Laparoscopic Surgery of the Fallopian Tubes

Transcription

1 Laparoscopic Surgery of the Fallopian Tubes and Ovaries M. Yusoff Dawood, MD Operative laparoscopy can be used for many surgical procedures on the fallopian tube and ovary. These include: (1) tubal sterilization; (2) salpingectomy and salpingostomy for tubal pregnancy; (3) fimbrioplasty, salpingoneostomy, and linear salpingostomy for tubal obstruction and infertility; (4) microsurgical tubal reanastomosis for reversal of tubal sterilization; (5) oophorectomy, cystectomy, cyst drainage and fulguration, and excision of ovarian tumors; (6) wedge resection and ovarian drilling for polycystic ovaries; and (7) fulguration and laser vaporization for endometriosis. Many of these procedures are conservative and involve reconstruction of the tube and ovaries to preserve fertility. Microsurgical techniques are incorporated into such fertility sparing or enhancing procedures. Comparison of similar surgical procedures on the tube and ovaries indicates better or similar surgical outcome when done through the laparoscope rather than laparotomy; less blood loss, faster recovery, and cheaper cost are the hallmarks when the procedure is done by laparoscopy. With further improvement and expansion in laparoscopy equipment, it can be expected that more surgical procedures on the adnexa can be undertaken safely and effectively. Copyright 1999 by W B. Saunders Company Key words: Salpingostomy, endometrioma, sterilization, ovarian cystectomy, ectopic pregnancy. A fter diagnostic laparoscopy was introduced, the earliest and most widely used form of operative laparoscopy was on the adnexae, initially for tubal ligation followed by adhesiolysis and, thereafter, a variety of radical and conservative adnexal surgery as better instruments became available. Laparoscopy is a means of minimal access into the peritoneal or pelvic cavity, and, although recovery is shorter than in laparotomy, careful consideration must be given to the selection of surgical access based on the goal of the surgery and the type of adnexal pathology. Safety and adequate access to the surgical site should not be jeopardized when choosing between laparoscopy and laparotomy, further governed by the expertise and experience of the surgeon. From the Division of Reproductive Endocrinology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Houston Medical School, Houston, TX. Address reprint requests to M. Yusoff Dawood, MD, Department of Obstetrics and Gynecology, Universiry of Texas Houston Medical School, 6431 Fannin, Suite 3.110, Houston, TX Copyright C 1999 by WB. Saunders Company /99/ $10.00/0 Laparoscopy for adnexal surgery includes sterilization, ectopic pregnancy, hydrosalpinx or distal tubal occlusion, reversal of tubal ligation, endometriosis, ovarian tumors and cysts, and gonadectomy. Tubal Sterilization The prevalence of surgical sterilization in American women 15 to 44 years of age rose from 16% in 1965 to 42% in 1995, and has remained stable at 41 % since. Concerns and higher expectations for contraceptive effectiveness, safety, and convenience are reasons for choosing surgical sterilization. Tubal sterilization can be performed through laparoscopy or laparotomy. Laparoscopic tubal ligation was initially performed as an alternative to minilaparotomy tubal sterilization. Although laparoscopic tubal sterilization can be performed in the immediate postpartum, the lax abdominal wall and enlarged uterus (up to the umbilicus) render minilaparotomy (same periumbilical incision as laparoscopy) easy, safe, and preferred by many obstetricians. Laparoscopic tubal ligation can be performed under general anesthesia or under local anesthesia. In most instances, only 2 abdominal punctures are required. The laparoscope is introduced through a periumbilical stab incision after a pneumoperitoneum is established. The second puncture (5 to 6 mm trochar) is usually through a midline suprapubic stab under direct visual guidance of the laparoscope. Laparoscopic tubal interruption includes electrocoagulation and clip or falope ring application to the tubes. The isthmal portion of the tube, about 1 to 2 cm after its emergence from the uterus, is the preferred site for interruption. Success rates of isthmal tubal reanastomosis is better if reversal is desired. Both bipolar and unipolar electrocoagulation of the tubes are performed, but the risk of thermal injury is less with bipolar current. Electrocoagulation may still be the method of choice when the tube is immobilized by adhesion, making it difficult to be lifted for clip or falope ring application without lacerating the mesosalpinx and tube. During tubal electrocoagulation, thermal injury to other vital struc- 58

2 59 tures must be avoided. The tube should be allowed to to avoid cool down before dropping it into the pelvis potential heat transfer and delayed thermal injury to other structures. Using the Kleppinger forceps, each tube is cauterized at 3 sites adjacent to each other because the sterilization failure rate is higher with electrocoagulation of only 1 site. To reduce the failure rate arising from potential tubal recanalization, the tube is divided after coagulation. With tubal electrocoagulation, there is increased risk of adhesions and the residual tubal lengths are shorter, with greater disparity in the lumens of the interrupted ends, thus reducing the success rate of subsequent tubal reanastomosis. The clips and falope rings (silicone rubber rings) are currently the most widely used devices for laparoscopic interruption of the tubes. The falope ring is loaded on an applicator, which is introduced through the second puncture port. At the end of the applicator emerges a pair of forceps that picks up the tube and squeezes it into a knuckle, over which the falope ring is applied. The falope ring now &dquo;strangulates&dquo; this knuckle of tube and interrupts it. With time, this portion undergoes ischemic -necrosis and the interrupted tube separates offwith the falope ring, usually hanging close to one of the ends as seen at subsequent surgery. The ring should be applied at the isthmal part of the tube. It is best to avoid the ampulla and distal end of the tube to avoid lacerations and dislodgement of the ring. Occasionally, the falope ring is dislodged, presumably because of poor placement, excessive tubal activity pushing it off, or a defective ring. Clips used for laparoscopic tubal ligation are made of metal (tantalum) or plastic. There are two types of clips in wide use, the Hulka-Clemens spring clip and the Filshie clip. Unlike falope rings, a knuckle of tube need not be lifted for its occlusion because the whole lumen is occluded at a single point. Less tube is damaged or interrupted with this procedure, but there is a comparatively high rate of the clips loosening and falling off into the pelvis. With improvements in the design of the clip, the sterilization failure rates have been reduced., The reported failure rates of sterilization vary from center to center and country to country. The risk persists for years after the tubal sterilization and varies by method of tubal occlusion and age. A United States multicenter, prospective cohort study of 10,685 women who underwent tubal sterilization was followed up for 8 to 14 years.2 The cumulative 10-year probability of pregnancy of 36.5 per 1,000 procedures was highest after clip sterilization cormpared with unipolar tubal coagulation (7.5 per 1,000 procedures), which was similar to postpartum partial salpingectomy. There is a higher failure rate in younger women in whom the cumulative risk of pregnancy was similar with bipolar coagulation (54.3 per 1,000 procedures) or clip sterilization (52.1 per 1,000 procedures). In a prospective, randomized study of 365 women undergoing interval laparoscopic tubal sterilization and followed up for only 6 to 24 months, there was a 4.5% pregnancy rate with the Hulka- Clemens clip compared with 2.6% with the falope ring.3 Ectopic Pregnancy There are no well-defined criteria if an ectopic pregnancy should be surgically managed by laparoscopy or laparotomy. Clearly, if there is acute rupture of a tubal pregnancy, acute hemoperitoneum, and the patient is hemodynamically unstable, it is prudent to proceed expeditiously with a laparotomy to stop the bleeding. Requiring special instrumentation, operating room personnel familiar with the instruments, and special surgical skill, operative laparoscopy may not be the appropriate choice when the necessary instruments and trained operating room personnel are unavailable and clinical laparoscopic experience is limited. The subsequent fertility rates seem to. be equivalent between laparoscopy and laparotomy. Thus, the surgeon who is more adept with performing a rapid and flawless minilaparotomy should undertake this approach for optimal outcome for the patient. On the other hand, the skilled laparoscopist might elect to perform operative laparoscopy even in the presence of some hemoperitoneum, because bleeding can be readily stopped with correct instrumentation and appropriate skill. Ectopic pregnancies of greater than 4 cm and surrounded by pelvic adhesions with anatomic distortion may be more difficult to treat laparoscopically by some, but can be undertaken by a skilled laparoscopist, especially one with experience in adhesiolysis of dense adhesions. Most ectopic pregnancies are in the fallopian tube, and a few are in the ovaries or the uterine cornu. Surgical management of tubal pregnancy requires the following: (1) salpingectomy (partial or total) if the tube cannot be salvaged for future function, or further childbearing is not desired; (2) linear salpingostomy if the pregnancy is unruptured, just minimally ruptured, and if retention of fertility is

3 60 desired; and (3) &dquo;milking&dquo; abortion of a tubal pregnancy. the tube if there is tubal Salpingectomy If future childbearing is not needed, salpingectomy is the surgical procedure of choice, irrespective of the tubal location or rupture. Salpingectomy should also be considered if (1) hemostasis cannot be achieved during conservative surgery, (2) repeated coagulation to stop bleeding at the salpingostomy induces extensive tubal damage only to defeat the primary intent of conserving fertility, (3) the tube has a recurrent ectopic pregnancy, and (4) the tube is irreparably damaged. There are two forms of laparoscopic salpingectomy, one using a loop ligature and the other electrocautery. With the ligature method, the tube is stabilized and displayed to show its fimbrial end. The endoloop, which is a prefabricated 0-chromic catgut loop, is introduced through another port into the abdomen, and the distal~end of the tube is grasped through the suture loop. The loop is then steadily tightened down proximal to the ectopic pregnancy and firmly ligated. A second loop is placed just beyond the first ligature to ensure added hemostasis. The distal end of the tube containing the ectopic pregnancy is then excised. The ligated pedicle is then inspected for hemostasis. Bipolar cautery could be used, should further hemostasis be needed. A retrospective cohort analysis of 213 laparoscopic salpingectomies compared with 127 laparotomy salpingectomies for ectopic pregnancies found the laparoscopic approach to be superior.4 The overall spontaneous conception was 70:4% with laparoscopy versus 53.2% for laparotomy, live birth rates were 50% and 37%, and the mean time to conception was 11 and 17.2 months, respectively. However, the recurrent ectopic pregnancy rates were similar with both surgical approaches (10.6% and 9.6%). Linear Salpingostomy Linear salpingostomy is best performed on ampullary pregnancy rather than isthmal or interstitial tubal occlusion or pregnancy because postoperative stenosis is greater in the latter sites. When performing a linear salpingostomy for an ampullary pregnancy, an incision is made on the antimesenteric side of the tube at or just proximal to the point of maximal bulge. If the bulge is close to the fimbria, the incision is extended to the fimbria so that the fimbrial opening of the tube is greatly enlarged. Good hemostasis is required and can be aided by injecting vasopressin solution (10 units in 20 ml of saline) into the antimesenteric side of the tube just proximal to and also distal to the bulge of the ectopic pregnancy to induce vasoconstriction. The salpingostomy incision can be made with a monopolar electrocautery needle combining both coagulation and cutting to ensure good hemostasis. Alternatively, the carbon dioxide (C02) laser can be used, using 1 mm spot size and superpulse beam. With the laser, the tissue incised over the bulging ectopic pregnancy is easily splayed on its own tension as the laser cuts through slowly. Hemostasis can be problematic if the surgeon does not move quickly because the C02 laser does not penetrate liquid such as blood, which has to be irrigated away or charred first before the laser beam can make contact with the tissue. Once the content of the ectopic pregnancy is visualized, it can be made to bulge out and be dislodged by hydrodissection with the suction irrigator. Good hemostasis should also be secured on the bed of the ectopic pregnancy. All trophoblastic tissue should be removed provided this does not induce uncontrollable bleeding. It is preferable not to suture or close the salpingostomy, which is allowed to heal by secondary intention. Although there is some concern for subsequent persistent ectopic pregnancy if some trophoblastic tissue is left, this potential complication can be managed with postoperative or subsequent methotrexate therapy. The incidence of persistent ectopic pregnancy after linear salpingostomy is about 5% to 20%, with risk factors including very early pregnancy (fewer days of amenorrhea since the last menstrual period) with therefore lower serum human chorionic gonadotrophin levels and smaller trophoblast tissue mass, and an ectopic pregnancy of less than 2 cm in diameter.5 Laparoscopic treatment of tubal pregnancy is less expensive than laparotomy.6,7 Gray et al8 found less striking cost differences between laparoscopy and laparotomy for ectopic pregnancy. As an alternative to laparoscopic surgery for tubal pregnancy, nonsurgical, medical therapy with methotrexate given as a single intramuscular dose (50 Mg/M2) or transvaginally into the ectopic pregnancy can be considered for unruptured tubal pregnancy. Because the fertility outcome is similar between methotrexate and laparoscopic salpingostomy,9 methotrexate is increasingly used to treat early unruptured tubal pregnancy and cornual pregnancy, which are technically difficult to manage laparoscopically. The direct cost of laparoscopic treatment of

4 61 tubal pregnancy is significantly higher than methotrexate therapy. 10,1 In one controlled clinical trial, systemic methotrexate was preferred by most patients as part of a completely nonsurgical management strategy.12 However, a multicenter randomized clinical trial found that systemic methotrexate had a more negative impact on health-related quality of life than did laparoscopic salpingostomy.13 In addition, human chorionic gonadotropin levels regressed more quickly to normal after laparoscopic treatment compared with methotrexate. Therefore, these factors should be considered in selection of appropriate therapy for tubal pregnancy. Distal Tubal Disease Distal tubal obstruction with varying degrees of dilatation and mucosal damage can result from acute salpingitis, intra-abdominal and appendiceal infection, pelvic surgery, or endometriosis. Usually, both tubes are affected, but one may be more severely damaged than the other. Tubal reconstruction aims at relieving the obstruction by exposing the remaining fimbriae, if any, and restoring the tubo-ovarian anatomical-functional relationships and mobility by freeing the tube from adhesions and reducing their subsequent reformation. Operative laparoscopy provides excellent visualization, fulfills the requirements of microsurgical tubal reconstruction if properly performed, and eliminates the risk of postoperative adhesion to the anterior abdominal wall. Fimbrioplasty Fimbrial agglutination, fimbrial encapsulation by fibrous tissue, or prefimbrial phimosis from stenosis of the tubal infundibulum can be laparoscopically repaired using video monitor for magnification, which is as good as or even better than the operating microscope at laparotomy. With the tubes distended with methylene blue or indigo carmine via transcervical instillation, the periadnexal adhesions are lysed and removed using either the needle electrode or the laser beam. Once completely freed, the tube is stabilized by gently grasping the antimesenteric serosa at its distal end with atraumatic forceps or the suction irrigator. Fimbrial agglutination can be corrected by introducing a small alligator forceps through the tubal ostium and the jaws opened in the lumen and withdrawn to dilate the opening. This may be repeated several times in different directions radially, and further assisted with hydrostatic dilatation of the ostium with the suction irrigator. If the agglutination is severe, dense, or extensive, it is better to perform a neosalpingostomy. Once. opened, the tube should be generously hydrotubated by transcervical instillation and by retrograde flushing of the tube from the newly enlarged distal opening with the suction-irrigator. Any intraluminal bands or adhesions should be excised and freed. Fimbrial bridges producing fimbrial encapsulation can be gently freed with the needle electrode, the laser, or microscissors. Once freed, the fimbriae, if undamaged, will pout and curl out freely, especially if the tube is floated in clear irrigation fluid. Prefimbrial phimosis is best correct ed by salpingostomy. The fibrous bands constricting the infundibulum are divided with the laser or needle electrode with an followed by a terminal linear salpingostomy incision on the antimesangial side of the tube start- - ing from the ostium and extending proximally to beyond the phimosis. By applying defocused laser beam or electrocoagulation to the serosal surface of the infundibulum, the tissue edges of the salpingostomy are everted to reduce the risk of postoperative closure or stenosis. Salpingoneostomy For hydrosalpinx, laparoscopic microsurgical salpingoneostomy can restore tubal patency, but the pregnancy remains poor if there is irreversible damage of the cilia and tubal wall. Because the outcome on the func- of tubal reconstruction depends largely tional status of the tube, laparoscopic microsurgery performed at the time of diagnostic laparoscopy is a more reasonable alternative to laparotomy tubal repair. Laparoscopic microsurgical salpingoneostomy is optimally performed under video camera visualization and monitoring. The tubes are rendered turgid with indigo carmine (see fimbrioplasty) to assist in identification of the scarred ostium at the distal end. The tube is freed from adhesions. The distal end of the tube is immobilized with atraumatic forceps. Using the needle electrode or the CO2 laser, a cruciate incision is made, with its intersection at the dimple of the scarred ostium. Immediate collapse of the tube can be deferred by avoiding a full thickness incision into the tubal lumen. Instead, the incision line is scored in layers, the laser beam being especially suitable for accomplishing this. Once the full length of the incision is scored, it is carried down deeper until dye is encountered. At this point, the microscissors may be used to complete the incision. The cruciate incision should be sufficiently long to produce a wide opening that will compensate for any potential postoperative cicatrization. The opening

5 62 will now have 4 petal-like segments whose serosal edges need to be everted. If residual fimbriae are present and trapped within the occluded tube, they will appear as it is incised. Although some infertility surgeons prefer to place absorbable sutures to secure the serosal edges of the new ostium to the ampullary serosa, many, including the author, prefer to achieve such eversion with application of the defocused CO2 laser beam at a 5 W setting. The serosal edges are desiccated to induce contraction of the serosa, which now pulls back the ostial margin. Needle electrocoagulation can also be used to accomplish this. There should be sufficient exaggerated eversion of the ostial margin to produce the appearance of a &dquo;cuffed&dquo; salpingostomy to prevent postoperative closure. Using the suction irrigation tip, retrograde hydrotubation is carried out through the newly created ostium to free any intratubal adhesions as well as hydrostatically widen the ostium. Excellent hemostasis should be achieved and the pelvis copiously irrigated to keep the tissues wet at all times To reduce postoperative adhesions, a layer of oxidized regenerated cellulose (Interceed) is placed over the new ostium by some surgeons, but laparoscopic placement of this material is often difficult. A simpler alternative is to instill up to no more than 100 ml of 32% dextran-70 (Hyskon), which will postoperatively draw fluid into the pelvis and keep the tubes afloat and separated from other structures. Ringer lactate and physiological saline have also been used, but they are quickly absorbed within less than 24 hours, although the critical period when adhesions may arise is the first 5 postoperative days. The use of dextran-70 and a nonsteroidal antiinflammatory drug given intraoperatively and continued for the first 5 days postoperatively to suppress inflammation during tubal healing is preferred. Periadnexal Adhesiolysis Pregnancy rates of infertile women with periadnexal adhesions can be significantly improved by lysis of the adhesions when compared with no treatment. 14 The use of microsurgical techniques over gross dissection and precise repair of peritoneal surfaces can double the pregnancy rate. 5 Consequently, operative laparoscopy, which observes these principles, should be ideal for periadnexal adhesiolysis and reduces the risk of adhesions to the abdominal wall that laparotomy can produce. Laparoscopic adhesiolysis is not without significant risks because bowel injury may occur from trochar placement or during enterolysis. Therefore, preoperative bowel preparation is advisable. In cases in which adhesions may be expected at the primary trochar placement site, open laparoscopy may be used so that any bowel or adhesions can be freed before directly visualizing intraperitoneal placement of the trochar. Blunt and forceful separation of adhesions should be avoided. Care should be exercised to identify the structures that the adhesions are attached to. The adhesions should be divided by sharp dissection with the microscissors, endoshears, needle electrode, or the laser beam. Aqua dissection can be used to find surgical planes and to gently dissect away the adhesions. The adhesions should be excised or vaporized with the laser beam. Adhesions on the surface of the ovary should be removed to restore the smooth surface of the ovary. Lysis should be complete to permit restoration of the anatomical and functional relationships of ovary, tube, and uterus. Some adhesions, especially those that are dense and do not affect uterine-tubal-ovarian functional relationships, are probably best left alone, because aimless extensive dissection may increase the risk of the tube and ovary becoming adherent to such sites. Excellent hemostasis should be attained using the needle electrode or the laser beam. The harmonic scalpel that cuts tissue by ultrasonic vibrations has been recommended to reduce tissue damage, but currently there is insufficient data comparing it with the other modalities in adhesiolysis in women. Comparing fertility outcome between patients who had adhesiolysis by laparotomy with laparoscopy, 3 studies found no significant difference The pregnancy rate was 78% after laparoscopic salpingowariolysis versus 75% after laparotomy adhesiolysis, whereas the ectopic pregnancy rate was 4% and 8%, respectively. 16 In 11 published studies of 802 patients who had laparoscopic adhesiolysis for their infertility, the pregnancy rate was 47% and the ectopic pregnancy rate 4%.&dquo; Laparoscopic lysis of pelvic adhesions has also been performed for chronic pelvic pain. Given that it is uncertain if pelvic adhesions are responsible for the pelvic pain and adhesions reformed postoperatively, laparoscopic adhesiolysis has produced mixed outcome in pain relief. As many as 89% reported ~ symptomatic improvement, 20 with return of greater pain with time in some series,21 but neither the study nor the pain assessment was controlled. Adhesion reformation is a concern even with laparoscopic adhesiolysis because it defeats the initial therapeutic goal. The available human data is lim-

6 z 63 ited and does not support the notion that laparoscopy eliminates postoperative adhesion formation. Although operative laparoscopic surgery reduces de novo adhesion formation, there is still a high incidence of adhesion reformation in up to as many as 97% of the women.22,23 Tubal Reanastomosis Reversal of tubal sterilization involves resecting the interrupted ends of the divided tube and microsurgically reanastomosing it with precise alignment. Although most tubal reanastomosis is performed through a laparotomy, laparoscopic reversal of tubal sterilization has been performed. Initial attempts involved using hysteroscopically placed wires or stents - into the fallopian tubes with the microanastomosis performed laparoscopically, and the stents removed intraoperatively24 48 hours,25 2 weeks,26 or even up to 6 weeks postoperatively.27 Given that video magnification and the techniques used in laparoscopic surgery of the adnexae are key components of microsurgery, laparoscopic tubal reanastomosis is carried out microsurgically. Because microsuturing can be timeconsuming and difficult, fibrin glue has been used for the reanastomosis. ~8 Stents have been largely given up, and currently transcervical dye instillation is used to distend the tube and guide the anastomosis. A suture is placed at the mesosalpinx (usually 6-0 polyglycolic acid suture) to approximate the cut ends of the tube. A 7-0 or 8-0 suture is then placed on the antimesangial side of the tube to incorporate the serosal and muscularis layers. Sutures can then be placed radially to complete the anastomosis. As few as 2 sutures but as many as 4 or even more~8 have been used for the anastomosis of each tube. The reanastomosis need not be water-tight, and patency can be evaluated with indigo-carmine chromotubation. Yoon et a129 have reported laparoscopic tubal reanastomosis in 54 women. With only 12 months follow-up in 49 who were attempting pregnancy, 78% became pregnant with a live birth rate of 59% and an ectopic pregnancy rate of 2%, which are comparable with the results from laparotomy and microsurgical tubal reanastomosis. Ovaries/Gonads The ovaries or gonads can be surgically managed with operative laparoscopy. Laparoscopic procedures that can be undertaken include oophorectomy, ovarian cystectomy, drainage and excision of ovarian cyst, wedge resection of the ovaries, ovarian laser drilling, laser vaporization or cauterization of ovarian endometriosis, lysis of periovarian adhesions (vide supra), and oophoropexy. Oophorectomy/Gonadectomy Indications for laparoscopic oophorectomy or gonadectomy include benign ovarian tumor, ovarian endometriosis, carcinoma of the breast, gonadal dysgenesis, and testicular feminization syndrome. Oophorectomy can be safely performed even in large ovarian cysts by decompressing the cyst with needle aspiration, followed by oophorectomy. The gonad to be removed is freed of any surrounding adhesions (see adhesiolysis) and steadied at its utero-ovarian - ligament and/or the infundibulo-pelvic ligament after identifying and visualizing the course of the ipsilateral ureter. The infundibulo-pelvic ligament is then transfi.red with the endoloop by placing it over the gonad and pulling the latter through the loop (see salpingectomy for ectopic pregnancy). The loop ligature is then steadily and firmly tightened over the infundibulo-pelvic ligament, ensuring that the ureter is safely out of the way. A second endoloop is similarly placed over the infundibulo-pelvic ligament adjacent to the first and tightened. The ovary or gonad is cut free and the pedicle containing ovarian vessels checked for hemostasis and their mouths sealed with gentle electrocoagulation. If salpingo-oophorectomy is to be performed, the tube is also included with the ovary. The ovary can also be readily removed by electrocoagulation of the infundibulo-pelvic ligament with a Kleppinger forceps, ensuring that there is no collateral thermal injury to vital tissues and that the ureter is safely free. After coagulating the ovarian vessels in the infundibulo-pelvic ligament completely twice, the cauterized segment of the ligament is divided with scissors and hemostasis checked. Patients with testicular feminization syndrome can have their testes similarly removed laparoscopically. Electrocoagulation is preferred over the endoloop because the latter can occasionally loosen and produce delayed postoperative hemorrhage. The freed gonad can be removed out of the pelvis through a laparoscopic colpotomy performed with the C02 laser beam and guided vaginally by distending the posterior fornix with a sponge stick, which also helps to maintain the pneumoperitoneum. Should the ovarian cyst be large, it can be carefully decompressed with a sucker or needle transvaginally as the ovary is partially delivered through the vagina. Alter-

7 64 natively, the cyst can be delivered through one of the suprapubic laparoscopic puncture sites by enlarging it into a small minilaparotomy incision. If ovarian cyst content spillage is a concern, the specimen can be put into a plastic bag delivered laparoscopically, and the bag removed with its newly acquired contents either vaginally or abdominally as previously described. Laparoscopic adnexectomy for ovarian mass is significantly less expensive than laparotomy.3 The recovery time is also significantly shorter with laparoscopic adnexectomy, and blood loss is significantly less than with laparotomy. Ovarian Cystectomy If the ovarian cyst is benign in appearance and the ovary needs to be conserved, laparoscopic ovarian cystectomy is performed. To reduce the risk of cyst rupture, it is tactically easier and quicker to remove it by making the incision below the equatorial plane of the cyst and closer to the normal portion of the ovary, usually near the hilum. Blood flow to the ovary can be partially slowed by compressing against the infundibulo-pelvic ligament near the hilum with the suction irrigator, which also steadies the ovary while the needle electrode is used to make the circular incision. Using atraumatic forceps, the remaining ovarian tissue is peeled off from the cyst by traction and hydrodissection, which help to open the tissue plane and free the cyst. The cyst can then be removed as described for the oophorectomy specimen under oophorectomy (vide supra). The exposed area of the ovary is either sutured, or, using defocused C02 laser beam, hemostasis as well as inward fenestration of the raw surface of the ovary is accomplished without having to suture the edges. This method is preferred over suturing because postoperative adhesions are less likely compared with suturing.31 A quicker and easier method is to apply fibrin glue (not available in the United States) over the raw area of the incised ovary after hemostasis is secured and compress the edges to stick together. Again, this produces fewer postoperative adhesions.32 Adjunctive measures to reduce adhesion formation as described under periadnexal adhesiolysis can also be used for laparoscopic ovarian cystectomy. Laparoscopic management of ovarian endometriomas has been compared with laparotomy.33-3s The surgical results were similar, but blood loss and morbidity were less and recovery time was shorter after laparoscopic surgery. A prospective randomized study compared 52 patients undergoing cystectomy or ovariectomy for benign ovarian tumor by laparoscopy with 5 patients by laparotomy.36 With laparoscopy, operating time and frequency of inadvertent ovarian tumor rupture were similar to laparotomy, but the laparoscopic approach reduced operative morbidity, postoperative pain, analgesic requirement, and hospital and recovery period. One concern of the laparoscopy approach for surgical management of ovarian masses in peri- and postmenopausal women is the risk of inadequate management, should the mass prove to be malignant. To reduce this risk, serum CA-125 levels of less than 35 IU/mL combined with sonographic appearance and clinical examination have been used for selection for operative laparoscopy37,38 in a multicenter study of laparoscopic management of such selected adnexal masses (10 cm or less) in 61 women.&dquo; Ninety-five percent (58 of 61) of the cases were successfully managed by operative laparoscopy. While reassuring, it should be recognized that the incidence of ovarian cancer is only around 1.0%, and a larger sample size is necessary for a definitive verdict. Nevertheless, in selected cases operative laparoscopy is the preferred method for surgical management of benign ovarian masses. Laparoscopy also allows excellent visualization of the pelvis, enabling anatomically distinct washings as well as clear inspection of the right hemidiaphragm, an important site for ovarian tumor metastases. In peri- and postmenopausal women with ovarian masses, oophorectomy with frozen section pathology report, if the gross pathology appearance is questionable, should be carried out. The laparoscopic procedure can be converted into a laparotomy for more extensive surgery if malignancy is encountered Ovarian Cyst Drainage and Coagulation Besides performing cystectomy for ovarian endometriomas, laparoscopic drainage and coagulation can be carried out. Through a small ovarian cystotomy, the suction irrigator can be used to aspirate the chocolate fluid followed by repeated irrigation of the cyst cavity and final aspiration. The cyst cavity is then opened with scissors, the cyst roof is excised, and the specimen sent for histological examination. The internal lining of the remaining cyst wall attached to the normal ovary can either be peeled off with atraumatic forceps and hydrodissection, or the cyst lining can now be electrocoagulated or vaporized with the laser beam. In a prospective randomized trial of 64 women with advanced stage endometriosis, cystectomy produced a significantly longer postopera-

8 65 tive duration of pelvic pain relief (19 months) and a higher 2-year cumulative pregnancy rate (66.7%) than cyst drainage and coagulation (9.5 months and 23.5%). 42 Although it is simpler, laparoscopic ovarian cyst aspiration is an unsatisfactory surgical substitute for ovarian cystectomy or oophorectomy. In a controlled but nonrandomized study, laparoscopic ovarian cyst aspiration had a cyst recurrence rate of 84% compared with 4% with laparoscopic cyst excision.43 Laparoscopic management of ovarian masses can be safely undertaken in the first and second trimesters of pregnancy and is best carried out with the patient in the supine rather than dorso-lithotomy position.&dquo;6 Laparoscopic cystectomy as well as oophorectomy can be performed using the techniques described in the nonpregnant women, except the placement of trochars on the abdomen may have to be appropriately modified to accommodate the enlarged gravid uterus. Because of the pregnant uterus, it is preferable and safer to perform open laparoscopy to avoid injury to the uterus with an initial blind trochar insertion. Wedge Resection and Drilling Laparoscopic ovarian wedge resection may be performed in benign ovarian tumors where it is difficult to get a dissection plane between normal ovarian tissue and the tumor. The tumor is wedged out by incising through the normal ovarian tissue beneath the tumor. The needle electrode or laser can be used for incision. To reduce potential bleeding, diluted vasopressin (see Linear Salpingostomy) can be injected into the incision plane, but often bleeding sites from the incised ovary can be readily electrocoagulated. The incised surface of the remaining ovarian tissue is managed intraoperatively as after ovarian cystectomy. Bilateral wedge resection is occasionally indicated in women with polycystic ovaries not responding to medical therapy. The risk of postoperative periovarian adhesions makes the laparotomy approach a less desirable choice over the laparoscopy. Preventive and adjunctive methods to reduce postoperative adhesions as discussed earlier (see Periadnexal Adhesiolysis) should be incorporated in laparoscopic microsurgical wedge resection of the ovaries. Laser or electrocoagulation drilling of the ovaries has been performed in women with bilateral polycystic ovaries to induce and restore ovulatory cycles. The numerous subcapsular cysts (small to large luteinized follicles) on the ovaries are drilled using the C02 laser beam, which is preferable to the needle electrode because there is no thermal injury of the ovarian surface with the former and, therefore, less risk of periovarian adhesions or even tuboovarian adhesions, which could compromise future fertility. In a large series of ovarian drillings, attractive rates of ovulation have been reported.47 It is unclear how ovarian drilling induces ovulatory cycles, but it may be a form of multiple, microwedge resections of the ovary and thus restores ovulation through similar mechanisms. Laparoscopic Ablation of Ovarian Endometriosis Besides ovarian endometrioma (vide supra), the ovary can be covered with endometrial implants on its surface. The ovary is the most common site of pelvic endometriosis. Even minimal endometriosis can be associated with infertility or pelvic pain. A recent collaborative, randomized, controlled trial of 341 infertile women with minimal or mild endometriosis found laparoscopic resection or ablation of endometriosis enhanced fecundity to 4.7 per 100 person-months versus 2.4 with diagnostic laparoscopy only.48 The endometrial implants on the ovaries and surrounding tissues can be fulgurated by cauterization with unipolar or bipolar electrocautery until the implants are completely coagulated. Electrodes with different tips (ball-shaped, needle, flat tip) are available. Alternatively, laser can be used to fulgurate the lesions. Four types of lasers have been used, including the C02 laser, the KTP (potassium titanyl phosphate), Nd:YAG (neodynium :yttrium-aluminium-garnet), and the Argon. The C02 laser will vaporize the implants and leave little collateral tissue damage of up to no more than 100 Am, whereas the other 3 types of lasers can penetrate through fluid and are able to coagulate, making them more effective for coagulating the internal lining of ovarian endometriotic cyst wall. The C02 laser is preferred when ablating ovarian or peritoneal implants of endometriosis, and it is safer than electrocautery when ablating lesions that are close to vital strictures such as the ureter. With the C02 laser, vaporization of endometrial implants is carried out using superpulsed or continuous beam. The tissue should be sufficiently vaporized, especially in depth, to ensure complete destruction of the implants until normallooking, healthy peritoneal or ovarian tissues are visualized. Vaporization is suitable for lesions of up to about 5 mm, whereas larger or extensive constella-

9 66 tions of closely interspersed lesions are better dealt with by sharp excision. Most published studies suggest that outcome (pregnancy rates) is better with operative laparoscopy for endometriosis, but the studies usually lack scientific rigor. When lower total medical cost of laparoscopy over laparotomy, shorter and quicker recovery, and reduced postoperative pain are also considered, operative laparoscopy for surgical management of ovarian endometriosis is preferable to laparotomy. Laparoscopic Oophoropexy Adnexal torsion usually caused by an ovarian cyst can be treated laparoscopically both in adults and children.49,50 Detorsion with resection of the cyst and preservation of ovarian tissue as described under cystectomy can be laparoscopically performed. If the utero-ovarian ligament is long, triplication of the ligament can be carried out laparoscopically as a form of oophoropexy and for prophylaxis against recurrence of torsion References 1. 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J Am Assoc Gynecol Laparosc 1:16-19, Dubuisson JR, Swolin K: Laparoscopic tubal anastomosis (the one stitch technique): Preliminary results. Hum Reprod 10: , Yoon TK, Sung HR, Cha SH, et al: Fertility outcome after laparoscopic microsurgical tubal anastomosis. Fertil Steril 67:18-22, Pittaway DE, Takacs P, Bauguess P: Laparoscopic adnexectomy: A comparison with laparotomy. Am J Obstet Gynecol 171: , Wood C, Maher P, Hill D: Diagnosis and surgical management of endometriomas. Aust N Z J Obstet Gynaecol 32: , Takeuchi H, Awaji M, Hashimoto M, et al: Reduction of adhesions with fibrin glue after laparoscopic excision of large

10 67 ovarian endometriomas. J Am Assoc Gynecol Laparosc 3: , Bateman BG, Kolp LA, Mills S: Endoscopic versus laparotomy management of endometriomas. Fertil Steril 62: , Catalano GF, Marana R, Caruana P, et al: Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate to severe endometriosis. J Am Assoc. Gynecol Laparosc 3: , Ruhlmann C, Vetrano R, Bernaldo DG, et al: Comparison of laparoscopic versus conventional treatment of ovarian endometrioma. J Am Assoc Gynecol Laparosc 3:S44, 1996 (suppl) 36. 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: , Parker WH, Levine RL, Howard FM, et al: A multicenter study of laparoscopic management of selected cystic adnexal masses in postmenopausal women. J Am Coll Surg 179 : , Shaleu E, Eliyahu S, Peleg D, et al: Laparoscopic management of adnexal cystic masses in postmenopausal women. Obstet Gynecol 83: , Canis M, Mage G, PoulyJL, et al: Laparoscopic diagnosis of adnexal cystic masses: a 12-year experience with long-term follow-up. Obstet Gynecol 83: , Childers JM, Nasseri A, Surwit EA: Laparoscopic management of suspicious adnexal masses. Am J Obstet Gynecol 175: , Dottino PR, Levine DA, Ripley DL, et al: Laparoscopic management of adnexal masses in premenopausal and postmenopausal women. Obstet Gynecol 93: , Beretta P, Franchi M, Ghezzi F, et al: Randomized clinical trial of two laparoscopic treatments of endometriomas: Cystectomy versus drainage and coagulation. Fertil Steril 70: , Marana R, Caruana P, Muzil L, et al: Operative laparoscopy for ovarian cysts: Excision vs. aspiration. J Reprod Med 41: , Yuen PM, Chang AMZ: Laparoscopic management of adnexal mass during pregnancy. Acta Obstet Gynecol Scand 76: , Cristalli B, Cayol A, Izard V, et al: Benefit of operative laparoscopy for ovarian tumors suspected of benignity. J Laparoendosc Surg 2:69-73, Howard FM, Vill M: Laparoscopic adnexal surgery during pregnancy. J Am Assoc Gynecol Laparosc 2:91-93, Rose BI: Ovarian drilling in infertile women with polycystic ovary syndrome. J Am Assoc Gynecol Laparosc 3: , Marcoux S, Maheux R, Berube S: Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian collaborative group on endometriosis. N Engl J Med 337: , Cohen Z, Shinhar D, Kopernik G, et al: The laparoscopic approach to uterine adnexal torsion in childhood. J Pediatr Surg 31: , Germain M, Rarick T, Robins E: Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 88: ,1996