[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

5. DISCUSSION

The results reported here confirm that it is possible to carry out adnexectomy via laparoscopy in patients with an adnexal mass (1-11).

The preoperative assessment for the diagnosis of malignancy in adnexal masses can not be established in 100% (16). Whether used separately or in combination, clinical examination, ultrasonography, doppler, and assaying for tumor markers do not allow the diagnosis of malignancy to be firmly established in an adnexal mass (Table 8). Anatomopathological study is required to reveal the benign versus malignant nature of an adnexal mass. In a previously published, manuscript we demonstrated that laparoscopy is as reliable as laparotomy for establishing the diagnosis of malignancy for an ovarian tumor (16).

Table 8. Value of pre-operative assessment for the diagnosis of malignancy in adnexal mass1

Preoperative assessmentSpecificitySensitivity
- Abdominal ultrasonography78%74%
- Vaginal ultrasonography 79%83%
- Doppler89%92%
- CA-12570%80%
- Associations62-99%78-100%

1: From Ref 16: Chapron et al. Hum. Reprod. Update (In press).

Our results of laparoscopic management of patients presenting with an adnexal mass are comparable to the previously published series (2-4) (Table 9).

Table 9. Reliability of laparoscopy for the diagnosis of malignancy in ovarian masses

References Cited From
Ref 2Ref 4Ref 3Ref 14
Number7571011550186
Malignant tumors194 1115
- Diagnosed1921115
- Unrecognized0200
Falsely suspicious masses2741430
Sensitivity100%50%100%100%
Specificity97%99%98%91%
Predictive value for malignancy41%33%44%50%

If the malignant nature of a lesion limited to the ovary is missed during the diagnostic phase of laparoscopy, there is a risk of dissemination with the problems of peritoneal dissemination and abdominal wall metastasis. To prevent these risks, we recommend adnexectomy without opening the cyst and to place the adnexae intact inside an endoscopic bag before extraction (13).

Provided that patients are selected very strictly, it is possible to carry out adnexectomy using laparoscopic surgery in patients with an adnexal mass. We propose in Figure 1, a therapeutic outline for the management of these patients. The different conditions for this therapeutic approach include the following. For adnexal masses which are obviously malignant and/or when there are signs of extra-ovarian dissemination, the treatment must be midline laparotomy from the outset. Laparoscopy can be carried out in all other cases. The first phase in this laparoscopy is devoted to the diagnosis and the search for any signs which indicate presence of a possible malignancy. The existence of any extra-ovarian suspicious signs of malignancy require immediate laparotomy under anesthesia. Whenever there is any doubt as to the existence of a malignant lesion strictly confined to the ovary, diagnostic ovariectomy via laparoscopy is feasible. This approach is only valid provided that the adnexectomy is carried out without opening the cyst, and that the excised tissues are extracted using an endoscopic bag, and that frozen examination is possible (16).

Figure 1. Management of organic ovarian cysts (16).

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