THE ROLE OF LAPAROSCOPY IN OVARIAN MASSES
M. Roy, M. Plante and M.C. Renaud
CHUQ-Hôtel-Dieu, Université Laval
Québec, CANADA
Correspondance:
Dr Michel Roy
CHUQ-HDQ, 11 Côte du Palais,
Québec, Québec
GIR 2J6, Canada
Michel.Roy@ogy.ulaval.ca
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THE ROLE OF LAPAROSCOPY IN OVARIAN MASSES
Introduction :
Laparoscopy is widely used in general or gynecologic surgery. It has become the standard
approach for the treatment of women with benign ovarian tumors (1). The rate of complication is
low and the success rate of a planned excision for benign ovarian cysts is high (2). Worldwide, in
recent years, laparoscopy has also emerged as a useful tool in gynecologic oncologic surgery,
especially for staging procedures in cervical and ovarian cancers (3). Despite the use of serum
tumor markers, imaging techniques, including transvaginal sonography and color Doppler, it
sometimes remains difficult to distinguish clinically between benign and malignant ovarian
tumors. So laparoscopic surgeons often will face an unexpected malignant tumor and has to be
ready to face that situation.
Assessment for evidence of malignancy
When the laparoscopic surgeon finds an obvious cancer of the ovary or peritoneal metastasis and
ascites, laparotomy is usually indicated, since complete removal of affected areas is mandatory for a
better prognosis for the patient. The problem arises when the signs of malignancy are more subtle.
They have to be searched each time a pelvic mass is approached. The signs of malignancy of a
pelvic mass at laparoscopy include external vegetations on the surface of the cysts or intracystic
vegetations with or without ascites. But as demonstrated by Canis (2), those changes can occur as
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frequently in benign as in malignant lesions. Therefore, removal of cystic masses or adnexae must
be performed with constant care not to contaminate the peritoneal surface with cancer cells coming
from tissue or fluid from the cyst. The use of endobags to retrieve the specimen is also mandatory
when the mass is suspicious enough to request a frozen section. A frozen section of the specimen
must also be done for all tumors measuring more than 5 cms, and any size if they are completely or
partially solid.
If the tumor is malignant on frozen section and the disease appears limited to the involved adnexa,
a laparoscopic staging is possible by experienced laparoscopic surgeons. Fertility preservation is
sometimes possible, since the conservation of the uterus and the contra-lateral ovary is possible
in selected cases of epithelial stage IA neoplasia and in most unilateral germ cell tumors. A
bilateral pelvic and para-aortic lymph node sampling is also required. It is important to point that
in the para-aortic area, the most important nodes to biopsy are between the renal vessels and the
inferior mesenteric artery on the left side and the ovarian vein on the right side (4). This is
particularly important in the staging of germ cell tumors. The operation is completed by an
omentectomy and biopsy of peritoneal surfaces of the gutters, the diaphragms and the mesentery.
At the end of surgery, to lower the risks of abdominal wall implantation, thorough washing of the
whole abdominal cavity and trocar insertion sites should be done.
Table 1 compares the results of laparoscopic staging with laparotomy at the Memorial-SlownKetering Cancer Center. It shows not only that laparoscopy is as adequate as laparotomy for
staging ovarian cancer, but that patients have less blood loss and have shorter hospital stay.
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Controversies:
1. It has been shown that delay in management is an important factor in the prognosis of ovarian
cancer unexpectedly found at laparoscopy (5). Therefore, if the laparoscopic surgeon is not
trained to perform staging procedures for ovarian cancer, the patient must be referred to a
Gynecologic Oncologist diligently for staging and/or neoadjuvant chemotherapy.
2. Rupture of a malignant ovarian cyst is thought to be a risk factor for intra-peritoneal malignant
cell contamination leading to carcinomatosis during laparotomy and trocar site implantation after
laparoscopy (6). Studies are contradictory but again delay in definitive treatment of the cancer
seems to be a more important factor in disease evolution than the rupture as such. Ideally, the
mass should be removed entirely without rupture. The puncture of the cyst fluid should be done
after the cyst has been put in an endobag. But when contamination occurs, extensive lavage of
the peritoneal cavity and trocar sites is clearly indicated.
3.CO2 Laparoscopy is widely used in general or gynecologic surgery, but has been suggested as
potentially deliterious in case of an intraabdominal cancer (7). Concerns have arisen in the last
years about its use in laparoscopic oncologic procedures, after the report of port site metastasis
and/or the intraperitoneal dissemination of cancerous cells (8). The role of abdominal distension
in the development of metastasis has been addressed by several authors. It would appear that it is
not so much the distension per se but the type of gas used that enhances the risk of implantation
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(9). Studies using air, CO2 or helium showed that CO2 influenced tumor growth favorably. Local
trauma also seems to play a role in trocar site metastasis. Tumor growth can occur after a simple
ascitic tap without surgery and has also been documented after thoracoscopy without the use of
CO2 (7). Canis (10) found a higher dissemination score in a laparotomy group compared with
laparoscopy in laboratory.
To lower the risk of peritoneal metastasis, gasless laparoscopy has been advocated (11). Gasless
laparoscopy mechanically elevates the abdominal wall without using any distension media.
Advantages and disadvantages of gasless laparoscopy are summarized in Tables 2 and 3.
Today, it is thought that the advantages of CO2 laparoscopy outweight its disadvantages even
when a malignancy is suspected.
Conclusions
When a laparoscopist is confronted with an ovarian mass, the possibility of cancer has to be a
major concern. Complete inspection of the peritoneal surfaces, lavage for peritoneal cytology,
careful dissection of the tumor avoiding any spillage, its removal in an endobag and request for
frozen section must be the rule. One has to remember that there is no substitute for good surgical
techniques. If cancer is confirmed, complete staging with laparoscopy or laparotomy is necessary.
Wound closure of trocar sites seems to minimize the risk of implantation. Irrigation of all
puncture sites is advocated. Because implantation of tumor cells seems to be somewhat rapid,
referral for staging, cytoreductive surgery or adjuvant chemotherapy, should be done within a
short interval (about 1-2 weeks after the laparoscopic surgery).
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de la coelioscopie. Gynecol Obstet fertil 2001;29 :278-87
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of gynecologic oncology 3rd ed. Lippincott Williams and Wilkins, Philadelphia, 2000:265-295.
4. Querleu D Laparoscopic paraaortic node sampling in gynecologic oncology: a preliminary
experience. Gynecol Oncol 1993;49:24-29.
5. Lehner R, Wenzl R, Heinz H et al. Influence of delayed staging laparotomy after laparoscopic
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Gynecol, 1998; 92: 104-108.
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pneumoperitoneum. Obstet Gynecol 1997;90:416-20.
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