The prevalence of adnexal masses in pregnancy ranges from 0.05 to 2.4 percent and approximately 1 to 6 percent of these masses are malignant. Patients typically present on prenatal ultrasound asymptomatically but some can have abdominal and back pain as well. Concerns for the fetus and complications in pregnancy cause surgeries to be postponed until after delivery; however, some adnexal masses require evaluation for malignancy.
We present a case of a 28-year-old female with a cystic adnexal mass that required laparoscopic salpingo-oophorectomy at 17 weeks gestation.
After the patient was prepped and draped,the initial laparoscopic port was placed in the left upper quadrant, 3 cm below the costal margin and in the midclavicular line. This area, known as Palmer’s point, was chosen as the site for the initial port placement in order to avoid the gravid uterus. After intraperitoneal placement, the abdomen was insufflated with CO2 gas. Laparoscopic ports were placed at the umbilicus and in the right lower quadrant under direct visualization. The port placed at the umbilicus was an Applied Medical GelPOINT Advanced Access Platform. The entire abdominal and pelvic cavities were examined for any lesions. An initial washing was done to examine for malignant cells. The left ovary was examined and determined to be normal. The right ovary was noted to be enlarged, to approximately 10 cm, and was displaced into the posterior cul de sac. Next the infundibulopelvic ligament, broad ligament, ovarian vessels, and ureter are identified. The ureter, which is typically able to be identified at the pelvic brim where it crosses over the bifurcation of the iliac vessels and passes medially, was noted to be well below the plane of dissection. If the ureter is unable to be located trans-peritoneally, a peritoneal incision can be made parallel to the ovarian vessels and the ureter located retroperitoneally in the medial leaflet of the broad ligament. The right fallopian tube and right utero-ovarian ligament were transected using the Ligasure bipolar device. We evaluated for hemostasis of the pedicles. The right suspensory ligament of the ovary containing the ovarian vessels was then isolated and cauterized and transected using the Ligasure bipolar device. A laparoscopic retrieval bag was introduced through the GelPOINT advanced access platform, the specimen was placed in the bag, and then the bag was brought to the surface of the patient’s abdomen. We were able to drain straw colored fluid from the cyst with the cyst contained safely within the bag. The remainder of the specimen was then able to be removed, contained within the bag. The patient’s abdomen was deflated and the ports were removed. The fascia at the umbilicus was closed with an 0 Vicryl (polyglactin) suture so as to avoid herniation at the site of the larger incision accommodating the GelPOINT. The rest of the ports were closed using subcuticular sutures.
Pathology revealed a mature cystic teratoma. The patient was discharged home on the same day of surgery with no complications. Fetal heart tones were within normal limits pre- and post-procedure. Laparoscopic surgery is a safe treatment for pregnant women with non-obstetrical surgical issues, including adnexal masses.
The patient is placed in the dorsal lithotomy position. An orogastric tube is placed to decompress the stomach. An incision is made at Palmer’s point, in the left upper quadrant, 3 cm below the costal margin and in the midclavicular line. A 5 mm Visiport trochar was placed under direct visualization entry. Once intraperitoneal placement was confirmed, the abdomen is insufflated with CO2 gas. After intraperitoneal placement of the trochar is confirmed, the patient is shifted slightly into left lateral decubitus position to avoid compression on the inferior vena cava by the gravid uterus. The umbilicus is then everted, and incision is made in the umbilicus and GelPOINT advanced access platform is placed. The patient is then placed in Trendelenburg position. Under direct visualization, an additional 5 mm trochar is placed in the right lower quadrant. The pelvis is inspected, and the diseased ovary visualized. The ureter is identified and noted to be well-below the plane of dissection. The diseased ovary and fallopian tube are then amputated using the Ligasure bipolar device - by clamping and cauterizing the fallopian tube at the uterine cornua, the utero-ovarian ligament, and then finally the suspensory ligament of the ovary (also known as the infundibulopelvic ligament). The ovary is then placed intact into a laparoscopic retrieval bag. The bag is pulled to the skin surface, and the ovary is then drained of cystic fluid. Once the ovary has been deflated, it is able to be removed in its entirety without spillage of contents. The pelvis is again inspected for hemostasis with irrigation if needed. The abdomen is deflated. The fascial incision at the umbilicus is closed with 0 Vicryl (polyglactin) suture. The skin incisions are closed with 4-0 Monocryl in a subcuticular fashion.
Large, symptomatic adnexal mass or mass with features concerning for malignancy
Inability to ventilate the patient in Trendelenburg position and with abdomen insufflated
Patient is in a dorsal lithotomy position in Allen stirrups. She is then bumped to a slight left lateral decubitus position in order to displace the gravid uterus off of the inferior vena cava
Instrumentation: 5 mm laparoscopic trochars, 0 degree laparoscope, Ligasure 5 mm laparoscopic bipolar device, 15 mm laparoscopic retrieval bag
Pelvic ultrasound; CA-125 marker was not obtained, as this can be elevated normally in pregnancy
Advantages to laparoscopy include decreased postoperative pain, decreased length of hospital stay, decreased risk of postoperative ileus, faster return to daily activities, lower risk of wound complications, and decreased risk of venous thromboembolism. Studies show no increased risk of fetal loss, low birth infant birth weights, or preterm birth in laparoscopy when compared with laparotomy.
Uterine perforation is a rare but serious complication in laparoscopic surgery during pregnancy. This is in addition to common risks of laparoscopic pelvic surgery including bleeding; infection; bladder, bowel, and ureteral injury. If uterine perforation occurs in an Rh negative patient, anti-D immunoglobulin should be given.
Dr. Aida Shanti M.D.
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