Use of Laparoscopic Support to Avoid Laparotomy in Vaginal Ovarian Cystectomy Masaaki Tanaka, MD, PhD*, Tetsuya Sagawa, MD, Yasunari Mizumoto, MD, Manabu Hashimoto, MD, PhD, Hideo Yoshimoto, MD, Rena Yamazaki, MD, Tadayuki Kasai, MD, PhD, and Masaki Inoue, MD, PhD From the Department of Obstetrics and Gynecology, Kanazawa University, School of Medicine, Kanazawa, Japan (Drs. Tanaka, Mizumoto, Hashimoto, Yoshimoto, Yamazaki, Kasai, and Inoue) and Sagawa Clinic, Kanazawa, Japan (Dr. Sagawa).

ABSTRACT The objective of our study was to evaluate the use of a procedure for vaginal ovarian cystectomy that is supported by the option to convert to laparoscopy. The ovarian cystectomy was initially approached transvaginally, and then if impossible, completed laparoscopically. We applied this operation system to 38 patients with benign ovarian cysts. Preoperative characteristics of patients, outcomes of colpotomy and vaginal ovarian cystectomy, conversion rate from a vaginal approach to a laparoscopic procedure or a laparotomy, completion rate, operating time, blood loss, complications, and postoperative outcomes were examined. Colpotomy was successfully performed in 37 (97%) of 38 cases and vaginal ovarian cystectomy was accomplished in 35 (92%) cases. Three (8%) cases, including 1 case of failed posterior colpotomy and 2 cases of intrapelvic adhesions, were converted from a vaginal approach to a laparoscopic procedure. In all (100%) cases, cystectomy was successful without laparotomy. Support by laparoscopy preserves the minimal invasiveness of vaginal ovarian cystectomy in cases that would normally require conversion to laparotomy. Thus, this operation system is an alternative procedure to an exclusively vaginal ovarian cystectomy. Journal of Minimally Invasive Gynecology (2008) 15, 350 –354 © 2008 AAGL. All rights reserved. Keywords:

Ovarian cyst; Teratoma; Cystectomy; Transvaginal surgery; Laparoscopy; Laparotomy; Minimally invasive surgery

Vaginal ovarian cystectomy, in which ovarian cysts are removed transvaginally, is a procedure practiced by only a handful of gynecologists [1]. When performed successfully, the procedure compares favorably with laparoscopic surgery in terms of its invasiveness [2]. Furthermore, the lack of abdominal scars makes this approach superior from a cosmetic standpoint. These advantages make this procedure a valuable addition to a surgeon’s repertoire. Despite its merits, however, vaginal ovarian cystectomy has failed to gain wide acceptance among gynecologists. Technical difficulties are the main factors why most gynecologists are reluctant to perform this procedure [3]. VagiThe authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Masaaki Tanaka, MD, PhD, Department of Obstetrics and Gynecology, Kanazawa University, School of Medicine, 13-1, Takaramachi, Kanazawa, Ishikawa 920-8641, Japan. E-mail: [email protected] Submitted August 23, 2007. Accepted for publication January 30, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ -see front matter © 2008 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.01.010

nal ovarian cystectomy consists of colpotomy and ovarian cystectomy via a vaginal route and technical difficulties exist in each step. In regard to posterior colpotomy, the incision of the vaginal wall toward the cul-de-sac may occasionally result in failure or may rarely injure the rectum [4]. In regard to subsequent ovarian cystectomy, adhesions between the ovarian cyst and the uterus may make it impossible to proceed with the resection of the cyst walls vaginally. The risks involved, coupled with the uncertainty of success, dissuaded most gynecologists from adopting this procedure. We recently proposed the technique of posterior colpotomy using transvaginal ultrasound and a balloon dilator to reduce the rate of failed colpotomy or the risk of rectal injury. This new technique enables us to safely perform posterior colpotomy [5]. In this study, we present countermeasures for cases in which ovarian cystectomy via a vaginal route is impossible, forcing conversion to laparotomy. To preserve the minimal invasiveness of the operation, we adopted a new operation system. In this system, the vaginal procedure is converted to

Tanaka et al.

Laparoscopic-supported Vaginal Ovarian Cystectomy

backup laparoscopy if a vaginal approach fails. The purpose of this study was to evaluate the use of this system, named “laparoscopically supported vaginal ovarian cystectomy” (LSVOC).

351 anterior or posterior colpotomy

if successful

transvaginal aspiration of content of cyst

Materials and Methods From April 2003 through January 2007, we applied the LSVOC operation system to 37 patients with ovarian cysts and 1 patient with a paratubal cyst. Cysts excluded from this study included those that were suggestive of malignancy, severely adhesive, or complicated with infertility. The presence of at least 1 of the following sonographic criteria was considered suggestive of malignancy: multilocular appearance, irregular border, papillary intracystic vegetation, or the presence of ascites. In some cases, magnetic resonance imaging was used to distinguish teratomas or endometriomas from other ovarian tumors including malignancies. Teratomas with serum squamous cell carcinoma antigen levels outside of the normal range (⬎1.5 ng/mL) were excluded, because of the possibility that teratomas with squamous cell carcinoma antigen levels beyond the normal range may have malignant transformation [6 – 8]. Endometriomas judged to be severely adherent to the uterus on bimanual examination or preoperative ultrasound were excluded. Age, parity, bilaterality, diameter, cyst location, incision site, outcome of colpotomy, outcome of vaginal ovarian cystectomy, rate of conversion from a vaginal approach to a laparoscopic procedure or a laparotomy, percentage of completed procedures, operating time, blood loss, complications, C-reactive protein (CRP) value on postoperative day 3, and histology were examined. C-reactive protein level increases when infection or inflammation occurs, thus we used CRP value as an indicator of infection, inflammation, and invasiveness after surgery. Normally distributed data were reported as mean ⫾ SD with 95% CI, whereas skewed data were reported as median with range. Student t test was used to test differences among normally distributed groups. Probability values less than 5% were considered statistically significant. The weight of discharge collected by an aspirator and gauzes absorbing blood were measured. The weight of blood loss was estimated by subtracting the weight of intact gauzes from the total weight measured. When discharge collected by an aspirator and gauzes absorbing blood contained a considerable amount of cyst contents, the estimated weight of the cyst contents was also subtracted from the measured weight. Specific gravity of blood was 1.05 and weight was almost equal to volume, so total weight of blood loss was represented as total (volume of) blood loss. Operative Procedure Laparoscopically supported vaginal ovarian cystectomy is performed as follows. The operation begins transvagi-

through vaginal wall defect

with descent of cysts into vagina

if unsuccessful

Laparoscopic Ovarian Cystectomy with no descent

Laparoscopic vaginal ovarian cystectomy is performed

Ovarian Cystectomy

Fig 1. Procedure of laparoscopically supported vaginal ovarian cystectomy operation.

nally with the patient in the dorsal lithotomy position on the operating table. When the cyst is located in the cul-de-sac, a posterior colpotomy is performed. If the cyst is in the vesicouterine fossa, an anterior colpotomy is selected. If the colpotomy is unsuccessful, the operation is carried on laparoscopically. If colpotomy is performed successfully, the ovarian cystectomy is subsequently done through the vaginal wall defect. The contents of the cyst are aspirated with a needle to reduce its volume and permit its exteriorization. When a teratoma has too many solid components or the cyst fluid is too viscous for drainage, the contents of cyst are removed by enlarging the outlet for it. Any cyst contents spilled into the peritoneum are carefully aspirated and wiped away. After descent of the cyst into the vagina, the transvaginal ovarian cystectomy is performed in a manner similar to that of the classic laparotomic procedure. After the repair of the remaining ovarian tissue, the defect in the vaginal wall is closed with sutures. If the vaginal ovarian cystectomy cannot be performed because of adhesions or uncontrolled bleeding, the cystectomy is carried on with gasless laparoscopy. Laparoscopic ovarian cystectomy is performed using a traditional laparoscopic procedure. After removal of the resected surgical specimen via the vagina, the vaginal defect is closed transvaginally (Fig. 1). With regard to the posterior colpotomy, we used either of 2 techniques. The first was the traditional method of incising the vaginal wall with scissors. The second was our recently proposed method of ultrasound-guided colpotomy [5]. Colpotomy was performed in the traditional way for the first 7 cases and with the new procedure in the last 26 cases. With regard to the anterior colpotomy, we adopted the traditional method of incising the anterior vaginal fornix. After injection of physiologic salt solution into the anterior vaginal fornix, distended tissue is cut with scissors. The myometrium of the portio is rubbed by fingers and separated from bladder, and then we can find the serosa on vesicouterine fossa, which is cut with scissors to open intraperitoneal cavity.

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Table 1

The mean CRP value on postoperative day 3 in all cases was 1.78 mg/dL with SD of 1.31 mg/dL. The mean CRP value in 35 cases of successful vaginal ovarian cystectomy was 1.79 mg/dL with SD of 1.33 mg/dL, whereas in 3 cases converted to laparoscopy mean value was 1.67 mg/dL with SD of 1.23 mg/dL. No difference existed between the mean CRP value of 2 groups (p ⫽.88). Histologic examination of the excised ovarian cysts revealed 21 teratomas, 10 endometriomas, 6 serous cystadenomas, 1 mucinous cystadenoma, and 1 paratubal cyst (Table 3).

Preoperative characteristics of patients, n ⫽ 38 Age (yrs) Nullipara Bilaterality Diameter (cm) Location of cyst Vesicouterine Cul-de-sac Incision of vaginal wall Anterior Posterior

34.1 ⫾ 10.1 (30.8–37.2) 15 (39) 2 (5) 6.7 ⫾ 2.2 (6.0–7.4) 5 (13) 33 (87) 5 (13) 33 (87)

Data are presented as mean ⫾ SD (95% CI) or n (%).

Results The mean age of all 38 patients was 34.1 years with SD of 10.1 years. Fifteen women were nullipara and 2 women had bilateral ovarian cysts. The mean maximum diameter of the cysts was 6.7 cm with SD of 2.2 cm. Five patients with cysts located in vesicouterine fossa underwent anterior colpotomy, and 33 patients with cysts in the cul-de-sac had posterior colpotomy (Table 1). Vaginal ovarian cystectomy was successful in all of the patients with anterior colpotomy. Posterior colpotomy was successfully performed in 32 of the 33 cases of cysts in the cul-de-sac. In the single case of failed posterior colpotomy, and the 2 cases of failed vaginal cystectomy because of adhesions, ovarian cystectomy was accomplished laparoscopically. Overall, colpotomy was successfully performed in 37 of all 38 cases, and vaginal ovarian cystectomy was accomplished in 35 cases. Three cases were converted from a vaginal approach to a laparoscopic procedure. Ovarian cystectomy was accomplished in all cases without laparotomy (Fig. 2). The mean operating time in all cases was 103 minutes with SD of 50 minutes. The mean operating time in 35 cases of successful vaginal ovarian cystectomy was 95 minutes with SD of 37 minutes, whereas in 3 cases converted to laparoscopy mean time was 205 minutes with SD of 75 minutes. The operating time in cases converted to laparoscopy was significantly longer than that of successful vaginal ovarian cystectomy cases (p ⬍.01). The data of blood loss showed skewed distribution and thus it was presented as median with range. The blood loss in all cases ranged from 20 to 230 mL with a median value of 70 mL. The blood loss in 35 cases of successful vaginal ovarian cystectomy ranged from 20 to 230 mL with a median value of 65 mL, whereas in 3 cases converted to laparoscopy it ranged from 120 to 220 mL with a median value of 140 mL. It was impossible to examine the difference of blood loss between vaginal and laparoscopic cases, because of the insufficiency of case numbers. One case of rectal injury occurred during the posterior colpotomy, which was performed with a traditional incision. Despite this, the ovarian cystectomy was completed transvaginally (Table 2).

Discussion The greatest benefit of vaginal ovarian cystectomy is that it results in no surgical scarring to the abdominal skin. Considering that most patients are young women, this approach is very attractive from a cosmetic standpoint. Moreover, a study reported that vaginal removal of cysts resulted in equal operation time, reduced spillage, and faster recovery compared with laparoscopy [9]. However, 1 randomized study reported that about 40% of patients undergoing the vaginal procedure had to be converted to laparotomy, in comparison with approximately 2% undergoing a laparoscopic procedure [3]. Conversion to laparotomy is not acceptable to patients who are expecting a minimally invasive surgery with no abdominal surgical scars. A significant difference exists between successful and unsuccessful cases; and this gap is a main reason why the vaginal approach for ovarian cystectomy has failed to gain wide acceptance among gynecologists. An operation system such as ours that guarantees the minimal invasiveness in vaginal ovarian cystectomy should be offered to patients desiring no visible scars. Laparoscopically assisted vaginal ovarian cystectomy has emerged as an alternative to the total laparoscopic ovarian cystectomy [10 –13]. After laparoscopic inspection, enucleation of the ovarian cyst is done transvaginally. Al-

38 cases

Successful colpotomy

Failed colpotomy

37 (97㸚)

1 (3㸚)

Successful

Failed

Laparoscopic

Vaginal Ovarian

Vaginal Ovarian

Ovarian

Cystectomy

Cystectomy

Cystectomy

35 (92㸚)

2 (5㸚)

3 (8㸚)

Data are presented as n (%).

Fig 2. Outcomes of colpotomy and vaginal ovarian cystectomy.

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Laparoscopic-supported Vaginal Ovarian Cystectomy

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Table 2

Intraoperative outcomes

Operating time (min) Blood loss (mL) Rectal injury/other complications

All cases, n ⫽ 38

Successful vaginal cystectomy, n ⫽ 35

Conversion to laparoscopy, n ⫽ 3

103 ⫾ 50 (88–120) 70 (20–230) 1/0

95 ⫾ 37 (83–108) 65 (20–230) 1/0

205 ⫾ 75 (119–291) 140 (120–220) 0/0

Operating time is presented as mean ⫾ SD (95% CI). Blood loss is presented as median (range). Complication is presented as n.

ternatively, the ovarian cyst is enucleated laparoscopically and the free mass removed via the posterior colpotomy. The merits of this procedure compared with the total laparoscopic cystectomy are that it permits removal of larger ovarian cysts, has a shorter operating time, and results in less cyst spillage. Although the precedence of laparoscopy over the vaginal approach enables the vaginal ovarian cystectomy to be performed safely and reliably, the universal use of laparoscopy detracts from the cosmetic advantage of the vaginal approach. Laparoscopically supported vaginal ovarian cystectomy is designed to maximize benefits and minimize drawbacks of vaginal ovarian cystectomy. The cystectomy is initially approached transvaginally and most patients are treated successfully with no surgical scars. The precedence of the vaginal approach maximizes the benefits of a transvaginal woundless procedure. In the few cases in which a vaginal approach is impossible, laparoscopy is used to complete the operation. If no support by laparoscopy existed, the cases that could not be treated vaginally would be converted to laparotomy. It is somewhat traumatic to impose the surgical scar of a laparotomy on a patient desiring a minimally invasive procedure and, thus, surgeons are reluctant to adopt a vaginal approach. The reluctance to convert to laparotomy is a major obstacle to transvaginal ovarian surgery that may be overcome by the laparoscopic support. Laparoscopically supported vaginal ovarian cystectomy is uncommon in that the cystectomy is initially approached transvaginally with laparoscopy supporting sequentially if needed. Both a vaginal approach and laparoscopy complement each other and minimize invasiveness in LSVOC.

In 3 cases of conversion to laparoscopy, the mean operating time significantly increased, compared with that of successful vaginal cystectomy cases (p ⬍.01). The median of blood loss in conversion cases seems to increase, although is not statistically significant. Despite these disadvantages, the mean CRP value on postoperative day 3 in conversion cases was equal to that of successful vaginal cystectomy cases (p ⫽ .88). Of most importance, the procedures were completed without laparotomy. That is, laparoscopy maintained the minimal invasiveness of the operation. The indications for vaginal removal of cysts must be well defined. Not all types of benign ovarian cysts are easily removed vaginally. For example, in cases in which infertility is a complicating factor, a vaginal approach is not recommended. The vaginal approach is unsuitable for examining the pelvic and abdominal cavities. Immobilization of the cyst by adhesions secondary to endometriosis initially necessitates a laparoscopic approach. Finally, a vaginal approach is unsuitable for diagnosing and lysing adhesions. However, cases associated with endometriosis or polysurgery are not always adhesive. In this report, 9 cases with endometriomas, and 1 case with bilateral dermoid cysts (8and 8-cm maximum diameter) and a history of cesarean section were successfully treated transvaginally. Cases for LSVOC should be carefully selected; however, the selection criteria are far less conservative than those of an exclusively transvaginal procedure, because cases expected to be adhesive are not always adhesive and laparoscopy finally supports in adhesive cases.

Table 3

Postoperative outcomes

CRP day 3 (mg/dL) Histology Teratoma Endometrioma Serous adenoma Others

All cases, n ⫽ 38

Successful vaginal cystectomy, n ⫽ 35

Conversion to laparoscopy, n ⫽ 3

1.78 ⫾ 1.31 (1.36–2.19)

1.79 ⫾ 1.33 (1.35–2.23)

1.67 ⫾ 1.23 (0.27–3.07)

21 10 6 2

19 9 5 2

2 1 1 0

(54) (26) (15) (5)

CRP ⫽ C-reactive protein. CRP is presented as mean ⫾ SD (95% CI). Histology is presented as n (%).

(54) (26) (14) (6)

(50) (25) (25) (0)

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As is the case for a laparoscopic approach, the vaginal approach is unsuitable for malignant tumors [14]. Thus, a preoperative evaluation of the ovarian cyst including ultrasound, magnetic resonance imaging, and tumor markers is essential to exclude ovarian malignancy [15–17]. Needless to say, laparoscopic techniques are indispensable for LSVOC. Although most cases are treated transvaginally, in cases with severe adhesions or uncontrolled bleeding, the cystectomy must be resumed laparoscopically. To perform LSVOC, the surgeon must be proficient in laparoscopic surgery. One case of rectal injury occurred in 33 cases of posterior colpotomy. This injury occurred in the first 7 cases using the traditional way of incision with scissors. In the last 26 cases, we adopted the ultrasound-guided posterior colpotomy to perform this step safely and reliably [5].

2. Massi GB, Savino L, Lena A, Susini T. Management of benign adnexal masses by vaginal route. Front Biosci. 1996;1:g8 –11. 3. Wang PH, Lee WL, Juang CM, Tsai WY, Chao HT, Yuan CC. Excision of mature teratoma using culdotomy, with and without laparoscopy: a prospective randomized trial. BJOG. 2001;108:91–94. 4. Hoffman MS, Lynch C, Lockhart J, Knapp R. Injury of the rectum during vaginal surgery. Am J Obstet Gynecol. 1999;181:274 –277. 5. Tanaka M, Sagawa T, Hashimoto M, et al. Ultrasound-guided culdotomy for vaginal ovarian cystectomy using a renal balloon dilator catheter. Ultrasound Obstet Gynecol. 2008;31:342–345. 6. Bal A, Mohan H, Singh SB, Sehgal A. Malignant transformation in mature cystic teratoma of the ovary: report of five cases and review of the literature. Arch Gynecol Obstet. 2007;275:179 –182. 7. Yamanaka Y, Tateiwa Y, Miyamoto H, et al. Preoperative diagnosis of malignant transformation in mature cystic teratoma of the ovary. Eur J Gynaecol Oncol. 2005;26:391–392. 8. Mori Y, Nishii H, Takabe K, et al. Preoperative diagnosis of malignant transformation arising from mature cystic teratoma of the ovary. Gynecol Oncol. 2003;90:338 –341. 9. Ferrari MM, Mezzopane R, Bulfoni A, et al. Surgical treatment of ovarian dermoid cysts: a comparison between laparoscopic and vaginal removal. Eur J Obstet Gynecol Reprod Biol. 2003;109:88 –91. 10. Childers JM, Huang D, Surwit EA. Laparoscopic trocar-assisted colpotomy. Obstet Gynecol. 1993;81:153–155. 11. Pardi G, Carminati R, Ferrari MM, Ferrazzi E, Bulfoni G, Marcozzi S. Laparoscopically assisted vaginal removal of ovarian dermoid cysts. Obstet Gynecol. 1995;85:129 –132. 12. Teng FY, Muzsnai D, Perez R, Mazdisnian F, Ross A, Sayre JW. A comparative study of laparoscopy and colpotomy for the removal of ovarian dermoid cysts. Obstet Gynecol. 1996;87:1009 –1013. 13. Ghezzi F, Raio L, Mueller MD, Gyr T, Buttarelli M, Franchi M. Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc. 2002;16:1691–1696. 14. Mecke H, Savvas V. Laparoscopic surgery of dermoid cysts–intraoperative spillage and complications. Eur J Obstet Gynecol Reprod Biol. 2001;96:80 – 84. 15. Vergote I, De Brabanter J, Fyles A, et al. Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. Lancet. 2001;357:176 –182. 16. Cohen L, Sabbagha R. Echo patterns of benign cystic teratomas by transvaginal ultrasound. Ultrasound Obstet Gynecol. 1993;3:120 – 123. 17. Patel MD, Feldstein VA, Lipson SD, Chen DC, Filly RA. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol. 1998;171:1061–1065.

Conclusion When transvaginal ovarian surgery is impossible, the option to convert to laparoscopy enables completion of the operation without the undesired conversion to laparotomy. The adoption of this operation system will have a dramatic effect on the vaginal approach for the removal of ovarian cysts. Gynecologists will be able to confidently recommend a vaginal approach to patients. Patients will be more likely to accept a vaginal approach if a minimally invasive procedure is more certain. Vaginal ovarian cystectomy combined with support by laparoscopy should be recognized as a new operation system. Both transvaginal surgery and laparoscopy complement each other to achieve a minimally invasive result. Thus, LSVOC is an excellent alternative to an exclusively vaginal ovarian cystectomy. References 1. Lee RA, Welch JS, Spraitz AF Jr. Use of posterior culdotomy in pelvic operation. Am J Obstet Gynecol. 1966;95:777–780.