Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger

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1 Journal of Minimally Invasive Gynecology (2005) 12, Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger Akihiro Takeda, MD, Shuichi Manabe, MD, Satoyo Hosono, MD, and Hiromi Nakamura, MD From the Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan (all authors). KEYWORDS: Adnexal disease; Laparoscopic surgery; Abdominal wall-lift method; Young girl Abstract STUDY OBJECTIVE: To evaluate the treatment by laparoscopic surgery of adnexal disease occurring in young girls. DESIGN: Retrospective analysis (Canadian Task Force classification II-1). SETTING: Department of gynecology at a general hospital. PATIENTS: Twelve consecutive girls aged 15 years or younger. INTERVENTIONS: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Seven patients had dermoid cysts, and three of these were associated with adnexal torsion. Two patients had ruptured lutein cysts with ovarian bleeding, and one of them was pregnant. Torsion of the tube with paraovarian cyst, torsion of normal ovary, and serous cystadenoma were noted in one patient each. Although the underlying diseases varied, the chief symptom in each of these patients was lower abdominal pain. Because the symptom is nonspecific, the clinical features were confusing, especially in emergency cases; in two patients with adnexal torsion with dermoid cysts and one patient with adnexal torsion of a normal ovary, there was substantial delay in diagnosis, and salpingo-oophorectomy was required as a result. CONCLUSION: Even in young girls, laparoscopic surgery can be performed in an acceptable manner using regular instruments designed for adults AAGL. All rights reserved. Corresponding author: Akihiro Takeda, MD, Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Maebata-cho 5-161, Tajimi, Gifu , Japan. reef@syd.odn.ne.jp. Submitted November 7, 2004; accepted for publication January 11, With advances in operative laparoscopic procedures and the development of surgical equipment, the indications for laparoscopic surgery in the field of gynecology have expanded in recent years. This form of minimal-access surgery provides the potential for improved cosmetic visualization, shorter hospital stay, reduced postoperative pain, and earlier postoperative return to daily activities. Therefore, the application of laparoscopic procedures for the treatment of gynecologic disorders in young girls during maturation would be highly desirable. 1-3 During laparoscopic treatment of gynecologic disease in young girls, consideration should be given to the different anatomic and physiologic conditions of pelvic organs from those of adults, and preservation of future fertility also should be considered in these patients. 1 Torsion of the adnexa, which occurs in young girls with a relatively high incidence compared with that in adults, 4-6 is an emergency 7 requiring early surgical intervention for preservation of reproductive function. However, if the condition occurs in a child, diagnosis and surgical intervention tend to be delayed because of the nonspecific symptoms. 8 Therefore, knowledge about gy /$ -see front matter 2005 AAGL. All rights reserved. doi: /j.jmig

2 Takeda et al Laparoscopic surgery in young girls 235 necologic disease in young girls is required for prompt and correct diagnosis and early surgical intervention. 9 If possible, surgical treatment for these patients should be performed by a specialist in reproductive medicine (i.e., gynecologist rather than pediatric surgeon). In this study, the results of 12 cases of adnexal disease occurring in young girls between 10- and 15-years old treated in our department by laparoscopic surgery are described, and the problems encountered during treatment of these patients are discussed. Materials and methods From July 1994 through October 2004, 671 cases of adnexal disease (mainly benign ovarian tumors) were treated by operative laparoscopy in our department. Of these, 12 patients were 15-years old or younger. Patient background, the clinical course before surgery, pathologic condition, and surgical procedures were examined. Surgical procedure Before surgery, informed consent was obtained from the patient and parents. If the patient was thought to be unable to understand the condition due to either age or symptoms such as severe pain, an explanation was given only to her parents. Under general endotracheal anesthesia, gasless laparoscopic surgery was performed by the abdominal wall-lift method as previously described. 10 Briefly, the abdominal wall was lifted using a subcutaneous lift system (Mizuho Co., Tokyo, Japan), and a 5-mm Optiview port (Ethicon Japan, Tokyo, Japan) was placed at the superior edge of the umbilicus to introduce the 5-mm laparoscope (Olympus, Tokyo, Japan). Two other Optiview ports were placed laterally under direct vision: a 5-mm port on the left side and 12-mm port on the right side at the level of the umbilicus. In cases of laparoscopic-assisted extracorporeal cystectomy or salpingo-oophorectomy, a 15- to 20-mm suprapubic port was made by either Lap-Protector Mini (Hakko Medical, Tokyo, Japan) or Alexis Wound Retractor (Applied Medical, Rancho Santa Margarita, CA). In cases of adnexectomy, ligaments and vessels were cut by Endo GIA (Tyco Healthcare Japan, Tokyo, Japan) before January 2001 or Ligasure Atlas (Tyco Healthcare Japan, Tokyo, Japan) starting in January The excised tissue was put into an Endopouch Retriever (Ethicon Japan, Tokyo, Japan) and removed from the body. The surgical wound was closed by Dermabond (Ethicon Japan, Tokyo, Japan) after subcutaneous suturing. During postoperative wound closure for a port of 10 mm or more, a fascial suture was placed carefully to prevent hernia development at the port site. Results The clinical background of the 12 patients is shown in Table 1. Four patients with dermoid cysts were treated by scheduled surgery, while emergency surgery was performed in seven patients. In the remaining patient with serous cystadenoma, the gynecologist who initially examined the patient suspected torsion of ovarian cyst and referred the patient to our department 1 day after. On our examination, torsion was considered less probable based on the physical findings. However, since the pain continued and the parents strongly desired surgical treatment, we conducted a semi-emergency procedure that day, and torsion was ruled out by surgical findings. If a mass lesion existed in the adnexa, diagnosis by image-diagnostic procedures such as computed tomography (CT) and ultrasonography was relatively easy. However, in the case of torsion of a normal ovary, the diagnosis itself was extremely difficult even for our gynecology staff, and diagnostic delay occurred. This premenarchal girl was brought to our emergency room with symptoms of severe left lower abdominal pain at 7:00 P.M., 8 hours after symptom onset, and was admitted to the pediatric ward of our hospital under a diagnosis of constipation. Because there was no improvement of the condition by enema, the first consultation with our department was made at 9:00 P.M. Although CT (Figure 1) and transrectal ultrasonography showed a slightly enlarged left ovary and the possibility of torsion of the adnexa was highly suspected, correct diagnosis was not made at that time, and we decided to observe the progress of the condition after pain relief by analgesic injection. Next morning, the pain became severe again, and trans-rectal ultrasonography showed that the left ovary had further enlarged, and pooling of ascites in the Douglas cavity became evident (Figure 2). At that time, we decided to perform emergency laparoscopic surgery under the suspicion of torsion of normal ovary after 1 day of symptom development. Surgical duration ranged from 37 to 93 minutes. In two patients with dermoid cysts with torsion and one patient with torsion of a normal ovary, laparoscopic surgery was performed 1 to 3 days after symptom development. Because necrotic change was severe and adnexal preservation was considered difficult after a period of observation following detorsion, unilateral salpingo-oophorectomy was performed. Surgical findings of torsion of a normal ovary are shown in Figure 3. Pathologic examination of excised tissues showed severe necrosis of the ovarian tissue and viable follicle tissue could not be detected. Figure 4 shows the histologic findings of excised ovarian tissue in the patient with torsion of a normal ovary. In one patient with a dermoid cyst with torsion, who underwent surgery 8 hours after, resumption of blood flow was seen when torsion was corrected, and cystectomy was performed. In four patients with dermoid cysts treated by scheduled surgery, one patient with serous cystadenoma, and one patient with ruptured corpus luteum cyst, cystectomy by the extracorporeal method was possible. In one patient with tubal torsion associated with paraovarian cyst, laparoscopic surgery was performed 14 hours after, and

3 236 Journal of Minimally Invasive Gynecology, Vol 12, No 3, May/June 2005 Table 1 Clinical background of 12 young girls with adnexal disease treated by laparoscopic surgery Age (yrs) Final diagnosis Menarche Height (cm)/ weight (kg) Chief symptoms Initial examination 11 Dermoid cyst (torsion) Pre 150/39 Lower abdominal pain Emergency room at public hospital (pediatrician) 11 Dermoid cyst (torsion) Pre 147/36 Lower abdominal pain Private hospital (physician) 11 Dermoid cyst (Torsion) Pre 147/37 Abdominal pain, vomiting Emergency room at our hospital (general surgeon) 15 Paraovarian cyst with Post 156/51 Abdominal pain Private hospital (physician) tubal torsion 12 Dermoid cyst (huge) Pre 153/44 Abdominal distension Private clinic (physician) and pain 14 Rupture of corpus Post 160/57 Right lower Private clinic (physician) luteum cyst abdominal pain 14 Dermoid cyst Post 155/55 Abdominal pain Private clinic (gynecologist) 13 Dermoid cyst Pre 159/48 Lower abdominal pain Outpatient clinic at our hospital (pediatrician) 13 Dermoid cyst Post 149/53 Lower abdominal pain Private clinic (gynecologist) 10 Torsion of normal Pre 138/33 Lower abdominal pain Private clinic (pediatrician) ovary 15 Rupture of corpus Post 148/48 Lower abdominal pain Private clinic (gynecologist) luteum cyst of pregnancy and amenorrhea 15 Serous cyst Post 165/42 Lower abdominal pain Private clinic (gynecologist) CT computed tomography; US ultrasonography. salpingectomy was necessary due to severe necrosis of the tube even after detorsion. In the patient with ruptured corpus luteum cyst with massive hemoperitoneum due to ovarian bleeding during pregnancy, suturing the ruptured site achieved hemostasis, and artificial abortion was subsequently performed at the patient s request. In this patient, autologous blood transfusion was performed after intraoperative recovery of 1050 g of blood in the abdominal cavity using Cell Saver5 (Haemonetics Japan, Tokyo, Japan), an intraoperative autologous-blood-salvage device. Thus, homologous blood transfusion could be avoided. None of the patients encountered complications during the intraoperative or postoperative periods, and postoperative hospital stay was 3 to 5 days depending on the recovery. Discussion The incidence of adnexal disease is lower in girls than in women. 5 However, the incidence of torsion is higher in young girls. 6 This is because the oviduct is relatively long due to the small uterus, and the position of the ovary is high with underdeveloped supporting connective tissue surrounding the ovary. 5,6 Ovarian torsion results from partial or complete twisting of the ovarian pedicle on its axis. The subsequent vascular compromise causes congestion of the ovarian parenchyma and leads to hemorrhagic infarction. 11 Once adnexal torsion develops, immediate diagnosis and emergency surgery are necessary to preserve ovarian function. 7 However, the most frequent symptom of adnexal disease is usually an acute abdomen in which the main complaint is only nonspecific lower abdominal pain. 7 If there is right lower abdominal pain, the differential diagnosis from acute appendicitis is extremely difficult. The symptoms that will allow accurate diagnosis become even more complicated if there is left lower abdominal pain. 8 Furthermore, if the patient is a young girl, the probability of consultation with a gynecologist from the beginning is low, and a significant delay in diagnosis and surgical treatment occurs more frequently than with adult patients. Actually, in six of the present seven patients in whom urgent surgery was necessary, the patients were not brought to gynecologists for initial examination, and substantial surgical delay occurred. As a result, in most of such cases, adnexal necrosis progressed, and preservation of the adnexal tissue became difficult. To avoid such tragedy, accurate and immediate preoperative diagnosis is extremely important, especially in the case of a young girl. However, if the patient is not brought to a gynecologist, delay is inevitable. Therefore, it is essential to strengthen cooperation with

4 Takeda et al Laparoscopic surgery in young girls 237 Initial diagnosis Diagnostic means Scheduled/ emergency operation Interval from diagnosis to surgery (min) Surgical duration (min) Surgical procedure Special notes Acute gastroenteritis CT Emergency Salpingo-oophorectomy 3 days passed after Acute enterocolitis CT Emergency Salpingo-oophorectomy 3 days passed after Ovarian tumor CT Emergency Cystectomy 8 hours passed after Acute appendicitis CT Emergency Salpingectomy 14 hours passed after Urinary retention US, CT Scheduled - 76 Cystectomy - Acute appendicitis US, CT Emergency Cystectomy 18 hours passed after Ovarian tumor CT Scheduled - 75 Cystectomy - Ovarian tumor CT Scheduled - 52 Cystectomy - Ovarian tumor CT Scheduled - 38 Cystectomy - Constipation US, CT Emergency Salpingo-oophorectomy 1 day passed after Gravid 6 weeks and hemoperitoneum Ovarian tumor (torsion suspected) US Emergency Hemostasis by suturing Autologous blood transfusion by cell saver US, CT Semi-emergency Cystectomy Torsion was less probable by our diagnosis doctors of other specialties such as physicians and pediatricians, by communicating information to promote understanding of the possibility of gynecologic disorders even in young girls. Figure 1 Computed tomography image of pelvic cavity at first gynecologic examination (estimated to be 12 hours after symptom onset) in a case of torsion of a normal ovary. The mass lesion (arrow), which is assumed to be the enlarged left ovary, is shown in the left adnexal region. Even when consultation with a gynecologist is carried out, bimanual vaginal examination and transvaginal ultrasonography, which are very useful diagnostic procedures in cases of adult emergency gynecologic disorders, are inapplicable to most young girls. Therefore, noninvasive diagnostic imaging procedures, especially CT, were useful in the present study, along with complementary transabdominal ultrasonography, as previously reported by others Although diagnosis was not difficult when a mass lesion existed, there were difficulties in diagnosing torsion of a normal ovary, and substantial delay occurred even in our department. In this patient, transrectal ultrasonography was useful in observing the progression of findings and in making a final decision. However, this procedure is not always applicable due to the patient s mental resistance. Further, for exclusion of a malignant tumor of germ cell origin 14 findings obtained by CT and ultrasonography are also important to determine indications for laparoscopic treatment, especially in emergency procedures. Adnexa showing necrotic change by torsion under laparoscopic observation are considered to have lapsed into irreversible change and should be resected. 8 This is also recommended due to the possibility that thrombus formed during torsion will be released after torsion is corrected, causing pulmonary embolus. 15 However, from recent

5 238 Journal of Minimally Invasive Gynecology, Vol 12, No 3, May/June 2005 Figure 2 Trans-rectal ultrasonographic image of bilateral ovaries just before surgery (estimated to be 26 hours after ) in a patient with torsion of a normal ovary. (A) Right ovary (arrow). (B) Enlarged left ovary (arrow). Figure 3 Findings of torsion of a normal ovary during laparoscopic surgery. (A) Left adnexal tissue was twisted 720 degrees. (B) Left adnexal tissue after detorsion. (C) Left adnexectomy by Ligasure atlas. (D) Excised tissue was placed in an Endopouch retriever.

6 Takeda et al Laparoscopic surgery in young girls 239 Figure 4 Histopathologic findings of excised twisted ovary showing massive necrosis of the tissue (hematoxylin-eosin stain, 100 magnification). reports including adult patients, thrombosis occurring after detorsion is less probable than previously thought. 4,16,17 Therefore, when considering that functional preservation of adnexal tissue is one of the important purposes of surgery for adnexal disease in young girls, detorsion of twisted adnexa should be positively carried out first, and the grade of blood-flow resumption should be carefully assessed by change in color tone. 4 It then should be determined whether to proceed with adnexectomy or cystectomy. However, at present, a consensus has not been reached regarding whether there is a time limit after the onset of symptoms or what the intraoperative findings for adnexectomy should be. 4,12 In our patients with adnexal torsion, adnexal preservation was possible only in one patient with a dermoid cyst who underwent surgery 8 hours after symptom onset. However, in other patients who were treated 1 to 3 days after symptoms developed, the preservation of adnexal tissue was difficult, and pathologic examination of the resected ovary revealed the absence of viable ovarian tissue in these patients. Furthermore, although carefully inspecting the recovery of tissue color after detorsion should be done before performing adnexectomy, the twisted tissue becomes fragile, and the surgical procedure for cystectomy may become very difficult if tissue necrosis has progressed. In the present report, a 10-year-old girl was the youngest patient in our series. In the case of comparatively mature children treated by gynecologists as in this report, laparoscopic surgery using surgical instruments for adults was possible. However, expansion of the abdominal wall tends to be poor compared with that in an adult. Particularly in patients with a prolonged interval after onset of torsion symptoms, paralytic expansion of the bowel occurred, and the laparoscopic view can be impaired. During laparoscopic surgery in young girls, especially in premenarchal girls, it is important to have knowledge about the anatomic characteristics of juvenile pelvic organs, because they give a different impression than the view of adult organs due to the undeveloped small uterus. The abdominal wall around the umbilicus is thin in a young girl compared with that in an adult, and the aorta exists directly under it. Therefore, surgeons need to pay careful attention so that no damage to a major blood vessel is caused during the first trocar insertion. 1 Because the upper edge of a child s bladder stays in a high position, 1 the bladder should be drained fully with an appropriate-sized pediatric Foley catheter, and attention should be paid to avoid bladder injury when establishing the suprapubic port. In our patients, because a uterine manipulator could not be used, it was slightly problematic during surgical procedures. When solid components such as teeth and hairball in the dermoid cyst were large, the suprapubic skin incision needed to be extended to approximately 3 cm to remove the excised tissue from the body, as the Douglas cavity could not be used as the route for tumor tissue removal. Incisional hernia is reported to occur more easily in younger patients because the fascial tissue is not developed compared with that in adults. 18 Therefore, when there is postoperative wound closure for a port of 10 mm or more, a fascial suture should be placed carefully to prevent hernia development at the port site. Conclusion During laparoscopic management of adnexal disease in young girls, gynecologists may occasionally compete with a pediatric surgeon. However, as a specialist in female reproductive medicine, a gynecologic laparoscopist should be involved with treatment of these disorders in young girls as much as possible. Further studies should be performed by accumulating cases to determine how a small child should be managed laparoscopically by a gynecologist. References 1. Sharp HT. Laparoscopy in children. Clin Obstet Gynecol. 1997;40: Davidoff AM, Hebra A, Kerr J, et al. Laparoscopic oophorectomy in children. 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