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  Introduction

Benign ovarian pathology remains as a significant disorder in females of reproductive age group [1,2]. Various types of adnexal masses are enlisted in Table 1[3].

Table 1: Types of adnexal masses.

During the last decade laparoscopy has become the gold standardfor the treatment of benign adnexal masses. Less adhesions, less operative pain and better cosmetic results are the advantages of this procedure[4]. However it remains controversial to decide in which cases, laparoscopy is indicated. Possibility of malignancy should be excluded pre-operatively byhistory, physical examination and ultrasonography of ovarian cyst.Ultrasonography findings of benign and suspicious malignant masses are given in Table 2[5].Along with ultrasound,other pre-operative investigations for ruling out malignancy are given in Table3.

Table 2: Ultrasonography findings of benign and suspicious malignant adnexal masses.

Table 3: Investigations to rule out malignancy.

Materials and methods

The study,laparoscopic management of adnexal masses,is a prospective observational study done from 2008 to 2015 in the Department of Obstetrics and Gynaecology,KIMShospital,Secunderabad,India.The cases included in this study are all patients planned for laparoscopic management of adnexal mass due to various indications.

Patients included in this study are females of more than 16 yearsof age with benign adnexal masses, and patients suspicious ofovarian malignancy are also included in this study,whowere willing to be a part of this study.

Patients not willing for laparoscopy,patients diagnosed with malignancy pre-operatively,and patients not willing to be apart of this study are excluded from this study.All the patients are well informedabout the study in all aspects and written consentswere obtained.Variables studied in this study are given in Table 4.

Table 4:Variables studied in this study.

Ultrasound is the imaging modality of choice in female pelvis. High resolution imaging of transvaginal ultrasound provides high diagnostic accuracy for pelvic pathology. However, there are some shortcomings with this modality, such as the limited field of view, obscuration of pelvic organs by the presence of bowel gas, inherent limitations depending on patient size, skill, and experience of the operator. When evaluating an adnexal mass on ultrasound, the diagnostic challenges that may arise, include accuracy in localizing the mass, determining whether or not it is ovarian in origin, and when complex, whether it is definitely benign or malignant. If a cystic mass of>5cms in a premenopausal woman, or >3cm in postmenopausal woman persisting or increasing in size on follow up ultrasound, MRI should be considered so that malignancy can be excluded. MRI should also be considered when a solid mass or a solid cystic adnexal lesion with internal color flow is detected by ultrasound. In these circumstances, it has been found that the use of MRI is cost effective in that it reduces unnecessary surgical procedures.

Statistical analysis

After confirming the homogeneity of data,all variables will be expressed as mean ± standard deviation.Categorial data will be expressed as percentage or frequency distribution charts. Associationbetween variables will be analyzed using spearman correlation analysis and/or logistic regression analysis. All data analysis will be done using Statistical Package for Social Sciences (SPSS), version 17.0, IBM computers, andNew York. P≤0.05 will be considered as significant.

Results

The study group consisted of 269 females, of more than 16years of age. In all patients the diagnosis was made histologically. According tothis result, 21(7.8%) patientswere of endometriosis,26(9.6%)patientswere of hydrosalpinx,42(15.6%)patientswere of serous cystadenoma,80(29.7%) patientswere of dermoid,44(16.4%) patientswere of ectopic pregnancy, 9(3.3%) patientswere of para-ovarian tumors,15(5.6%)patientswere of follicular cyst, 12(4.5%) patientswere of adnexal mass with uterine pathology,7(2.6%) patientswere of ovarian torsion,8(3%) patientswere of mucinous cystadenoma,2(0.7%) patientswere of pregnancy with hydrosalpinx with torsion, 2(0.7%) patientswere of fibroma,1(0.37%) patientwas of Brennertumor.

In 3patientslaparoscopy was converted to laparotomy due to technical difficulties. In one case severe bowel adhesions were seen between uterus and ovaries which was a case of endometriosis. In another case, specimen was removed using mini-laparotomy incision, as the size of the specimen was 24cms.And the third case was found to have frozen pelvis for which diagnostic laparoscopy was done,and it was converted to laparotomy. Intotal5 cases frozen sections were sent intra-operativelyin view of suspicion of malignancy,and all 5 cases were found to be benign on frozen section.

The cyst was removed in plastic bag in all patientsalong with adnexal mass. A few complications were recorded like post-surgicalfever,mild infection and pain at the suture site. The women were discharged normally two days after surgery. There was no major complication noted in any case.

Discussion

Benign ovarian masses consist of one of the most common issues which the gynaecologists have to treat. Laparotomy was considered to be the indicated treatment method until laparoscopic methods were developed years ago. Since that time the continuous development in methods of laparoscopy allowed to accept it as an alternative method to laparotomy, which has additional advantages concerningpatient’s condition after surgery. Patients with big adnexal mass can be operated with laparoscopy, givingthem the advantages of less post-operative pain and good cosmetic incision.

In this study a mass measuring 20cm was removed laparoscopically. It was a 20cm simple cyst in a young unmarried female, cyst was punctured and aspiration was done without any spillage, later cyst was removed using an endobag.

While operating on ovarian tumors with papillary projections, frozen section was taken which turned out to be benign on histopathology. In cases of adnexal mass with uterine pathology,totallaparoscopic hysterectomy was done along with adenectomy,and in these cases adnexal mass was removed vaginally.

A meta-analysis of related studies[6] comparing laparoscopy to laparotomy in the treatment of benign adnexal masses, point out the advantages of this procedure. It has been shown that laparoscopy caused less adverse effect, less post-operative pain, shorter stay in hospital, less readmission rates, better panoramic view, significantly low cost. Today it is almost accepted that laparoscopy is more beneficial than laparotomy but the importance of patient selection and the availability of gynaec-oncologist should be taken into account. Potential malignant tumors should be carefully excluded from laparoscopic option. This isperformed byuse of combined transvaginal ultrasonography wherever possible with doppler and 3D ultrasound[7]. In that case parameters to be examined with attention are diameter of cyst larger than 5cm, existence of septae, solid particles of papillomatous structure. Regarding the tumor markers, CA-125 has a special predictive value. Ultrasound morphology is significantly more important than CA-125 in detecting malignancies. In a large ovarian cyst (>10cm) transvaginal scans might be limited in visualising entire cyst contents,so transabdominal scan and MRI could yield better results[8].

Conclusion

Laparoscopy for the management of adnexal mass has the advantages of lower morbidity,shorter length of stay at hospital, decreased post-operative pain, lesser de-novo adhesion formations, better cosmetic results, faster recovery, and reduced overall cost of care. However,careful pre-operative evaluation is important for successful and appropriate use of laparoscopy for removal of adnexal masses and the advantages of laparoscopic approach,in no way, should compromise the clinical outcome in women with malignancy. Patient’s age,history, findings of physical examination, and the results of serum marker in combination with the imaging assessment, such as doppler sonography, MRI or CT,should be used to reach the correct diagnosis pre-operatively. Lastly, laparoscopy as a successful treatment of any adnexal mass depends on surgeons’ skill and experience.

Acknowledgement

TheDepartments of Obstetrics & Gynaecology, Radiology &Imageology, Krishna Institute of Medical Sciences, Secunderabad, India.

Conflicts of interest

There are no conflicts of interest and all the authors were in tone of study.