy with or without hysterectomy (26.5%). The median operative time was 90.0 minutes. The median mass dimension was 6.4 cm with 17.9% (n = 60) greater than 10 cm. Masses were categorized as simple (11.4%) and complex (69.5%). Although the majority (87.4%) of masses were benign, 7.4% were malignant, and 5.2% were borderline. Benign masses were physiologic (16.6%), serous cystadenomas (19.1%), mucinous cystadenomas (6.8%), endometriomas (12.3%), myomas (12.3%), and mature teratomas (9.2%). In malignant cases (7.4%), serous carcinoma was the most frequent histology (58.3%). The rate of adverse outcomes within 30 days, including reoperation (0.0%), intraoperative injury (1.5%), venous thromboembolism (0.3%), and transfusion (0.6%), was low. The development of incisional cellulitis was 4.6%. The rate of incisional hernia was 4.0%, with a median occurrence of 18.3 months. Diabetes mellitus (p = .03) and obesity (p = .04) were significant predictors for a hernia, but mass complexity (p = .28), American Society of Anesthesiologists class (p = .83), and smoking (p = .82) were not.

CONCLUSION

In patients undergoing SPL for the removal of adnexal masses in a gynecologic oncology practice, the rate of benign disease is high. SPL removal of adnexal masses is feasible and safe with favorable surgical outcomes, rare short-term adverse outcomes, and a low incisional hernia rate.

Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases

This study analyzes updated clinical, diagnostic, and surgical directions for the treatment of ovarian neoplasms in children and adolescents, comparing them with a retrospective analysis of 32 cases treated in two Pediatric Surgery University Institutions. From January 2005 to December 2015, 32 pediatric patients were surgically treated for 32 ovarian tumors: 28 (87.5%) benign and 4 (12.5%) malignant neoplastic lesions. Median age at surgery was 11.2 years (12.8 years in patients with benign neoplasms, 7.25 years in patients with malignant ones). All patients with malignant and 25% of patients with benign ovarian lesions had elevated serum level of tumors markers. The surgical approach was laparotomic in 62.5% and laparoscopic in 37.5%; 81.2% surgeries were performed in elective surgery and 18.8% in emergency. Intraoperative frozen section analysis was performed in 18.75% of patients. The most frequent surgery (96.8%) was unilateral oophorectomy. After a median follow-up of 76 months (range 6-132 months), 31/32 patients are alive and disease-free. In case of malignant tumors, fertility-sparing surgery with accurate staging must be performed. Laparoscopic multiport is the gold standard approach for benign pediatric ovarian neoplasms, but the use of laparoscopy in full respect of oncological principles also for early stage malignant tumors is currently increased.