腹腔镜手术治疗卵巢良性肿瘤（图文演示）

10. Adnexectomy
• Exposure

The ureter is identified.
The ovary is grasped at the level of the infundibulo-ovarian ligament with a Babcock clamp.
Traction is exerted on the ovary, superiorly and medially, to place tension on the suspensory ligament.
The uterus is anteverted and tipped laterally away from the cyst.
Exposure of the suspensory ligament often requires mobilization of the sigmoid colon on the left, and of the cecum on the right.
In the case of a large cyst that is not suspicious, puncture and suction of the cyst may be useful.

• Skeletonization

The suspensory ligament is skeletonized.
This skeletonization is not performed by all surgeons.
It is essential, however, to create a space between the suspensory ligament and the ureter, which is the procedure’s only dangerous relationship.
An extended opening of the summit of the broad ligament is performed with scissors after the peritoneum is tented with grasping forceps. This opening extends from the round ligament to the crossing of the ligament on the iliac axis.
The loose subperitoneal areolar tissue of the broad ligament is pushed away.
The ureter is retracted posteriorly by pushing down with closed scissors, using the deep surface of the posterior surface of the broad ligament as support.
An opening is made in the posterior surface of the broad ligament, and then enlarged with sweeping, cephalad to caudad movements.

• Suspensory ligament

Hemostasis of the suspensory ligament is achieved by cauterization with a bipolar grasper. It should be extended over approximately 2 cm. Division of the pedicle should be performed in several steps, with repeated cauterizations, as the suspensory ligament is a thick pedicle. Secondary bleeding rarely occurs. The skeletonization of the suspensory ligament, which separates it from the ureter, protects the ureter from thermal injury.
Hemostasis can be achieved with an endoloop.
Cauterization with ultrasonic dissectors is effective, but requires specific instruments and equipment.
The use of clips is not advised. Automatic staplers do not always obtain perfect hemostasis, and are costly.

• Utero-adnexal pedicles

The adnexa are isolated on the utero-adnexal pedicles by dividing the posterior peritoneum.
The fallopian tube is electrocauterized with the bipolar grasper. The cauterization should involve the interstitial portion of the tube, to prevent a subsequent pathology of the stump. The stump should be long enough to avoid the formation of a uteroperitoneal fistula.
The proper ligament of the ovary is electrocauterized and divided.

11. Results/complications

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Feasibility
Most benign-appearing ovarian tumors can be managed laparoscopically. In a study of 481 patients and 508 ovarian tumors confirmed during laparoscopy, 87% of the ovarian tumors were treated by laparoscopy (Mage et al., 1990).

Mean operating time
The procedure is not very lengthy. In 3 published studies, involving a total of 1221 ovarian cysts, the mean operating time varied from 69 to 76 minutes, with considerable individual variations (Lok et al., 2000; Shushan et al., 1999; Mettler et al., 2001).

Conversion to laparotomy
Conversion to laparotomy is rare. In half of the cases it is the result of an intraoperative suspicion of malignancy, and in the other half it is needed because of technical problems due to adhesions, hemorrhage, or a tumor that is too large for laparoscopy. In the publications of Lok et al. (2000) and Mettler et al. (2001), the rate of conversion to laparotomy was 1% for 587 cysts and 2.4% for 493 cysts respectively.

Hospital stay
Hospital stay is relatively short. In the study of Lok et al. (2000), the mean hospital stay was 2.6 /-1.5 days.

Complications
Serious complications are rare (Lok et al., 2000). Besides digestive and vascular injuries, complications involve ureteral lesions that occur during the adnexectomy.
Ovarian remnant syndrome can be observed following an incomplete oophorectomy, particularly in women with pelvic adhesions or endometriosis (Nezhat et al., 2000).
Granulomatous peritonitis is a rare but serious complication. It is due to the rupture of a dermoid cyst and the spreading of its contents. If rupture occurs, abundant lavage (6 to 9 liters) must be performed to prevent this complication.

Recurrences
After cystectomy, the usual recurrence rate is low. It is highest in cases involving endometriomas (23% of 161 cases after 42 months), particularly after fenestration and vaporization of the outer surface (58% of 70 cases after 42 months) (Saleh and Tulandi, 1999).

Effects on fertility
Cystectomies do not seem to affect fertility (Canis et al., 1992) nor the quality of ovarian response during IVF-embryo transfer (Canis et al., 2001; Donnez et al., 2001).

12. Reference
Canis M, Bassil S, Wattiez A, Pouly JL, Manhes H, Mage G et al. Fertility following laparoscopic
management of benign adnexal cysts. Hum Reprod 1992;7:529-31.
Canis M, Pouly JL, Tamburro S, Mage G, Wattiez A, Bruhat MA. Ovarian response during IVF-embryo
transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum
Reprod 2001;16:2583-6.
Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum
Reprod 1996;11:641-6.
Donnez J, Wyns C, Nisolle M. Does ovarian surgery for endometriomas impair the ovarian response to
gonadotropin? Fertil Steril 2001;76:662-5.
Lok IH, Sahota DS, Rogers MS, Yuen PM. Complications of laparoscopic surgery for benign ovarian
cysts. J Am Assoc Gynecol Laparosc 2000;7:529-34.
Mage G, Canis M, Manhes H, Pouly JL, Wattiez A, Bruhat MA. Laparoscopic management of adnexal
cystic masses. J Gynecol Surg 1990;6:71-9.
Mettler L, Jacobs V, Brandenburg K, Jonat W, Semm K. Laparoscopic management of 641 adnexal
tumors in Kiel, Germany. J Am Assoc Gynecol Laparosc 2001;8:74-82.
Mettler L, Semm K, Shive K. Endoscopic management of adnexal masses. Jsls 1997;1:103-12.
Nezhat CH, Seidman DS, Nezhat FR, Mirmalek SA, Nezhat CR. Ovarian remnant syndrome after
laparoscopic oophorectomy. Fertil Steril 2000;74:1024-8.
Salat-Baroux J, Merviel P, Kuttenn F. Management of ovarian cysts. Bmj 1996;313:1098.
Saleh A, Tulandi T. Reoperation after laparoscopic treatment of ovarian endometriomas by excision and
by fenestration. Fertil Steril 1999;72:322-4.
Shushan A, Mohamed H, Magos AL. How long does laparoscopic surgery really take? Lessons learned
from 1000 operative laparoscopies. Hum Reprod 1999;14:39-43.