Author(s): Walid A. Abdelsalam* and Abdel-Razik El-Sayed Abdel-Razik
Surgical management strategies of benign ovarian cysts diagnosed during pregnancy include cyst resection, ovarian excision, or salpingo-oophrectomy but the best surgical procedure is still controversial. Using laparoscopic assisted methods has been extensively used in management of many gynecologic related diseases in non-pregnant women. Previously, performing laparoscopic surgeries for management of benign ovarian cysts during pregnancy was limited to only case reports, case series and retrospective studies.
The incidence of occurrence of benign adnexal masses encountered during pregnancy is increase and they are most probably benign; the commonest subtype is corpus luteum cyst that mostly disappeared before the 2nd trimester in ninety percent of cases, after which come the serous cysts and benign cystic teratoma that are the most common histopathologically diagnosed subtypes. The incidence of ovarian malignancy encountered during pregnancy is very rare; about 1 in 25,000 pregnancies. Ovarian tumors diagnosis and its related patients morbidity during pregnancy is increasing, this is due to refinement and availability of accurate diagnostic procedures in addition to increased incidence of performing assisted reproductive techniques. There are many hazards for many mothers and fetus of any surgical interventions during pregnancy particularly in emergencies as fetal death and premature labor. But if pregnant women are complaining of acute pelvic pain due to the presence of adnexal masses larger than six cm in size, surgical excision is highly needed [1-4]. With progression of pregnancy ovarian cysts became more liable to; cyst torsion, leakage or rupture that inversely affected both mother and fetus [5]. Generally speaking surgical management strategies of benign ovarian cysts diagnosed during pregnancy include cyst resection, ovarian excision, or salpingobut the best surgical procedure is still controversial. Since the 1990s, using laparoscopic assisted methods has been extensively used in management of many gynecologic related diseases in non-pregnant women. Nowadays, laparoscopy was found to be a safe, simple and effective procedure which can be used during pregnancy, with few drawbacks and many benefits as; less postoperative pain, less amount of analgesic use and shorter time of hospitalization [6-8]. But there are still fears about performing minimally invasive surgeries during pregnancy due to limited surgical manipulations, higher liability of perforation of gravid uterus and higher risks of hypercarbia. Previously, performing laparoscopic surgeries for management of benign ovarian cysts during pregnancy was limited to only case reports, case series and retrospective studies. In the current study we aimed to compare between laparoscopic and conventional open surgery for management of benign adnexal cysts in pregnant women, regarding; pregnancy outcome, benefits and drawbacks on mother and fetus, operative and perioperative details [9-11].
We have evaluating all pregnant females that underwent laparoscopic assisted excision or laparotomy for management of benign ovarian cysts who were admitted to Department of Obstetrics and Gynecology, Zagazig University Hospitals in the period between September 2014 and September 2019. After taking a written consent of inclusion in the study we were sure of the presence of complete medical files of the patients the benign nature of the tumor was confirmed clinically, radiologically and pathologically
Pregnant women with benign ovarian cysts, clinical, radiological and histopathologically confirmed diagnosis. Patient acceptance to be included in the study. Patients with good general condition without comorbid condition.
Pregnant females with complicated ovarian cysts needing emergent operations, patients clinically suspected to have borderline or malignant ovarian tumors were excluded to avoid misinterpretation of surgical and pregnancy outcomes by the presence of acute abdominal pain or malignant tumor. We included 80 pregnant females with benign ovarian cysts who were eligible for the study, splitting them in to 2 cohorts each group contain 40 patients the first cohort underwent laparoscopic excision of the ovarian cyst and the second cohort underwent conventional laparotomy for management of the ovarian cysts.
For pregnant patients who underwent laparoscopic assisted excision of the ovarian cyst we have informed them that there is a liability of converting laparoscopic surgery to open surgery in cases of certain operative situations.
Preoperative preparations included: complete physical examination, laboratory blood and biochemical tests, radiological evaluation as pelvic ultrasonography, in addition to electrocardiogram were performed. We have obtained a complete surgical history, marital history and allergy history. We have given included pregnant women antibiotic prophylaxis of I.V. cefotiam about 24 hours pre- and post-operatively in case of liability to infection.
Patients were laid in the supine position. We have applied spinal-epidural anesthesia for laparotomic surgeries. We made an incision about 2 cm above the symphysis pubis or at site of previous scar in the abdomen. The incision length was about 6-10 cm, according to tumor size.
Patients were laid in the lithotomy position. We have applied general anesthesia for laparoscopic assisted surgeries. We made an incision about 2.5 cm for the hole of 1st puncture at the umbilicus or at a location between the umbilicus and cartilageoensiformis, according to uterine and tumor size.
We introduced a Trocar of about 10 mm in the abdominal cavity, placed the celiac lens into the abdomen and established CO2 pneumo-peritoneum and maintained inra-abdominal pressure at about 10-12 mmHg. Then, we have introduced 3 other Trocars in the abdominal cavity under continuous tips visualization. We have exposed the ovary carefully; we have completely separated and excised the ovarian tumor with, avoidance of the uterus. We have made an ovary suture instead of performing an electric coagulation for ensuring adequate hemostasis.
We have observed pregnant women post-operatively in the resuscitation room for about 2 hours, then we sent them back to the wards, observed their pulse, blood pressure and respiratory rate every 0.5 hour using ECG monitors until the first post-operative day. We monitored the fetal heartbeat post-operatively every eight hours. We performed the 1st post-operative ultrasonography about three days after the operation and the 2nd ultrasonography one day before they left the hospital. We followed included patients by telephone after leaving the hospital.
We recorded surgical time, intra-operative and postoperative blood loss, occurrence of postoperative urine retention, postoperative temperature, duration of administration of antibiotics prophylaxis, length of the incision, degree of wound healing, length of postoperative hospitalization time and costs.
We recorded occurrence of fetal state, uterine contractions, and administration of prophylactic tocolytic therapy, fetal age at delivery, rate of performing caesarean delivery and rate of premature delivery.
We have used the SPSS 18.0 program (Chicago, IL, USA) for the statistical analyse of collected data. We used t test for continuous variables, and used chi square test or Fisher test was used for frequency data analysis. P < .05 was considered statistically significant.
There were no statistically significant differences between both studied groups regarding patients age, gestational time at the time of surgery or pre-operative tumor size (as fined by ultrasound).
Chi square test #Independent sample t test
Table 1: Correlations between Laparoscopy and Laparotomy for Excision of Benign Ovarian Masses in Pregnant Women Regarding Demographic and Pathological Parameters.
We found that the most commonly diagnosed subtypes were; mature cystic teratoma, endometriotic cysts, serous cystademona and mucinous cystadenoma. We found no statistically significant differences between both groups regarding hisopathological subtypes.
We found statistically significant differences between both studied groups regarding the overall costs of the operation as; anesthesia, surgery, and materials costs and in comparison with laparotomy, the laparoscopy related costs associated were higher (p < 0.001).
We found that duration of post-operative hospital staying was shorter in laparoscopy group than laparotomy group (p < 0.001) and the patients were more satisfied with that. The rate and duration of antibiotic prophylaxis was lower in laparoscopy group than laparotomy group (p < 0.001). The rate of wound healing was higher in the laparoscopy group. The postoperative fever rate and degree of maximum temperature was less in laparoscopy group than laparotomy group (p = 0.005). We found no statistically significant differences between both included groups regarding; postoperative blood loss, overall surgical time, occurrence of postoperative urine retention, gestational age at time of delivery, rate of preterm delivery, rates of performing caesarian delivery, weight of the newborn, duration of administration of prophylactic tocolytic therapy or postoperative uterine contraction occurrence.
Table 2: Correlations between Laparoscopy and Laparotomy for Excision of Benign Ovarian Masses in Pregnant Women Regarding Postoperative Findings and Patient Outcome.
Detailed prospective comparative studies about performing laparoscopy versus laparotomy in pregnant females diagnosed with benign ovarian cysts were limited. As the main priority is avoidance. The main consideration in laparoscopy was that it requires a big amount of carbon dioxide for pneumoperitoneum. Increasing intra-abdominal pressure might decrease uterine blood flow and reduce maternal venous return which could lead to intrauterine fetal hypoxia, additionally trans-peritoneal absorption of carbon dioxide lead to fetal acidosis [12].
In the present study we showed that performing laparoscopic assisted surgical excision of benign adnexal masses during pregnancy have a better surgical outcomes and patients convenience than laparotomy, similarly showed that pregnancy outcomes in laparoscopic group has lower risks of premature labor, shorter duration of hospital staying and lower amount of blood loss in comparison to laparotomy group with open surgery [1, 5, 4, 13]. Moreover they found no statistically significant differences between both included groups regarding; post-operative blood loss, overall surgical time, occurrence of postoperative urine retention, gestational age at time of delivery, rate of preterm delivery, rates of performing caesarian delivery, weight of the newborn, duration of administration of prophylactic tocolytic therapy or postoperative uterine contraction occurrence which is near previous researchers [4, 5, 13]. We showed that laparoscopy has many advantages than laparotomy as reduced antibiotics usage and the less risk of postoperative infection that is more beneficial for mother and fetus that was similar to [1].
Although laparoscopy group encountered a shorter duration of post-operative hospitalization and less analgesic utilization, but due to higher costs of surgical procedures and instruments in laparoscopic assisted surgeries made its costs higher than those of laparotomy. Previous studies showed that spontaneous abortion rate was not different between both laparotomy and laparoscopy patients [4, 6]. These results were in line with our results. Showed that laparoscopy was not associated with increased abortion rates in comparison with laparotomy [14]. Moreover we detected no adverse effects on fetus in case of reaching a maximum pressure pneumoperitoneam of 12 mmHg and the time of less than 30 min similar to results of [1].
Another concern about using laparoscopic assisted surgery during pregnancy is risk of enlarged uterus injury [15]. We encountered results similar to, that if we placed the initial port using the open method we could decrease liability of perforation of gravid uterus [6]. In our results we found no statistical significance in risks of fetal loss in those underwent laparoscopic surgery and open surgery similarly [16].
Showed that laparoscopy was related to decreased intraoperative blood loss due to bester visualization of deep vasculature and shorter duration of hospital stay [17]. Regarding the time of performing the laparoscopic assisted excision of benign ovarian cysts we showed that the 2nd trimester was the best and safest time for performing the operation as the uterine sensitivity is lower, the size of the uterus uterine gives a sufficient space for performing surgery, in addition to the amount of secreted progesterone by the placenta adequately maintains the pregnancy which is near results of [1, 18].
Moreover it was found that during the 1st trimester, great majority of ovarian cysts disappeared and performing any surgical manipulations during this trimester is associated with a higher risk of abortion also huge size of the uterus during third trimester hinder any surgical manibulations and lead to high liability of fetal and material drawbacks [5].
Using anesthesia during the period of pregnancy was found to be safe and feasible taking appropriate precautions [5]. In the present study as the anesthesia was made and adequately monitored by an experienced anesthetist, none of patients included in the study have any complications.
We concluded that performing laparoscopic assisted surgical procedure for excision of benign ovarian cystic masses in pregnant women has many advantages and few drawbacks taking the suitable sufficient precautions. Laparoscopy lead to less blood loss, shorter hospitalization better wound healing with no increased risks of fetal or maternal complications. Although laparoscopy has higher costs but it was more accepted by the patients as it is minimally invasive.
