Design:Case histories of 3 women with cystic adenomyoma treated with total laparoscopic resection.
Setting:Department of Obstetrics and Gynecology of Prefectural Hospital.
Patients:Three women (mean age 20.y.; range 16e27 y) with cystic adenomyoma.
Intervention:Laparoscopic surgery under trans vaginal or trans trocar ultrasonographic (US) guidance.
Measurements and Main Results:Three patients of cystic adenomyoma with severe dysmenorrhea were treated total laparoscopic resection. In general, cystic adenomyoma located intra-myometrium and not so large lesion. Laparoscopically, we cannot identify the lesion of cyst from the surface of uterus. Therefore we used trans-vaginal US guidance to previous two cases and trans-trocar US guidance to last case. Transvaginal ultrasonography is usable to almost all gynecologists easily, however there are two drawbacks. First, ultrasound is interfered by intra-peritoneal gas.
We overcame this drawback by using the physiological saline instead of CO2gas. Second, vaginal space is occupied by US probe and we cannot use the intrauterine device like manipulator in severe adhesion case. Last patient had expected severe adhesion because of previous open surgery.
Therefore we selected trans trocar US guidance to last case. The mean time of surgery was 174 min (100e234 min); the mean blood loss was 50 ml (0 e 100 ml). After surgery their dysmenorrhea were totally disappeared and they had no recurrence at least one year.
Conclusion: We report three cases of echo-laparoscopy for cystic adenomyoma. This approach is minimally invasive and succeeded in relieving our patients’ typically severe symptoms. In conclusion echo- laparoscopy is efficient for the laparoscopic surgery for intra-uterine small lesion like cystic adenomyoma.
410
Giant Ovarian Cysts: Is the Primary Laparotomy Still a Gold Standard?
Roman H, Mathieu N, Tarrab S, Chanavaz-Lacheray I, Marpeau L.
Gynecology and Obstetrics, University Hospital Rouen, Rouen, France Study Objective:Despite the development of laparoscopic surgery, the management of giant ovarian cysts is still mainly performed by laparotomy, probably for two reasons. Firstly, it is difficult to manipulate giant cysts in laparoscopy. Secondly, there is always the worry that it may be malignant. Our aim is to show that the large size of ovarian cysts is not an obstacle to laparoscopic management.
Design:Case report.
Setting:University Hospital.
Patients: A 63-year-old woman presented with abdominal pain and increased abdominal volume. Computed tomography performed in emergency showed an ovarian cyst measuring 30x27x18 cm, with no sign suggesting malignant character.
Intervention: Bilateral adnexectomia was carried out laparoscopically, with four trocars placed according to the cyst size.
Histological examination showed a mucoidal cystadenoma. Postoperative outcomes were favourable.
Measurements and Main Results:The large size of a cyst does not forbid the use of laparoscopy, but requires to adapt the surgical procedure.
Openlaparoscopy should be carried out in upper quadrant in order to avoid cyst injuries. The trocars should be placed higher, allowing the drilling the cyst followed by aspiration of the content through an operative 5 mm trocar. Laparoscopy allows not only careful inspection of both the peritoneum and the cyst, but also accurate evaluation of chances to perform complete removal of malignant dissemination. When the cyst appears to be malignant and the complete removal is unlikely, laparoscopical approach avoids a useless laparotomy. The chemotherapy is therefore not delayed. Contrarily, when the cyst is benign, laparoscopical approach allows complete removal.
Conclusion: In women with giant ovarian cyst, the primary surgical approach can always be laparoscopical and respectful of the rules of oncological surgery, whatever cyst size and histology. The large size of the cyst is not an obstacle against the laparoscopical approach, but requires to adapt several stages of the laparoscopical procedure, in order to make it safe and reproducible.
411
Laparoscopy for Big Ovaraian Dermoid Cysts
Sahly NN, Alsibiani SA, Rouzi AA. Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Western, Saudi Arabia
Study Objective: To report a case series of big ovarian dermoid cysts removed by laparoscopy.
Design:Retrospective case series.
Setting:University referral center.
Patients: From January 1997 through January 2007, all operative laparoscopy notes at King Abdulaziz University Hospital, Jeddah, Saudi Arabia were reviewed. The records of women with big ovarian dermoid cyst were reviewd. Ten women with ovarian dermoid cysts 8 cm2 (meanSD) underwent ovarian laparoscopic cystectomy by a single surgeon. The age was 277 years (meanSD).They all had normal tumor markers (CA 125, CEA, alpha fetoprotein, and beta human chorionic gonadotropin). Eight women were multiparous and two women were nulliparous. The presenting symptoms were pelvi-abdominal pain in six women, secondary infertility in two women, and abnormal vaginal bleeding in two women. Eight women had unilateral dermoid cyst and two women had bilateral dermoid cysts.
Intervention:Laparoscopic ovarian cystectomy.
Measurements and Main Results:Laparoscopic ovarian cystectomy was successfully done in all women. There was no conversion to laparatomy S109 Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
in this series. The mean operative time was 9015 minutes. Estimated blood loss was 30050 ml. There was no intraoperative complications.
Histology showed benign cystic teratoma. Long term follow up (73 years) showed no recurrence of the cyst and five women got pregnant after the procedure (two infertility women, two previous nulliparous women and one multiparous woman).
Conclusion:Laparoscopic ovarian cystectomy is effective for big ovarian dermoid cysts.
412
A Rare Case of Ovarian Cystic Lymphangioma Treated with Laparoscopic Bilateral Salpingo-Oophorectomy Using the Culdotomy Technique
Singer T,1Seckin TA,1Feldman N,1Jormark S,2Divon MY.11Obstetrics and Gynecology, Lenox Hill Hospital, New York, New York;2Pathology, Lenox Hill Hospital, New York, New York
Study Objective:CYSTIC LYMPHANGIOMA (CL) is a rare, benign malformation of the lymphatic system. CL may arise in different sites In the chest, abdomen and pelvis. Retroperitoneal CL is extremely rare and its true incidence is unknown. The majority of cases are symptomatic during childhood with Variable Clinical presentation. Typically, this is a slow-growing tumor and it remains asymptomatic for a long period of time. It is most often found incidentally during abdominal or pelvic imaging studies, surgeries or autopsies. Total surgical removal of the lesions with microscopically clear margins is the best approach when it is possible.
Design:Case report.
Setting:Community Hospital.
Patients:A post menopausal 52-year-old woman presented with abdominal pain, hematuria and dysuria. Her physical exam was unremarkable other then a systolic murmur and a left side pelvic mass. Pelvic ultrasound showed a left ovarian mass measuring 6X3X6 cm and an 8X7.3 cm fibroid uterus. Ca 125 was 7.1 and renal ultrasound was normal. Pelvic MRI confirmed the enlarged fibroid uterus and the left ovarian cystic mass measuring 6.1x6.7 cm.
She underwent a laparoscopic bilateral salpingo oopherectomy and sampling of the peritoneal fluid for cytology. In addition to an enlarged left ovary and uterus perihepatic adhesions and a small amount of chylous milky ascites were seen. Both adnexa were removed and were exteriorized intact via a culdotomy. Frozen section was read as benign.
Final Histology and immunohistochemistry established the diagnosis of Cystic Lymphangioma originating from the left ovary.
Intervention: Laparoscopic bilateral salpingo-oopherectomy using the culdotomy technique.
Conclusion:We report a very rare case of cystic lymphangioma arising from the ovary in a post-menopausal woman and present the feasibility and the advantages of laparoscopic surgery in performing intact bilateral salpingo-oopherectomy using a culdotomy bag, allowing accurate diagnosis, optimal treatment and minimal risk for the patient.
413
Treatment of Omental Cyst by Laparoscopic Surgery
Song RK,1Bae JH.21Obstetrics & Gynecology, Catholic University Sungka Hospital, Wonmi-gu, Gyeonggi-Do/Bucheon Si, Republic of Korea;2Obstetrics & Gynecology, Catholic University Kangnam St.Mary’s Hospital, Seocho-gu, Seoul, Republic of Korea
Study Objective:To report a case of treatment of an huge omental cyst by laparoscopic surgery.
Setting:Kangnam St.Mary’s Hospital, Seoul.
Patients:A 27-year-old female had a several months history of abdominal distension and intermittent pelvic discomfort. Her medical and family history were unremarkable. The laboratory findings, including complete blood count, biochemistry, tumor markers were within normal range. The abdominal CT and sonographic images showed a 22)26)20 cm cystic mass, located from the pelvic cavity to both paracolic gutters behind the subhepatic space. No solid component or papillary projection within the mass was identified.
Intervention:Under general anesthesia, three trocars were inserted into intraabdominal space in the umbilicus (10 mm trocar) and right and left paraumbilical regions (5 mm trocars). A large volume of serous fluid was observed with insertion of the first trocar. Following aspiration, the cyst was separated from intraabdominal and intrapelvic organs. The uterus, ovaries, colon, intestine, iliac vesseles, and abdominal aorta were covered with cyst wall. A vascular stalk of the cyst was attached to the infracolic omentum. After excision, the cyst was removed with a nylon bag via the port of the umbilical trocar.
Measurements and Main Results:Omental cysts are rare intraabdominal tumors, generally congenital and asymptomatic that are usually detected in teenagers, with 11e19% of patients pressent with acute abdominal symptoms due to rupture or torsion of the mass. Complete resection with abdominal exploration has been a treatment of choice. More recently, the advantage of laparoscopic surgery has been suggested. In this case, the cyst was removed by laparoscopic surgery successfully and the pathological examination confirmed the diagnosis of the cyst consistent with omental tissue with focal fibrosis. Postoperative recovery was uneventful.
S110 Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
