[Frontiers in Bioscience 1, g1-7, December 1,1996]
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CAVEAT LECTOR



PLACE AND MODALITIES OF LAPAROSCOPY IN SURGICAL MANAGEMENT OF SUSPECTED ADNEXAL MASSES

Charles Chapron, Jean-Bernard Dubuisson, Sylvie Capella-Allouc & Xavier Fritel

Service de chirurgie Gynécologique, Clinique Universitaire Baudelocque, C.H.U. Cochin Port-Royal, 123, Boulevard Port-Royal, 75014, Paris, France

Received 9/16/96; Accepted: 9/26/96; On-line 12/01/96

4. RESULTS

From January 1, 1989 to December 31, 1994, we performed adnexectomy for an adnexal mass in 186 cases (14). The modalities of the surgical treatment are presented in Table 1.

It was possible to perform the treatment by operative laparoscopy in 65.1% of the cases (121 cases). Sixty five patients (34.9%) were treated by laparotomy. For 46 patients (24.7%), the laparotomy was decided from the outset and in 19 cases (10.2%) it was changed to laparotomy. The rate of laparoscopic treatment increased with the surgeon's experience (Table 1).

Table 1. Surgical modalities for adnexectomy carried out for adnexal mass1

Operative Procedure1989-19911992-1994Total
n 2%n 2%n 2%
Laparotomy2950.03628.16534.9
- From the outset2237.92418.74624.7
- Conversion712.1129.41910.2
Operative Laparoscopy2950.09271.912165.6

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

The indications for laparotomy from the outset (n = 46) are presented in Table 2.

Table 2. Surgical modalities for adnexectomy carried out for adnexal mass: Indications for laparotomy from the outset1

INDICATIONS1989-19911992-1994Total
n 2%n 2%n 2%
Ovarian cancer:522.71458.21941.4
- Certain from pre operative workup:29.12 8.248.8
- Very strong suspicious of malignancy:313.61250.01532.6
Size of the mass418.314.2510.9
Associated hysterectomy836.4312.51123.7
Hemoperitoneum14.500.012.2
Severe infection (pelvic abscess)14.500.012.2
Serious past history of surgery14.5520.9613.0
Medical counter indication for laparoscopy29.114.236.6
TOTAL22100.024100.046100.0

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

The decision for laparotomy from the outset was motivated by a suspicion of ovarian malignancy in 41.3% of cases (19 patients) (Table 2). For the 27 other patients (58.7%), the indications for laparotomy were the following: emergency operation in a context of considerable hemoperitoneum (2 liters) in a patient with adnexal torsion (1 case) (15); voluminous but not suspicious ovarian masses (5 patients): in three cases, these were dermoid cysts, measuring 9, 10 and 15 cm while two cases were ovarian fibrothecomas each measuring 10 cm; severe infectious abdomino-pelvic syndrome (pelvic abscess) (1 patient); past history of considerable surgery and severe adhesions (6 patients); medical contraindication for laparoscopy (3 patients); and the need to associate hysterectomy with the adnexectomy (11 patients).

The indications for conversion to laparotomy (n = 19) are presented in Table 3. For 11 patients (57.9%), the laparotomy was performed since malignancy was suspected during the diagnostic phase of laparoscopy. In 8 cases (72.7%), the final pathology results confirmed that there was indeed a malignant tumor (6 borderline tumors and 2 cancers). In 42.1% of cases (8 patients), the laparotomy was done for the following reasons: the necessity of carrying out myomectomy under anesthesia for an interstitial myoma measuring 8 cm (1 patient); the finding of severe tight adhesions between the adnexae and bowel (7 cases; 36.8%).

Table 3. Surgical modalities for adnexectomy carried out for adnexal mass: Indications for conversion to laparotomy1

Indications1989-19911992-1994Total
n 2%n 2%n 2%
Severe adhesions114.3650.0736.8
Associated procedure00.018.315.3
Suspicion of maligancy3685.7541.71157.9
Total7100.012100.019100.0

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

3: during diagnostic phase of laparoscopy when pre operative workup was reassuring

The pathological findings are presented in Table 4.

Table 4. Surgical modalities for adnexectomy carried out for adnexal mass: Histological results1

Final HistologyLaparotomy N = 65Laparoscopy N = 121TOTAL N = 186
n 2%n 2%n 2%
1) Benign lesions:a) Benign Ovarian cyst (OC):4366.110788.415080.6
- serous:1523.04234.75727.9
- dermoid:710.8119.1189.7
- endometrioma:69.23014.13619.4
- mucinous:69.275.8137.0
- fonctional:34.6119.1147.5
- context of torsion:23.110.831.6
- not specified:46.154.194.8
b) Adnexal masses with no OC:710.81411.62111.3
- Hydrosalpinx:34.632.563.2
- false peritoneal cyst:11.521.731.6
- Tubo-ovarian abscess:11.500.010.5
- Fibrothecoma:23.143.363.2
- Para-tubal cyst:00.054.152.7
Sub total5076.9121100.017191.9
2) Malignant lesions:Malignant OC:1523.100.0158.1
TOTAL65100.0121100.0186100.0

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

We performed a frozen section examination in 13 cases. For all these cases (100%), the final histology confirmed the results of frozen section examination. The reliability of laproscopy for the diagnosis of malignancy in adnexal masses is presented in Table 5.

Table 5. Reliability of laparoscopy for the diagnosis of malignancy in adnexal masses1

Suspected DiagnosisFinal Histology
BenignMalignant
N2n2%n2%
Malignant301550.01550.0
Benign156156100.000.0

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

For the 30 patients (16.1%) suspected of having malignant lesions, only half the patients (50%; 15 cases) did in fact had a neoplastic ovarian lesion. All the neoplastic lesions (100%) were detected as suspicious either during the preoperative workup or during the diagnostic phase of laparoscopy. All patients with a malignant lesion were operated by laparotomy (Table 6).

Table 6: Surgical modalities for adnexectomy carried out for patients presenting a malignant pathology1.

Operative procedure1989-19911992-1994Total
n 2%n 2%n 2%
Laparotomy7100.08100.015100.0
- From the outset228.6562.5746.7
- Conversion571.4337.5853.3
Operative Laparoscopy0 0.000.000.0
TOTAL7100.08100.015100.0

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

For patients presenting with benign adnexal masses, it was possible to perform a laparoscopic treatment in 70.8% of cases (121 patients) (Table 7).

Table 7. Surgical modalities for adnexectomy carried out for patients presenting a benign pathology1.

Operative procedure1989-19911992-1994Total
n 2%n 2%n 2%
Laparotomy2243.12823.35029.2
- From the outset2039.21915.83922.8
- Conversion23.997.5116.4
Operative laparoscopy2956.99276.712170.8
TOTAL51100.0120100.0171100.0

1: From Ref. 14: Chapron et al. Eur. J. Obstet. Gynecol. Reprod. Biol. (In press).

2: n = number of patients.

These results demonstrate that for the diagnosis of malignancy, the preoperative workup and the diagnostic phase of laparoscopy have a sensitivity of 100%, a positive predictive value of 50% and a negative predictive value of 100%.

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