Laparoscopic Managment of Adnexal Mass Prof Dr Fuat

Laparoscopic Managment of Adnexal Mass Prof. Dr. Fuat Demirkıran I. U Cerrahpaşa School of Medicine. Department of OB&GYN Division Of Gynocol Oncol TJOD 2012 Antalya,

Adnexal Masses %80 benign masses %10 -15 malignant masses %5 Metastatic masses

Ultrasonography Conventional Doppler 3 D-4 D Tumor Markers Other Imaging Techniques BT MR PET-CT

Management of Adnexal Mass Follow-Up USG-guided Cyst Aspiration Laparoscopic Surgery Open Abdominal Surgery

Laparoscopy is associated with a reduction in the following: febrile morbidity, urinary tract infection, postoperative complications, postoperative pain, days in hospital, and total cost.

Low risk masses for malignancy

Many studies document that, after careful preoperative screening, the relative frequency of encountering a malignancy during laparoscopic evaluation is low(2%).

Cystadenomas

Endometrioma

Solid Mass

Dermoid cysts

There were no operative or postoperative complications related to cyst content spillage, regardless of the surgical approach.

Timmerman D, Valentin L, Bourne TH, Collins WP, Verrelst H, Vergote I, International Ovarian Tumor Analysis (IOTA) Group: Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysi (IOTA)Group. Ultrasound Obstet Gynecol 2000; 16: 500– 505. Adneksiyal kitlelerin morfolojik sınıflandırılması ve malignite riski (IOTA)

papillary projections

Frozen –section evaluation

Malignant masses

What about laparoscopic surgery for malignant adnexal mases

Laparoscopic surgery for Ovarian Cancer The adequacy of minimally invasive surgery compared to traditional laparotomy for staging. The risk of tumor cyst rupture. The incidence and long-term implications of port-site metastases. The effect of CO 2 pneumoperitoneum on tumor growth.

Gynecologic Oncology 105 (2007) 409– 413 results suggest that laparoscopic comprehensive surgical staging of EOC is as safe and adequate as the standard surgical staging performed via laparotomy.

Cyst rupture 33% 75%

Prognostic Effect of Cyst Rupture increase stage author Un-change stage n author n Gleeson NC 23 Sevelda P Lehner R 70 Kruitwagen RF 219 Ahmed FY 194 Abu-Rustum NR 289 Leminen A 154 Vergote I 1545 Gleeson NC, Am J Obstet Gynecol, 2001; Sevelda P, Gynecol Oncol, 1989 Lehner R, Obstet Gynecol, 1998; Kruitwagen RF, Gynecol Oncol, 1996 Leminen A, Gynecol Oncol, 1999; Ahmed FY, J Clin Oncol, 1997 Vergote I, Lancet, 2001; Abu-Rustum NR, Gynecol Oncol, 2003 60

s e o P t r e t i s - e m a t s

Preventive measures for reduction of port-site metastases Minimize tissue trauma and the number of instrument transfers Rinse trocars in 5% povidine-iodine before insertion Perform trocar fixation Rinse tip of instruments in 5% povidine-iodine when interchanging instruments Resect tumor with adequate margins Use protective bags to retrieve tumor Remove all intraabdominal fluid before trocar removal Deflate the abdomen with trocars in place Irrigate site of trocars with 5% povidine-iodine Close peritoneal trocar sites (10 - to 12 -mm trocars)

Effects of CO 2 pneumoperitoneum There have been limited human studies evaluating this effect.

The accuracy and adequacy of laparoscopic surgical staging were comparable to laparotomic approach, and the surgical outcomes were more favorable than laparotomic approach. However, the oncologic safety of laparoscopic staging was not certain.

Surgical approach to adnexal masses Malignancy risk with USG Low Laparoscopic surgery and others intermediate diagnostic laparoscopy laparoscopic surgery Laparotomy high laparotomy