Complications of Laparoscopic Surgery for Benign Ovarian Cysts

Transcription

1 November 2000, Vol. 7, No. 4 The Journal of the American Association of Gynecologic Laparoscopists Complications of Laparoscopic Surgery for Benign Ovarian Cysts Ingrid H. Lok, MRCOG, Daljit S. Sahota, Ph.D., Michael S. Rogers, M.D., and P. M. Yuen, MRCOG Abstract Study Objective. To assess complications of laparoscopic surgery in the management of ovarian cysts. Design. Prospective observational study (Canadian Task Force classification II-2). Setting. University-affiliated hospital. Patients. Consecutive patients (513) undergoing laparoscopic surgery for ovarian cysts not suspected to be malignant. Intervention. Laparoscopic surgery. Measurements and Main Results. A total of 587 ovarian cysts were removed from 513 women. Conversion to laparotomy was necessary in five cases (<1%). Mean ± SD cyst diameter was 5.5 ± 2.9 cm, with endometriomas (44.5%) and dermoids (24.3%) being the two most common pathologies; 6.6% were functional. Mean ± SD operating time was 69 ± 31 minutes, and hospital stay and postoperative convalescence was 2.6 ± 1.5 and 14.3 ± 9.6 days, respectively. The overall complication rate was 13.3%. Major complications occurred in three patients (0.6%): one small bowel injury and two ureter injuries. Cannula site complications were five inferior epigastric vessel injuries and four incisional hernias at the 10-mm lateral port site. Conclusion. Laparoscopic ovarian surgery was associated with 13.3% complications, with 0.6% being major. Careful patient selection and proper surgical training are critical to ensure safe performance of laparoscopy. (J Am Assoc Gynecol Laparosc 7(4): , 2000) The past decade has seen a shift from performance of major open surgery to minimal access surgery in gynecology. Ovarian cysts are a common problem, and removal of benign ovarian cysts is one of the most frequently performed laparoscopic procedures in gynecology. Laparoscopic surgery has many advantages over laparotomy; however, most of them were reported by experienced surgeons, and the number of patients in these series was usually small. 1 5 Associated complications may be overlooked or underreported. In most teaching units, laparoscopic removal of benign ovarian cysts is performed by less experienced surgeons undergoing specialty training, and the complication rate may be higher than expected. In our unit in a major teaching hospital, laparoscopic surgery for benign ovarian cysts was performed predominantly by trainees under supervision for 4.5 years. Materials and Methods Approximately 2000 gynecologic operations are performed in our unit every year. Since the introduction of laparoscopic surgery to the unit in 1992, all operative laparoscopies and outcomes are monitored continuously using a standard data form. About 15% of procedures are adnexal surgery for benign ovarian cysts, 80% of which are performed laparoscopically. Initially, all procedures were performed by two senior surgeons who developed the technique. In 1994, a training program was introduced and all physicians in From the Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China (all authors). Address reprint requests to Dr. Ingrid H. Lok, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China; fax Accepted for publication August 14, Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, November 2000, Vol. 7 No The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL. 529

2 Complications of Laparoscopic Surgery for Benign Ovarian Cysts Lok et al training performed the operations over a period of 4 months under direct supervision of the two senior surgeons. Patient Evaluation We reviewed charts of 513 women (mean age 35.6 ± 9.8 yrs; multiparous 322, 62.8%; menopausal 28, 5.5%; pregnant 11, 2.1%) who underwent laparoscopic surgery for benign ovarian cysts from November 1992 to March Patients symptoms are summarized in Table 1. Of the 513 women, 109 (21.2%) had had previous abdominal or pelvic surgery. The charts were cross-checked against operating room records to ensure that there were no missing data. Patients who had concurrent problems necessitating other major laparoscopic procedures were excluded. Preoperative assessment was the same as for conventional surgical procedures. Transvaginal ultrasonography was performed to evaluate the size and internal characteristics of masses to exclude malignancy. All cystic masses with a distinct border and no evidence of irregular solid areas, thick septa, or ascites were considered benign, except for dermoid cysts, which may have an echogenic mural focus or echogenic material in a nondependent area. 6,7 Cysts that were 5 cm or smaller were reevaluated in 2 to 3 months to exclude functional cysts. Serum CA125 level was measured only in postmenopausal women. All patients had a repeat ultrasound scan on the day before surgery to confirm previous sonographic findings and persistence of the cyst. Operative Procedure and Postoperative Course All operations were performed under general anesthesia with endotracheal intubation. Pneumoperitoneum was established with carbon dioxide with a Veress needle through a vertical intraumbilical incision. Open laparoscopy was performed in patients TABLE 1. Patients Symptoms Symptom Number (%) Pelvic mass 147 (28.6) Asymptomatic 124 (24.1) Chronic pelvic pain 131 (25.6) Acute pelvic pain 41 (8.0) Menstrual disturbance 41 (8.0) Infertility 20 (4.0) Others 9 (1.7) with a large ovarian cyst, previous laparotomies, or pregnancy. Most procedures were performed with two secondary ports in the lower abdomen, one on each side. The decision between cystectomy and oophorectomy depended on the clinical situation, in particular, menopausal status, amount of residual ovarian tissue, and technical difficulty. Specimens were removed in a bag through a 10-mm port in the left lower abdomen. 8 Postoperatively, patients were allowed to resume a normal diet when they were fully conscious and were discharged when they were afebrile and mobile, and did not require narcotic analgesics. At follow-up visit in 8 weeks, late complications were recorded. Results Over the study period, 587 ovarian cysts (mean ± SD diameter 5.5 ± 2.9 cm) were removed laparoscopically from these women. Twenty-eight (4.8%) were larger than 10 cm, with the largest being a 25 cm simple cyst that was removed from a postmenopausal woman. Thirty-one cysts (6%) were smaller than 3 cm and most were endometriomas. Mean ± SD operating time was 68.9 ± 31.3 minutes. Operating time was less than 60 minutes in 37.5%, 60 to 120 minutes in 60.3%, and longer than 120 minutes in 2.2% of women. Mean estimated blood loss was 65.5 ml (range ml), and no patients required blood transfusion. Sixty-nine percent of patients did not require postoperative analgesia. For those who did, the mean number of intramuscular meperidine doses was 1.5 and that of oral Dologesic-32 (paracetamol 325 mg, propoxyphene napsylate 50 mg) was 2.3. Mean hospital stay was 2.6 days. Eighty-three percent of women were discharged within 3 days and 96% within 5 days. Seven patients (<2%) stayed longer than 1 week because of postoperative febrile morbidity (3), small bowel herniation (2), pelvic hematoma (1), and urinary retention (1). Mean ± SD return to normal daily activities was 14.3 ± 9.6 days. Complications In all, 68 patients (13.3%) developed intraoperative or postoperative complications. There was no difference in the complication rate between the time when operations were performed by the two senior surgeons compared with those performed by surgeons in training. Five patients (1%) required conversion to laparotomy. One was due to difficulty achieving 530

3 November 2000, Vol. 7, No. 4 The Journal of the American Association of Gynecologic Laparoscopists hemostasis after laparoscopic drainage of bilateral ovarian abscesses, two because of dense pelvic adhesions secondary to endometriosis, and one because of suspected ovarian malignancy. The last one was a bowel injury after primary cannula insertion in the presence of extensive bowel adhesions after previous salpingectomy for tubal pregnancy. There were 11 other intraoperative complications. Ureteric injury occurred in two women (0.4%) with an endometrioma and extensive pelvic adhesions. One had superficial thermal damage that was identified during the operation. A ureteric stent was inserted and the patient recovered with no complications. The other patient developed a urinoma from a right uretericperitoneal fistula 15 days postoperatively and required reimplantation. Five patients (1%) had an injury to the inferior epigastric artery during insertion of the 10-mm ancillary cannula; two were controlled with bipolar coagulation, two with a Foley catheter, and one with an Atad Ripener device. 9 Four (0.8%) uterine perforations occurred during insertion of the Hegar dilator, which was used as a uterine manipulator. Forty-four women (8.6%) experienced postoperative complications. Four (0.8%) had an incisional hernia, all at the left lower abdominal wound with a 10- or 11-mm port through which the specimen was removed. Two of these were complicated by incarcerated bowel herniation and required laparotomy for bowel resection. One woman developed extensive bilateral ecchymoses extending from loin to groin and the upper thigh 2 days after uneventful laparoscopy. Although her hemoglobin level dropped by 3 g/dl, she recovered spontaneously. Postoperative febrile morbidity, defined as temperature greater than 38 C on two occasions 4 hours apart excluding the first 24 hours postoperatively, occurred in 20 patients (3.9%). It was due to pelvic hematoma (2), ureteric injury (1), wound hematoma (2), and urinary tract infection (2). No cause could be identified in the remaining women. Seventy-four patients had bilateral ovarian cysts and 394 a single cyst. Endometriomas occurred in 58.1% and 39.8%, respectively (p<0.05, OR 2.09, 95% CI ). Patients undergoing a bilateral procedure had significant increases in operating time (81.7 ± 35.5 vs 67.5 ± 32.1 min, p<0.001), hospital stay (2.9 ± 1.8 vs 2.5±1.4 days, p<0.05), and overall (21.6% vs 11.2%, p<0.001, OR 2.19, 95% CI ) and postoperative complication rates (16.2% vs 8.9%, p<0.05, OR 1.99, 95% CI ). Although no single type of complication was statistically accountable for the difference, the trend was for more postoperative febrile morbidity (5.4% vs 3%, OR 1.82, 95% CI ) and urinary tract infection or retention (10.8% vs 5.3%, OR 2.15, 95% CI ) in patients with bilateral surgery. Seven women (1.4%) required reoperation, four for hernia, one for ureteric injury, one for borderline malignancy, and one for bowel injury. One woman (0.2%) was readmitted for pelvic hematoma. Histopathology Histopathology varied widely (Table 2). Endometriomas (44.5%) and dermoid cysts (24.3%) were the most common. There were 39 functional cysts, accounting for only 6.6% of all cysts. A necrotic tumor of uncertain nature was found in a 38-year-old woman who had torsion of an 8-cm ovarian mass. There were two (0.4%) cases of cystadenoma of borderline malignancy, one in a 37-year-old woman with a 6-cm cyst and the other in a 25-year-old woman with a 10-cm cyst. Both cysts were unilocular with no solid parts or papillary growth on preoperative transvaginal ultrasound scan. Two (0.4%) cases of ovarian malignancy were encountered. A 29-year-old patient had a 4-cm left ovarian cyst suspected to be an endometrioma. 10 Laparoscopic left oophorectomy was performed because of necrotic tissue found at attempted cystectomy. Histologic examination revealed a poorly differentiated Sertoli-Leydig cell tumor. A 51-year-old woman who had a 15-cm left ovarian simple cyst on ultrasound scan underwent laparoscopic bilateral TABLE 2. Pathology Pathology Number (%) Endometrioma 261 (44.5) Dermoid 143 (24.3) Serous cystadenoma 40 (6.8) Mucinous cystadenoma 38 (6.5) Functional cysts 39 (6.6) Paraovarian cysts 22 (3.7) Hemorrhagic cysts 17 (2.9) Simple cysts 13 (2.2) Borderline malignancy 2 (0.4) Malignancy 2 (0.4) Others a 10 (1.7) a Two ovarian abscesses, two adenofibromas, one fibroma, one ovarian pregnancy, one Brenner tumor, one pseudocyst, one necrotic tumor, and one unclassified cyst. 531

4 Complications of Laparoscopic Surgery for Benign Ovarian Cysts Lok et al salpingo-oophorectomy. Fleshy papillary tissue was noted during specimen removal and histology confirmed a poorly differentiated papillary cystadenocarcinoma. On review of preoperative ultrasound films, a small solid area could be seen inside the cyst, raising the suspicion of malignancy. The patient refused further operation until 9 months later, when she developed local recurrence. Debulking surgery was then performed, followed by adjuvant chemotherapy. Cystectomy was performed in 70.5% of women and oophorectomy or salpingo-oophorectomy in the rest. The mean diameter of ovarian cysts in the cystectomy group was significantly smaller than that in the oophorectomy group (5.1 ± 2.3 vs 6.6 ± 3.8 cm, p<0.01). The overall rupture rate during surgery was 60.9% and was related to pathology and type of operation but not to cyst size. By excluding endometriomas, the rupture rate was 47.5% for the cystectomy and 14.4% for oophorectomy groups, respectively, with an overall frequency of 39.6%. Discussion Although operative laparoscopy has largely replaced conventional laparotomy for removal of benign ovarian cysts, the frequency of complications remains a concern. Most reported studies are retrospective reviews and procedures were usually performed by experienced surgeons. The actual complication rate may therefore have been underestimated. Furthermore, the true complication rate of laparoscopic ovarian surgery is largely unknown as most published reports included a variety of procedures. Our study was confined to laparoscopic ovarian surgery performed mainly by inexperienced physicians in training. As data were collected prospectively, the results should be more reflective of the underlying risk associated with this particular procedure. Operating on a malignancy without proper preoperative preparation is one of the main arguments against performing laparoscopic ovarian surgery. Despite careful patient selection and strict preoperative assessment, malignancy can occur regardless of the approach. The reported frequency of unexpected ovarian malignancy is 0.4% to 0.5% We encountered two cases of borderline malignancy and two of ovarian malignancy. Three of these women had no evidence of malignancy on either ultrasonographic or laparoscopic assessment. In the remaining patient the suspicious feature on ultrasound was missed. Had it been recognized, the patient would have been scheduled for laparotomy instead of laparoscopy. Due to minimal risks perceived by many surgeons and increasing popularity of laparoscopic surgery among patients, the tendency is to overtreat benign ovarian cysts. This is reflected by the high frequency (30 70%) of functional cysts being operated on. 4,12 Indications for removal should remain unchanged regardless of surgical approach, and only those cysts are pathologic or persistent should be removed. The low frequency of functional cysts in our series (6.7%) reflects strict preoperative assessment protocol. Similar to other interventions, despite all efforts to the contrary, adverse clinical outcomes occur. Prevention of complications of laparoscopic surgery starts by raising awareness of risks and precautions necessary to ensure safety. Although a few large series reported complications in recent years, many included both diagnostic and minor procedures The complication rate after laparoscopic ovarian surgery alone has not been described adequately. In a review of 188 patients undergoing laparoscopic surgery for ovarian cysts, the complication rate was 10.1%, with 1.6% being major, 12 comparable with our series. As the complication rate for adnexal surgery performed by laparotomy is seldom reported in the literature, it is difficult to compare modalities. In a prospective, randomized study, laparotomy was associated with a higher rate of postoperative complications than laparoscopy. 5 In an observational study, two (1.8%) major complications occurred in the laparoscopy group, compared with none in the laparotomy group. 1 However, the number of patients involved was small and adnexal operations were not specifically confined to ovarian surgery. The conversion rate was 2.9% in 700 cases of laparoscopic adnexal surgery, with the risk highest for dermoid cysts (14.7%) and endometriomas (6.2%). 18 A 4.3% conversion rate was reported for benign ovarian cysts, mainly due to technical difficulty and bleeding. 12 Our conversion rate was much lower despite the wide range of pathology encountered and the fact that most surgeries were performed by surgeons in training. With proper training and adequate supervision, most ovarian cysts can be removed laparoscopically. Ureteric injury during adnexal surgery for benign conditions is uncommon, except in cases of severe endometriosis or when there are extensive adhesions 532

5 November 2000, Vol. 7, No. 4 The Journal of the American Association of Gynecologic Laparoscopists in the pelvic sidewall. The magnified view of laparoscopy provides good delineation of tissue planes for dissection. However, it reduces the surgical field and causes loss of depth perception and orientation, especially if the camera is not held in an upright position. The anatomic position of deep pelvic structures may be overlooked, particularly if anatomy is distorted, as in the presence of dense adhesions and endometriosis. Electrocoagulation further increases the risk because of lateral spread of thermal energy. Early identification of injury is important to allow prompt intervention and prevention of complications. In a nationwide review of major laparoscopic complications in Finland, 57 (0.18%) ureteric injuries occurred in 32,205 operative laparoscopies, 3 of which followed salpingo-oophorectomy. 17 Unfortunately, data were not analyzed according to operative procedure, and the frequency of these injuries was not specified. Two uretric injuries (1.2%) occurred after bilateral salpingo-oopohoerectomy in 161 women with severe endometriosis undergoing laparoscopic adnexectomy or ovarian cystectomy. 19 The frequency of ureteric injury in our series was much lower (2, 0.4%) and both injuries occurred in women with severe endometriosis with extensive pelvic adhesions. To minimize the likelihood of this injury, anatomic orientation and depth of dissection should be regularly assessed in a panoramic view to allow identification of the course of the ureter. Use of an illuminated ureteric stent to enhance visualization of the ureter may help to reduce the risk of injury. 20 The frequency of bowel injury in laparoscopic ovarian surgery is also not well reported. In a review of 14,622 cases of major operative laparoscopies that included procedures for ectopic pregnancy, benign ovarian cysts, and adhesiolysis for endometriosis, 35 bowel injuries occurred (0.24%). 16 In our patient the bowel laceration occurred during insertion of the primary cannula as a result of the extensive abdominopelvic adhesions with involvement of the anterior abdominal wall. It is unlikely that injury would have been avoided even during open laparoscopy, as the view is usually limited. In a retrospective review of over 600,000 laparoscopies, the risk of bowel injury after closed technique for establishment of pneumoperitoneum was 0.083% and that after an open method was 0.04%. 21 Incisional hernia after laparoscopy is generally considered uncommon. The reported frequency after diagnostic laparoscopy or laparoscopic sterilization ranges from 1/5000 to 1/10,000. With increasing use of multiple ancillary ports and extirpative procedures, this complication is more frequent than expected. In a multicenter review of 3560 operative laparoscopies, 4 small bowel hernias and 2 omental hernias were reported, for an overall frequency of 0.17%. 22 The risk of incisional hernia increases with lateral placement of the cannula, with larger ports (>10 mm), and when fascia is left unclosed. Four of our patients developed incisional hernias, all at the extraumbilical 10-mm port site. The higher frequency after ovarian surgery may be attributed to removal of specimens through the 10-mm port by bag retrieval, which could enlarge the fascial defect, especially with bulky cysts with solid components, as in dermoids. All our incisional hernias occurred during the time when we tried to close fascial defects with conventional sutures. It is difficult to ensure that fascia is properly closed, especially when the patient is obese and if the cannula is inserted obliquely. Since 1996, using a specially designed needle, the EndoClose (AutoSuture, USA), we have had no further cases of incisional hernia. Injury to the inferior epigastric vessels was uncommon when laparoscopy was confined to diagnosis and sterilization. With increased complexity of pelvic laparoscopy, lateral placement of ancillary cannulas is necessary and this increases the risk of laceration of these vessels. This is a potentially serious complication, as bleeding can be difficult to control and may result in conversion to laparotomy, stroke, and even death. 23 The frequency of laceration of epigastric vessels in operative laparoscopy was reported to be around 1.5%. 24 This is comparable with our experience (1%). The complication is avoidable, as vessels can be easily identified as they run beneath the lateral border of the rectus muscle above peritoneum. It is important to avoid inserting the cannula in an oblique angle toward midline, especially when a cutting tip instrument is used. Conclusion Laparoscopic removal of benign ovarian cysts is a common operative procedure and technically feasible in most cases. Although it is simple and relatively safe, major complications do occur occasionally. Prevention of complications starts by raising awareness of the associated risk and learning the limitations of 533

6 Complications of Laparoscopic Surgery for Benign Ovarian Cysts Lok et al this approach. Adherence to basic surgical principles with proper training and supervision is the key to ensure safe application. References 1. Meltomaa SS, Taalikka MO, Helenius HY, et al: Complications and long-term outcomes after adnexal surgery by laparotomy and laparoscopy. J Am Assoc Gynecol Laparosc 6(4): , Lin P, Falcone T, Tulandi T: Excision of ovarian dermoid cyst by laparoscopy and by laparotomy. Am J Obstet Gynecol 173: , Mais V, Ajossa S, Piras B, et al: Treatment of nonendometriotic benign adnexal cysts: A randomized comparison of laparoscopy and laparotomy. Obstet Gynecol 86: , De Wilde RL, Hesseling M: Safety and efficacy of the endosurgical management of ovarian cysts in premenopausal women: A prospective study. Gynaecol Endosc 3: , Yuen PM, Yu KM, Yip SK, et al: A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol 177: , Herrmann UJ, Gotteried WL, Goldhirsch A: Sonographic patterns of ovarian tumors: Prediction of malignancy. Obstet Gynecol 69: , Granberg S, Wikland M, Jansson I: Macroscopic characterization of ovarian tumors and the relation to the histological diagnosis: Criteria to be used for ultrasound evaluation. Gynecol Oncol 35: , Yuen PM, Rogers MS: Laparoscopic removal of ovarian cysts using a zipper storage bag. Acta Obstet Gynecol Scand 73(10): , Yuen PM, Rogers MS: The use of an Atad Ripener device in the management of inferior epigastric artery injury during operative laparoscopy. Acta Obstet Gynecol Scand 74: , Yuen PM, Leung TN: Unexpected ovarian malignancy diagnosed after laparoscopic surgery. Aust NZ J Obstet Gynaecol 36(1):98 99, Hulka JF, Parker WH, Surrey MW, et al: Management of ovarian masses: AAGL 1990 survey. J Reprod Med 37: , Parker J, Bethune M, Lau P, et al: Operative laparoscopic management of adnexal cysts: Initial experience at the Royal Women s Hospital Aust NZ J Obstet Gynaecol 36:1:31 35, Nezhat F, Nezhat C, Welander CE, et al: Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses. Am J Obstet Gynecol 167: , Bateman BG, Kolp LA, Hoeger K: Complications of laparoscopy Operative and diagnostic. Fertil Steril 66:30 35, Jensen FW, Kapiteyn K, Trimbos-Kemper T, et al: Complications of laparoscopy: A prospective multicentre observational study. Br J Obstet Gynaecol 104: , Chapron C, Querleu D, Bruhat M, et al: Surgical complications of diagnostic and operative gynaecological laparoscopy: A series of cases. Hum Reprod. 13(4) , Härkki-Siren P, Sjöberg F, Kurki T: Major complications of laparoscopy: A follow-up Finnish study. Obstet Gynecol 94:94 98, Audebert AJM: Technical limits in the treatment of adnexal masses. A series of 700 cases. J Obstet Gynecol 2: , Saidi MH, Vancaillie TG, White AJ, et al: Complications of major operative laparoscopy: A review of 452 cases. J Reprod Med 41: , Low RK, Moran ME: Laparoscopic use of the ureteral illuminator. Urology 42: , Bonjer HJ, Hazebroek EJ, Kazemier G, et al: Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 84: , Kadar N, Reich H, Liu CY, et al: Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol 168: , Nordestgaard AG, Bodily KC, Osborne RW, et al: Major vascular injuries during laparoscopic procedures. Am J Surg 169: , Vasque JM, Demarque AM, Diamond MP, et al: Vascular complications of laparoscopic surgery. J Am Assoc Gynecol Laparosc 1: ,