Author Information
Borse M*, Latkar P**, Prasad R***
(* Consultant Obstetrician and Gynecologist , Deenanath Mangeshkar Hospital, Pune; India ** Consultant Obstetrician and Gynaecologist, Yashashri Hospital, Pune, India; Clinical attache to Dr. Mahindra Borse.)
Abstract
Adnexal masses are seen in 1-2% of pregnant women and paraovarian cysts account for the third most common type. They can be of various sizes ranging from 1-20 cm are often diagnosed incidentally on an ultrasound, during physical examination or when a Woman experiences symptoms related to them. Small cysts can be closely observed during the course of pregnancy but large ones, even if asymptomatic, should be excised in order to prevent complications like torsion, rupture, hemorrhage, infection and dystocia. Excision of large cysts can be done in pregnancy, safely, using laparoscopy and here we report one such case.
Introduction
Adnexal masses are seen in 1-2% of pregnant women1 and paraovarian cysts account for the third most common type after serous cystadenomas and mature cystic teratomas.[2] They are epithelium - lined extra-peritoneal cysts arising from the remnants of the mesonephric or paramesonephric ducts.[3] Though they are often seen in women in the 3rd or 4th decade of life, they have been reported in pre – menarchal girls with an incidence of 4%.[4] Here, we report a case of a large paraovarian cyst diagnosed during routine physical examination at 11 weeks of gestation that was excised laparoscopically.
Case Report
A 22 year old, primigravida registered for antenatal care at 11 weeks of gestation. She was otherwise asymptomatic and had no past medical or surgical complaints. On examination, a cystic mass was palpable per abdomen, arising from the pelvis corresponding to an 18-week size uterus. On per vaginal examination, a 12 – week size uterus deviated to the left was felt. In the right fornix a 12x10x10 cm, cystic, mobile, non-tender mass was felt separately from the uterus. The left fornix was empty. A provisional diagnosis of a right ovarian cyst was made. The woman underwent an ultrasound examination which confirmed the presence of a large 12*15 cm right ovarian cyst without internal septae or solid component. CA -125 was 8 IU/ml. The rest of the obstetric scan was normal. After discussing the pros and cons with the couple, a decision for laparoscopic cyst excision was taken in view of its large size.
At 14 completed weeks of gestation, the procedure was performed under general anesthesia. At the time of surgery the cyst along with the gravid uterus corresponded to a 20-week size pelvic mass. The patient was put in low lithotomy position and the operating table was given a 300 left lateral tilt. A 10 mm central port was put along the midline mid-way between the xiphisterum and umbilicus using Hasson’s technique. Pneumoperitoneum was created using air insufflation and pressure was maintained at 14 mm of Hg. A unilocular 15x12x10 cm cyst was seen within the leaves of the right broad ligament and the right ovary was seen separately from the cyst (Figure 1). The left ovary and both fallopian tubes were normal. A 14 week gravid uterus with an arcuate fundus was seen. The broad ligament over the cyst was opened and a small nick was made on the cyst so as to drain the 800ml of straw-coloured fluid, thus decompressing the cyst (Figure 2). The redundant cyst wall was peeled off from the surrounding tissue (Figure 3) and removed through one of the additional ports. After ensuring hemostasis (Figure 4) using bipolar energy source, the pneumoperitoneum was deflated (Figure 5). Post – operative ultrasound showed a live fetus with a fetal heart rate of 150 beats per minute with adequate liquor and a normal placenta. There was no evidence of retro placental hemorrhage. The total operative time was 20 minutes. She had an uneventful recovery and was sent home in 24 hours. She received a single shot of intravenous third generation cephalosporin and was put on oral third generation cephalosporin for the next 5 days. She did not receive any tocolysis. Sutures were removed after a week and she made an uneventful recovery. At 2 week follow- up visit, there was adequate fetal growth. The histopathological report of the cyst wall showed that it was lined with flattened cells and fibro collagenous stroma with no solid areas or signs of malignancy. Her further antenatal course was uneventful and she delivered vaginally at term.
Figure 1: Right paraovarian cyst seen separately from the right ovary.
Figure 2: Decompression of the cyst using a suction tip.
Figure 3: Peeling of cyst wall.
Figure 4: Cauterized base of cyst.
Figure 5: Redundant broad ligament peritoneum with right ovary.
Discussion
Paraovarian cysts tend to grow in pregnancy as they are hormone – dependent. They are detected incidentally on routine ultrasound, during physical examination or when the patient becomes symptomatic. These cysts can be either managed conservatively or surgically via laparotomy or laparoscopy. However, there are several concerns with conservative management. Firstly, a paraovarian cyst cannot always be differentiated from an ovarian cyst on an ultrasound scan.[5,6] A large study conducted in Egypt on 1853 women, concluded that paraovarian cysts could be detected only in 44% of women with these cysts.[7] Secondly, the concern of malignancy – the risk though small i.e. 2%[8]cannot be completely ruled out as tumor markers for ovarian malignancy are not very reliable in pregnancy and thus one has to rely only on sonographic markers (25-30%).[9] Thirdly, being hormone dependent these cysts continue to grow during pregnancy thus putting the woman at a higher risk of complications like torsion, rupture, hemorrhage, infection.[10] dystocia and increased incidence of operative delivery. Lastly, large paraovarian cysts rarely resolve spontaneously.[11] Several studies in recent times have demonstrated the safety of laparoscopic surgery in pregnancy12. Though initially procedures were electively scheduled in the second trimester in order to reduce the rates of spontaneous abortions and preterm labor, recent studies have reported that surgery can be safely performed in all trimesters.[12] The patient can be made to lie in the supine position or in low lithotomy with a left lateral tilt to the operating table of 15-300 in order to prevent vascular compression by the gravid uterus. In case of a smaller cyst the primary port can be placed along the midline. However, large cysts can occupy the entire abdomen, necessitating a lateral port. Rouzi was the first to report laparoscopic excision of a large paraovarian cyst containing 2.5litres of fluid at 20 weeks of gestation in 2011[13]using a left subcostal port for entry. Abdominal entry can be achieved using a Verre’s needle or by Hasson’s technique. CO2 gas is preferred for creation of pneumoperitoneum as it is cheap, easily available and has rapid blood solubility. However, there have been concerns of fetal hypoxia with its use, though fetal acidosis has not been reported.[14] A study followed up children, whose mothers underwent laparoscopic surgery when pregnant, with CO2 as distension medium, up to 8 years of age and found no developmental delay in them.[15] Also, the functional residual capacity that is already compromised is pregnant women further reduces due to gas insufflation. Hence, it is recommended to keep insufflation pressures between 12-15 mm of Hg and monitor end tidal CO2 ( EtCO2) in order to gauge maternal acid-base status.[12] Alternatively, air insufflation can be used. However, if the operative time is prolonged, due to poor solubility of air there is a small risk of air embolism.
The cyst can be decompressed by making a small nick on the surface and introducing a suction tip through it. In order to prevent intraperitoneal spillage, a closed drainage system can be created by direct puncture of the cyst using a 5 mm trocar – canula inserted through the ipsilateral iliac fossa. A suction tube can be directly attached to the side channel of the canula or alternatively a suction tip can be put into the cyst through the canula in order to drain the cyst fluid. This helps to achieve a clean operative field and reduces operative time. The cyst wall after dissection can be removed through an ipsilateral side port using an endobag.
Laparoscopic surgery has other advantages to conventional laparotomy which include lesser post-operative pain and post – operative ileus, shorter hospital stay and early recovery. Moreover, long term studies have shown no difference in maternal or fetal outcome with either surgical modality.[16] Prophylactic tocolysis also has no role to play.[17]
Conclusion
Minimally invasive surgery is safe and effective for management of large paraovarian cysts in pregnancy.
References
Borse M, Latkar P, Prasad R. Laparoscopic Excision Of A Large Paraovarian Cyst In Pregnancy. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/laparoscopic-excision-of-large.html
Borse M*, Latkar P**, Prasad R***
(* Consultant Obstetrician and Gynecologist , Deenanath Mangeshkar Hospital, Pune; India ** Consultant Obstetrician and Gynaecologist, Yashashri Hospital, Pune, India; Clinical attache to Dr. Mahindra Borse.)
Abstract
Adnexal masses are seen in 1-2% of pregnant women and paraovarian cysts account for the third most common type. They can be of various sizes ranging from 1-20 cm are often diagnosed incidentally on an ultrasound, during physical examination or when a Woman experiences symptoms related to them. Small cysts can be closely observed during the course of pregnancy but large ones, even if asymptomatic, should be excised in order to prevent complications like torsion, rupture, hemorrhage, infection and dystocia. Excision of large cysts can be done in pregnancy, safely, using laparoscopy and here we report one such case.
Introduction
Adnexal masses are seen in 1-2% of pregnant women1 and paraovarian cysts account for the third most common type after serous cystadenomas and mature cystic teratomas.[2] They are epithelium - lined extra-peritoneal cysts arising from the remnants of the mesonephric or paramesonephric ducts.[3] Though they are often seen in women in the 3rd or 4th decade of life, they have been reported in pre – menarchal girls with an incidence of 4%.[4] Here, we report a case of a large paraovarian cyst diagnosed during routine physical examination at 11 weeks of gestation that was excised laparoscopically.
Case Report
A 22 year old, primigravida registered for antenatal care at 11 weeks of gestation. She was otherwise asymptomatic and had no past medical or surgical complaints. On examination, a cystic mass was palpable per abdomen, arising from the pelvis corresponding to an 18-week size uterus. On per vaginal examination, a 12 – week size uterus deviated to the left was felt. In the right fornix a 12x10x10 cm, cystic, mobile, non-tender mass was felt separately from the uterus. The left fornix was empty. A provisional diagnosis of a right ovarian cyst was made. The woman underwent an ultrasound examination which confirmed the presence of a large 12*15 cm right ovarian cyst without internal septae or solid component. CA -125 was 8 IU/ml. The rest of the obstetric scan was normal. After discussing the pros and cons with the couple, a decision for laparoscopic cyst excision was taken in view of its large size.
At 14 completed weeks of gestation, the procedure was performed under general anesthesia. At the time of surgery the cyst along with the gravid uterus corresponded to a 20-week size pelvic mass. The patient was put in low lithotomy position and the operating table was given a 300 left lateral tilt. A 10 mm central port was put along the midline mid-way between the xiphisterum and umbilicus using Hasson’s technique. Pneumoperitoneum was created using air insufflation and pressure was maintained at 14 mm of Hg. A unilocular 15x12x10 cm cyst was seen within the leaves of the right broad ligament and the right ovary was seen separately from the cyst (Figure 1). The left ovary and both fallopian tubes were normal. A 14 week gravid uterus with an arcuate fundus was seen. The broad ligament over the cyst was opened and a small nick was made on the cyst so as to drain the 800ml of straw-coloured fluid, thus decompressing the cyst (Figure 2). The redundant cyst wall was peeled off from the surrounding tissue (Figure 3) and removed through one of the additional ports. After ensuring hemostasis (Figure 4) using bipolar energy source, the pneumoperitoneum was deflated (Figure 5). Post – operative ultrasound showed a live fetus with a fetal heart rate of 150 beats per minute with adequate liquor and a normal placenta. There was no evidence of retro placental hemorrhage. The total operative time was 20 minutes. She had an uneventful recovery and was sent home in 24 hours. She received a single shot of intravenous third generation cephalosporin and was put on oral third generation cephalosporin for the next 5 days. She did not receive any tocolysis. Sutures were removed after a week and she made an uneventful recovery. At 2 week follow- up visit, there was adequate fetal growth. The histopathological report of the cyst wall showed that it was lined with flattened cells and fibro collagenous stroma with no solid areas or signs of malignancy. Her further antenatal course was uneventful and she delivered vaginally at term.
Figure 1: Right paraovarian cyst seen separately from the right ovary.
Figure 2: Decompression of the cyst using a suction tip.
Figure 3: Peeling of cyst wall.
Figure 4: Cauterized base of cyst.
Figure 5: Redundant broad ligament peritoneum with right ovary.
Discussion
Paraovarian cysts tend to grow in pregnancy as they are hormone – dependent. They are detected incidentally on routine ultrasound, during physical examination or when the patient becomes symptomatic. These cysts can be either managed conservatively or surgically via laparotomy or laparoscopy. However, there are several concerns with conservative management. Firstly, a paraovarian cyst cannot always be differentiated from an ovarian cyst on an ultrasound scan.[5,6] A large study conducted in Egypt on 1853 women, concluded that paraovarian cysts could be detected only in 44% of women with these cysts.[7] Secondly, the concern of malignancy – the risk though small i.e. 2%[8]cannot be completely ruled out as tumor markers for ovarian malignancy are not very reliable in pregnancy and thus one has to rely only on sonographic markers (25-30%).[9] Thirdly, being hormone dependent these cysts continue to grow during pregnancy thus putting the woman at a higher risk of complications like torsion, rupture, hemorrhage, infection.[10] dystocia and increased incidence of operative delivery. Lastly, large paraovarian cysts rarely resolve spontaneously.[11] Several studies in recent times have demonstrated the safety of laparoscopic surgery in pregnancy12. Though initially procedures were electively scheduled in the second trimester in order to reduce the rates of spontaneous abortions and preterm labor, recent studies have reported that surgery can be safely performed in all trimesters.[12] The patient can be made to lie in the supine position or in low lithotomy with a left lateral tilt to the operating table of 15-300 in order to prevent vascular compression by the gravid uterus. In case of a smaller cyst the primary port can be placed along the midline. However, large cysts can occupy the entire abdomen, necessitating a lateral port. Rouzi was the first to report laparoscopic excision of a large paraovarian cyst containing 2.5litres of fluid at 20 weeks of gestation in 2011[13]using a left subcostal port for entry. Abdominal entry can be achieved using a Verre’s needle or by Hasson’s technique. CO2 gas is preferred for creation of pneumoperitoneum as it is cheap, easily available and has rapid blood solubility. However, there have been concerns of fetal hypoxia with its use, though fetal acidosis has not been reported.[14] A study followed up children, whose mothers underwent laparoscopic surgery when pregnant, with CO2 as distension medium, up to 8 years of age and found no developmental delay in them.[15] Also, the functional residual capacity that is already compromised is pregnant women further reduces due to gas insufflation. Hence, it is recommended to keep insufflation pressures between 12-15 mm of Hg and monitor end tidal CO2 ( EtCO2) in order to gauge maternal acid-base status.[12] Alternatively, air insufflation can be used. However, if the operative time is prolonged, due to poor solubility of air there is a small risk of air embolism.
The cyst can be decompressed by making a small nick on the surface and introducing a suction tip through it. In order to prevent intraperitoneal spillage, a closed drainage system can be created by direct puncture of the cyst using a 5 mm trocar – canula inserted through the ipsilateral iliac fossa. A suction tube can be directly attached to the side channel of the canula or alternatively a suction tip can be put into the cyst through the canula in order to drain the cyst fluid. This helps to achieve a clean operative field and reduces operative time. The cyst wall after dissection can be removed through an ipsilateral side port using an endobag.
Laparoscopic surgery has other advantages to conventional laparotomy which include lesser post-operative pain and post – operative ileus, shorter hospital stay and early recovery. Moreover, long term studies have shown no difference in maternal or fetal outcome with either surgical modality.[16] Prophylactic tocolysis also has no role to play.[17]
Conclusion
Minimally invasive surgery is safe and effective for management of large paraovarian cysts in pregnancy.
References
- Dede M, Yenen MC, Yilmaz A, Goktolga U, Baser I. Treatment of incidental adnexal masses at cesarean section: a retrospective study. Int J Gynecol Cancer 2007; 17: 339-341.
- Bignardi T, Condous G. The management of ovarian pathology pregnancy. Best Prac Resear Clin Obstet Gynecol. 2009; 23: 539-548.
- Athey PA, Cooper NB. Sonographic features of paraovarian cysts. AJR. 1985; 144: 83–86.
- Samaha M, Woodruff JD. Paratubal cysts: frequency, histogenesis, and associated clinical features. Obstet Gynecol. 1985; 65: 691–694.
- Kiseli M, Caglar GS, Cengiz SD, Karadag D, Yilmaz MB. Clinical diagnosis and complications of paratubal cysts: Review of the literature and report of uncommon cases. Arch Gynecol Obstet 2012;285: 1563–69.
- Barloon TJ, Brown BP, Abu-Yousef MM, Warnock NG. Paraovarian and paratubal cysts: preoperative diagnosis using transabdominal and transvaginal sonography. J Clin Ultrasound. 1996; 24(3): 117–122.
- Darwish A, Amin A, Safwat AM. Laparoscopic Management of Paratubal and Paraovarian Cysts. JSLS. 2003 Apr-Jun; 7(2): 101–106.
- Stein AL, Koonings PP, Schlaerth JB, Grimes DA, d'Ablaing G. 3rd.Relative frequency of malignant parovarian tumors: should parovarian tumors be aspirated? Obstet Gynecol. 1990; 75: 1029–1031.
- Savelli L, Ghi T, De Iaco P, Ceccaroni M, Venturoli S, Cacciatore B. Paraovarian/paratubal cysts: comparison of transvaginal sonographic and pathological findings to establish diagnostic criteria. Ultrasound Obstet Gynecol. 2006; 28: 330–334
- Janovski NA, Paramanandan TL. Ovarian tumors: tumors and tumor-like conditions of the ovaries, fallopian tubes, and ligaments of the uterus. Philadelphia: W. B. Saunders. 1973:191-194.
- Levine D et al. Management of asymptomatic ovarian and other adnexal cysts imaged at ultrasound. Society of Radiologists in Ultrasound Consenses Conference statement. 2010; 256(3): 943-954.
- SAGES - Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for Diagnosis, Treatment, and Use of Laparoscopy for Surgical Problems during Pregnancy.2007. Publication #23 Jan 2011.
- Rouzi AA.Operative laparoscopy in pregnancy for a large paraovarian cyst. Saudi Med J. 2011; 32(7):735–7
- Comitalo JB, Lynch D. Laparoscopic cholecystectomy in pregnant patient. Surg Laparoscopic Endoscopy. 1994. 4; 268-271.
- Rizzo AG. Laparoscopic surgery in pregnancy: long -term follow- up. Journal of laparoendoscopic and advanced surgical techniques. 2003. 13; 11-15.
- Soriano D, Yefet Y, Seidman DS, Goldenberg M, Mashiach S, Oelsner G. Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril 1991.71;955-960.
- Katz VL, Farmer RM. Controversies in tocolytic therapy. Clinical obstetrics and gynecology. 1999. 42;802-819.
Borse M, Latkar P, Prasad R. Laparoscopic Excision Of A Large Paraovarian Cyst In Pregnancy. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/laparoscopic-excision-of-large.html