BJOG: an International Journal of Obstetrics and Gynaecology December 2002, Vol. 109, pp. 1401 1405 Adnexectomy for benign pathology at vaginal hysterectomy without laparoscopic assistance Shirish S. Sheth Of 166 consecutive women with a benign adnexal mass scheduled for vaginal hysterectomy with adnexectomy, the operation was successful in 158 (95%). Preoperatively, attempts were made to ascertain that adnexal mass was benign and either freely mobile or with only slightly restricted mobility. Laparotomy was required in eight women, in five for adhesions and in three for malignancy detected during the operation. No woman required laparoscopic-assisted surgery. The 158 women who had successful vaginal hysterectomy with adnexectomy were compared with 100 similar women who had a laparotomy performed by same single operator. The vaginal group had a lower morbidity, speedier recovery and shorter hospital stay. Introduction In the last decade, laparoscopic-assisted vaginal hysterectomy has become increasingly popular, and is responsible for promoting vaginal surgery. In this paper, I report my own experience of vaginal hysterectomy with adnexectomy in women with an adnexal mass, and compare the results of this vaginal surgery with similar women with adnexal masses treated by laparotomy. Methods From July 1974 to June 1999, 166 consecutive women with benign adnexal masses were considered for adnexectomy with vaginal hysterectomy. The characteristics of the women are shown in Table 1. In 144 women (87%), vaginal hysterectomy was performed for excessive menstruation, the adnexal mass being incidental; in 22 women (13%), adnexectomy and vaginal hysterectomy were performed to treat an ovarian cyst. All women were subjected to careful clinical examination, investigations for operative fitness, ultrasound study and thorough examination under anaesthesia in the operating theatre just before the start of operation. Special attention was given to confirm that the pouch of Douglas was empty. The mobility of the ovary and the possibility of its dislocation into the pouch of Douglas were evaluated digitally through the vagina. It was essential that the uterus was freely mobile or only has slightly restricted mobility. The women were advised that laparoscopic surgery or laparotomy would be carried out if operative difficulties were encountered or malignancy was suspected (Appendix A). All the women consented to possible laparotomy, oophorectomy and hysterectomy. Some women preferred to keep at least one ovary. Vaginal hysterectomy and adnexectomy was not considered if the malignancy was suspected, if mass was solid or had solid component and if the uterine size was greater than 12 to 14 weeks of gestation. Of 166 women, 130 underwent ultrasound investigations (78%), 82 of whom underwent transvaginal sonography 1 3 (49%), 44 colour Doppler (27%) and 22 underwent magnetic resonance imaging or computed tomography (13%). CA125 was performed in 104 women (63%), with increase in 36 (35% of 104) and with more than 100 iu in four. Large size was not considered a contraindication to vaginal adnexectomy if a cyst was unilocular or teratomatous. Four of the 10 benign teratomas were 7 to 17 cm in diameter (Appendix B). If the operative field appeared roomy and the adnexa easily accessible for exteriorisation into the operative field with or without aspiration, then all connections were severed from the uterus leaving the uterus hinged on the upper pedicle only containing the adnexal pathology in 84. Keeping the cyst intact, the round ligament was divided 3 5 cm Table 1. Adnexal pathology. Adnexal pathology Patients Failure/laparotomy Breach Candy Hospital and Research Centre, Mumbai, India Sir Hurkisondas Nurrotamdas Hospital, Mumbai, India Correspondence: Dr S. S. Sheth, 2/2, Navjivan Society, Lamington Road, Mumbai 400 008, India. D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology PII: S 1 47 0-0 3 2 8(0 2)0 0 9 00-X Ovarian cyst 84 3* Hydrosalpinx 26 Tubo-ovarian mass/adhesions 56 5 Total 166 8 * These were not a failure, but frozen histopathology study revealed malignancy and laparotomy followed. www.bjog-elsevier.com
1402 Fig. 1. Uterus after severance of left lateral tissues. Infundibulo-pelvic ligament clamped to complete salpingo-oophorectomy of right pathological adnexa. [Adnexal pathology. In: Sheth SS, Studd JWW, editors. Vaginal Hysterectomy (Chap. 15, Fig. 15.1). UK: Martin Dunitz, 2002, p. 170.] Fig. 2. Ovary delivered and clamp applied on meso-ovarium, close to utero ovarian ligament. To be followed by excision of left upper cornua to complete hysterectomy. distance from the uterus to obtain better access 4. The entire infundibulo-pelvic ligament was carefully clamped, the ureter being 3 cm 3 or more away from the clamp (Fig. 1). Twenty-eight out of 84 cysts required aspiration, and for this, the uterus was turned laterally and the pathological cyst was gently pulled intact, bit by bit into the operative field with Babcock or Allis forceps (Table 2). Disposable plastic drapes were spread over the rectum, colon and sides of the pelvis. The head end was raised (Reversed Trendlenberg position) to assist gravitational flow of spillage via the speculum into a container. The cyst was aspirated by a needle attached to a tubing and a suction apparatus, followed by a similar procedure as above when the cyst was intact, to complete salpingo-oophorectomy. Exteriorised ovarian cyst can be exised easily after clamping meso-ovarium, followed by remaining surgery (Fig. 2). If required, prophylactic oophorectomy or salpingo-oophorectomy (Fig. 3) on the severed contralateral normal side was performed (84 women, 51%). In 42 cases, it was easier to complete the hysterectomy along with the normal adnexa, followed by oophorectomy or salpingo-oophorectomy of the pathological adnexa which had been severed earlier from the uterine cornual. In 40 women, vaginal hysterectomy was first performed, followed by adnexectomy on the pathological side, and then, if necessary, prophylactic salpingo-oophorectomy on the normal side. In general, access to the ovarian cyst was much better when it was attached to the uterus due to the traction Table 2. Ovarian cyst. Dermoid 10 Pseudomucinous 4 Simple serous cystadenoma 20 Simple serous 6 Follicular 4 Endometrial 40 Total 84* * Three turned out to be malignancies on frozen study. Fig. 3. Shows round ligament cut separately, away from the uterus and clamp applied on infundibulo-pelvic ligament to perform prophylactic salpingo-oophorectomy.
1403 applied on the uterus. A stay suture on the ovary or the utero-ovarian ligament may assist exposure. Use of a large roller gauze to hold back the intestine, a specially designed ovarian clamp, and the presence of an experienced assistant helped considerably 5. In 30 women with a hydrosalpinx or tubo-ovarian adhesions, healthy ovaries were preserved according to the wishes of the women. Digital adhesiolysis was used in freeing the ovary. When the ovaries were to be preserved, after freeing the uterine tube to its fimbrial end, the mesosalpinx was clamped along its length starting from the cornual end, and the tube was excised. Palpation of the ovary followed by careful digital adhesiolysis and freeing the ovary and the uterine tube from the surrounding tissues proved effective in 28 women. The severity of the adhesions varied from flimsy to dense, sometimes requiring sharp dissection (40 cysts, 34 with tubo-ovarian adhesion). Results Vaginal adnexectomy with vaginal hysterectomy was successful in 158 of 166 women (95%). Of the 166 women, 84 had an ovarian cyst (51%), 26 had a hydrosalpinx (16%) and 56 had a tubo-ovarian mass with adhesions (34%). In eight women, laparotomy had to be performed. The time taken to perform the additional surgery for adnexectomy varied from 7 to 35 minutes, with average of 14 minutes. In eight women, diagnostic laparoscopy was performed soon after examination under anaesthesia and before the start of the hysterectomy to evaluate the pelvic findings for the feasibility of vaginal adnexectomy. Laparotomy was not performed if the adnexa appeared benign and was free of adhesions. Laparotomy was performed in eight women, none of whom had a diagnostic laparoscopy. In five women, laparotomy by a Pfannenstiel incision for tuboovarian adhesions was performed for the removal of endometriotic cysts of the ovary or inflammatory tubo-ovarian masses. Three women underwent vaginal hysterectomy with bilateral salpingo-oophorectomy for apparently benign mobile ovarian cysts, which proved to have adenocarcinoma on frozen section. The women then had a laparotomy through a right paramedian incision for inspection of the abdomen and pelvis, palpation of the para-aortic lymph nodes and liver and omentectomy. One woman had tuberculosis and one had lymphoma of the ovary revealed by the frozen section. Both were put on appropriate chemotherapy without laparotomy. The woman with ovarian lymphoma had undergone abdominal surgery with omentectomy about one year previously. At follow up both these women had no signs of residual disease. Opening the pouch of Douglas required extra care with adhesiolysis to gain access to the peritoneal cavity in 56 women, because of tubo-ovarian adhesions due to pelvic inflammatory disease in 22 women and endometriosis in 34. Table 3. Comparative hospital stay. While attempting to open the pouch of Douglas, the scissors or pushing fingers should be flush with the posterior surface of the cervix and the lower uterine body until the peritoneum is reached. This precaution may prevent trauma to the bowel. In this case series no woman sustained injury to the intestine, but in one woman the bladder was opened, requiring closure in three layers. Ooze or bleeding from the vaginal edge was more than usual in 63 of the 166 women. One unit of blood was required in four women with a pre-operative haemoglobin concentration less than 11 g. The present series of adnexectomy unilateral or bilateral salpingectomy or oophorectomy or both at vaginal hysterectomy in 166 women is compared with 100 women who had abdominal hysterectomy with bilateral salpingooophorectomy. No one from either group needed rehospitalisation. Shorter stay by two to four days, averaging 2.6 days (Table 3), the patients were more cheerful and the operation proved to be more economical in the vaginal group than in those operated abdominally. Discussion stay 1 3 stay 4 5 stay > 5 Vaginal group 86 58* 22* Abdominal group 108 42 * Either prior to 1992 and/or associated anterior colporrhaphy, or repair for stress urinary incontinence (SUI). Quite often, a cyst excised laparoscopically is often removed through a posterior colpotomy 6,7 ; this being the case, the same can be achieved at vaginal hysterectomy, with more space for the operative procedure. There are also occasions when adnexal pathology comes as a surprise during the course of a planned vaginal hysterectomy and is recognised while attempting to open the pouch of Douglas or towards the completion of the operation. Adhesions to adjoining structures can usually be separated with patience. The size of an ovarian cyst is not by itself a limiting factor, as the cyst can usually be aspirated and then excised. If the adnexal mass is mobile and benign, the operator may be surprised that vaginal adnexectomy is usually possible. The procedure needs a thorough clinical and ultrasonic evaluation to exclude malignancy as far as possible. In postmenopausal women, prophylactic salpingo-oophorectomy on the opposite side should be performed 8. The requirements for vaginal adnexectomy for an adnexal mass are: 1. Experience of performing bilateral salpingo-oophorectomy at vaginal hysterectomy, where the ovaries are
1404 normal 9,10 ; and ovarian cystectomy with uterus in position 11,12 ; 2. Examination under anaesthesia suggests (a) free or minimally restricted mobility of the uterus; and (b) adnexal mass is freely mobile 13 ; 3. Clinical examination, ultrasound, CT or MRI scans and tumour markers confirm the benign nature of the mass 14 17 ; 4. Pre-operative counselling and informed consent to frozen section, and a change to laparoscopic-assisted surgery or laparotomy; 5. If required, laparoscopic evaluation of the pelvic findings. Teng et al. 18 cautions that before any vaginal approach via posterior culdotomy, laparoscopy is necessary. Contraindications to vaginal adnexectomy are: an adherent mass; a suspicion of malignancy; frozen section not being available; and the operator s lack of experience salpingo-oophorectomy at vaginal hysterectomy. Acknowledgements The author would like to thank the Medical Directors of Sir Hurkisondas Nurrotamdas and Breach Candy Hospitals for the necessary assistance and permission to publish the data. References 1. Mage G, Canis M, Manhes H, et al. Laparoscopic management of adnexal cystic masses. J Gynecol Surg 1990;6:71 79. 2. 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 1992;167:790 796. 3. Maiman N, Seltzer V, Boyce J. Laparoscopic excision of ovarian neoplasms, subsequently found to be malignant. J Obstet Gynecol 1991;777:563. 4. Sheth SS, Sonkawde R. Surgical importance of round ligament. J Gynecol Surg 1999;15:163 167. 5. Sheth SS, Malpani A. Technique of vaginal oophorectomy during vaginal hysterectomy. J Gynecol Surg 1994;10:197 202. 6. Reich H, McGlynn F, Sekel L, et al. Laparoscopic management of ovarian dermoid cystic. J Reprod Med 1992;37:640 644. 7. Pardi G, Carminati R, Ferrori MM, et al. Laparoscopically assisted vaginal removal of ovarian dermoid cysts. J Obstet Gynecol 1995;85:129 132. 8. Magrina JF. The place of prophylactic oophorectomy at hysterectomy. In: Sheth SS, Studd JWW, editors. Vaginal Hysterectomy. London: Martin Dunitz, 2002:143 152. 9. Sheth SS. Vaginal oophorectomy for breast cancer. J Obstet Gynecol 1989;9:236 238. 10. Dalvi S, Agarwal S, Thakur Y, Sheth SS. Place of vaginal oophorectomy for high risk menorrhagia. A case report. Indian J Obstet Gynecol 1993;43:301 302. 11. Yuen PM, Yu KM, Yip SK, Lau WC, Rogers MS, Cheng A. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol 1997;177:109 114. 12. Sheth SS. Management of ovarian dermoids without laparoscopy or laparotomy. Eur J Obstet Gynecol Reprod Biol 2001;99:106 108. 13. Sheth SS. Adnexal pathology. In: Sheth SS, Studd JWW, editors. Vaginal Hysterectomy. London: Martin Dunitz, 2002:165 178. 14. Shalev E, Eliyahu S, Peleg D, et al. Laparoscopic management of adnexal cystic masses in post-menopausal women. J Obstet Gynecol 1994;83:594 596. 15. Shalev E, Bustan M, Romano S, et al. Laparoscopic resection of ovarian benign cystic teratomas: experience with 84 cases. Hum Reprod 1998;13:1810 1812. 16. Goldhirsch A, Triller JK, Geiner R, et al. Computed tomography prior to second look operation in advanced ovarian cancer. JObstet Gynecol 1983;62:630 633. 17. Weinreb JC, Barkoff ND, Megibow A, et al. The value of MR imaging indistinguishing leiomyomas from other solid pelvic masses when sonography is indeterminate. Am J Roentgenol 1990;154:295. 18. Teng FY, Muzsnai D, Perez R, et al. A comparative study of laparoscopy and colpotomy for the removal of ovarian dermoid cysts. J Obstet Gynecol 1996;87:1009 1013. Accepted 12 February 2002
1405 Appendix A. Appendix B. Vaginal adnexectomy at vaginal hysterectomy.