Eric L. Eisenhauer and Jeffrey M. Fowler
Box 24-1 Master Surgeon’s Corner
Identify the ureter before dividing the infundibulopelvic (IP) ligament.
Divide the IP ligament at least 2 cm from the proximal ovarian border.
For prophylactic bilateral salpingo-oophorectomy, cauterize the uterine cornua to ablate the tubal remnant.
Unilateral salpingo-oophorectomy (USO) and bilateral salpingo-oophorectomy (BSO) are performed for a wide variety of indications. In gynecologic oncology, there is a fundamental distinction between USO/BSO performed for an identified lesion (eg, pelvic mass, ovarian cyst) and risk-reducing salpingo-oophorectomy (RRSO) performed to decrease the risk of subsequent ovarian and breast cancer in women at increased genetic risk. Indications for USO/BSO for symptoms or suspected ovarian malignancy are detailed more completely in Chapter 11. Recommendations for RRSO should be based on the individual woman’s risk for ovarian cancer. In the recent report of the Society of Gynecologic Oncologists Clinical Practice Committee, Berek et al1 detail these risk groups. Women with BRCA1 and BRCA2 mutations may reduce their risk of an associated gynecologic cancer by 96% and their risk of an associated breast cancer by 50% to 80% by undergoing RRSO after completion of desired childbearing. Women without a germline mutation who are at higher than average risk because of a strong family history of breast or ovarian cancer may also benefit from RRSO, but the absolute risk reduction is less clear. In premenopausal women at average risk for ovarian cancer undergoing hysterectomy for benign disease, the decision for oophorectomy should be individualized based on the patient’s personal risk factors.
Clinical outcomes after salpingo-oophorectomy as an isolated procedure are determined by both the surgical approach and menopausal status of the patient. Minimally invasive USO/BSO is generally an outpatient procedure with a short recovery period and low complication rate, whereas recovery after USO/BSO requiring laparotomy is longer as determined by the larger incision. Oophorectomy in premenopausal women results in menopausal symptoms in the majority of patients. Subsequent therapy for surgical menopause is determined by the severity of symptoms, specific risks related to hormone therapy, and patient choice. There are several studies suggesting an overall negative health impact when BSO is performed before the age of menopause. Among other findings, an observational study from the Nurse’s Health Study found that women younger than 50 years who had BSO and never used estrogen had increased rates of all-cause mortality, coronary heart disease, and stroke.2
Preoperative evaluation for most patients consists of physical examination and radiologic and/or serologic studies. Pertinent examination findings include the size and mobility of a palpable mass, associated or referred pain symptoms, or the presence of adjacent cul-de-sac nodularity. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can each play a role in preoperative characterization of adnexal findings and associated abnormalities within and outside of the pelvis. Serologic studies can include both standard preoperative testing (eg, complete blood count, chemistry, type and screen, and pregnancy test, as appropriate) and testing directed toward the risk of malignancy (eg, tumor markers, as detailed in Chapter 11). Preanesthesia risk assessment should be individualized by cardiopulmo-nary risk factors and other relevant medical issues.
Considerations for informed consent include those specific to the surgical approach, as well as those determined by menopausal status and hereditary risk factors. Blood loss is generally minimal, but may be higher for large masses or those associated with endometriosis. Wound infection risk is low for both minimally invasive and open approaches, but may be increased by obesity, diabetes, and other risk factors. Because several studies have suggested an overall negative health impact when BSO is performed before menopause, clear discussion of expected benefits and risks should be held before surgery. Finally, women with BRCA1 and BRCA2 mutations should be informed that despite the substantial ovarian and breast cancer risk reduction, the risk of peritoneal carcinoma after RRSO remains approximately 1%. A small tubal remnant remains in the uterine cornua after the fallopian tube is divided medially. However, fallopian tube cancers generally originate in the fimbriated portion, and the risk for subsequent cancer developing in this retained segment is uncertain but probably low.3
Patients should have nothing by mouth for 6 to 8 hours before surgery. Bowel preparation is not required but may be preferred by some surgeons to improve exposure for minimally invasive approaches. Intravenous antibiotics prior to skin incision should be administered to decrease wound infection risk. The myriad tools available to perform USO/BSO result in similar outcomes and are determined by availability and preference, but should be requested when the case is scheduled to limit delays on the day of surgery.
Box 24-2 Caution Points
The position of the ipsilateral ureter varies, but generally passes under the infundibulopelvic (IP) vessels to descend over the pelvic brim medial to the IP.
Ovarian tissue may extend into the IP ligament up to 1.5 cm from the visible margin.
A small tubal remnant remains in the uterine cornua after the fallopian tube is divided medially.
The patient may be positioned in modified dorsal lithotomy in Allen stirrups if vaginal access is required for dilation and curettage or if use of uterine manipulator is preferred. Alternatively, supine positioning is appropriate if these procedures are not required. A Foley catheter should be placed, and an oral-gastric tube is preferred before minimally invasive port placement to decrease the risk of gastric injury. Open approaches generally involve a midline incision extended as necessary for the pelvic mass, and a fixed retractor may be helpful. For minimally invasive approaches, port placement will depend on the mode favored (laparoscopic or robotic) but should be arranged superior to the known ovarian mass. At a minimum, these approaches require a camera port and at least 2 instrument ports, and ports should be spaced to allow instruments to be moved independently. The diameter of the ports is determined by preference and availability; cameras, instruments, and cautery devices can range from 3 to 10 mm. Incorporating at least one 10-mm port facilitates removal of the surgical specimen. The camera port is placed first, and either open placement of a Hasson cannula or closed insufflation with a Veress needle may be used. The remaining ports are placed under direct visualization. Recently, successful outcomes have been reported after laparoendoscopic single-site RRSO.4 This approach involves multiple ports closely placed within a single 2-cm umbilical incision and is a viable approach worthy of further study.
Regardless of approach, the remaining steps involve safely dividing the ovaries and tubes from their supportive and vascular attachments. Peritoneal washings are taken and sent for cytology. Adnexal and other adhesions are dissected free to maximize exposure and biopsied if suspicious for malignancy. The lateral pelvic peritoneum is divided from the round ligament to the level of the infundibulopelvic (IP) ligament (Figure 24-1). At laparotomy, the broad ligament is opened using sharp scissor dissection or the electrosurgical unit. At laparoscopy, laparoscopic scissors, harmonic scalpel, or argon beam coagulator can be used. The medial leaf of the broad ligament is retracted toward the midline, the para-rectal space is developed toward the pelvic floor, and the ureter is identified at the pelvic brim and traced distally along the broad ligament or vice versa (Figure 24-2). It is important to determine the proximity of the ureter at the pelvic brim to the IP ligament and the proximal ovarian border. Because ovarian tissue can be extended within the IP up to 1.5 cm from the visible ovarian border, the IP should be divided approximately 2 cm from the ovary.5 Identifying the ureteral position at the pelvic brim ensures that this can be done safely. The IP ligament is then mobilized from the pelvic sidewall vessels and isolated by creating a window in the medial leaf of the broad ligament between it and the ureter. The ovary can be elevated and the IP safely divided between clamps (Figure 24-3). A single or double suture ligature of 0 or 2-0 delayed absorbable suture is used to secure the infundibulopelvic ligament pedicle (Figure 24-4). Laparoscopic options for dividing and sealing the IP include bipolar cautery, LigaSure (Covidien, Mansfield, MA), harmonic scalpel, stapling devices, and laparoscopic or open ties (Figures 24-5 and 24-6).
FIGURE 24-1. Peritoneal incision with identification of ureter and infundibulopelvic ligament.
FIGURE 24-2. Salpingo-oophorectomy. Development of para-rectal space and relationship of ureter and infundibulopelvic ligament.
FIGURE 24-3. Salpingo-oophorectomy. Clamping of infundibulopelvic ligament (ovarian vessels).
FIGURE 24-4. Salpingo-oophorectomy. The infundibulo-pelvic ligament is secured with a suture ligature.
FIGURE 24-5. Salpingo-oophorectomy. The infundibulopelvic ligament is divided using a vessel-sealing device (LigaSure).
FIGURE 24-6. Salpingo-oophorectomy. Infundibulopelvic ligament is divided by a vessel-sealing device.
The broad ligament is then divided medially along the superior border of the round ligament to the uterine cornua. The fallopian tube and utero-ovarian ligament are divided individually when using a minimally invasive surgical approach or divided as a combined unit if approached via laparotomy and secured with a Heaney transfixion stitch of 0 or 2-0 delayed absorbable suture (Figures 24-7 and 24-8). Any of the previously mentioned laparoscopic instruments can be used for this purpose. Consideration should given to cauterizing the tubal remnant in the uterine cornua for all women at increased genetic risk; this is most easily performed with the bipolar cautery or LigaSure. For minimally invasive procedures, the specimen is placed in an endoscopic bag and delivered through the 10-mm port site. Larger cystic ovarian masses can be decompressed once the open end of the bag is brought out through the incision. Solid masses may require extending the skin and fascial incisions for removal. Instrument ports should be removed under laparoscopic visualization to prevent bowel or omentum being drawn up into the defect. The fascia at all port sites larger than 8 mm should be closed laparoscopically or directly to decrease the risk of port site hernia, and the skin should be closed with subcuticular suture, skin adhesive, or both.
FIGURE 24-7. Salpingo-oophorectomy. Division of utero-ovarian ligament and fallopian tube.
FIGURE 24-8. Salpingo-oophorectomy. Utero-ovarian ligament and fallopian tube pedicle secured with a transfixion stitch.
Box 24-3 Complications and Morbidity
Ureteral injury at the pelvic brim
Occult bowel injury from trocar placement or instrument
Port site or incisional hernia
Bleeding from inadequately secured infundibulopelvic ligament
For minimally invasive USO/BSO, patients are generally discharged home with instructions and oral pain medication, whereas after open procedures, patients may be admitted for 1 to 2 days. Complications after USO/BSO are rare but generally appear after this period. Bleeding from an unsecured IP ligament may initially cause low urine output and weakness from associated anemia. If left undetected, patients will acutely worsen as they develop hemorrhagic shock. Ureteral injuries can occur through ligation, transection, or devascularization. Ligation injuries may manifest after several days with ipsilateral flank pain due to hydroureter, hydronephrosis, or pyelonephritis. Transection or devascularization injuries may manifest later with fever or drainage through the vaginal cuff if a hysterectomy was also performed. Unless both ureters are ligated, any increase in serum creatinine is likely to be transient and may be missed after the first postoperative day. Occult bowel injury will usually present with signs of infection as peritonitis develops and may be detected by contrast-enhanced CT scan. Port site hernias can develop early or late and may be found when the patient has either incisional or gastrointestinal discomfort. If incarcerated, these patients may become acutely worse and require bowel resection. Fortunately, by investigating the patient symptoms, hernias can often be detected and reduced before bowel resection is required.
Box 24-4 Master Surgeon’s Corner
Radiation exposure should decrease the further the ovary is mobilized from the radiation field.
Ovarian transposition itself can cause ovarian failure if the gonadal vessels are compromised through excessive angulation or tension.
The ovary should therefore be secured as high above the pelvic brim as mobilization of the gonadal vessels allows.
Ovarian transposition, or oophoropexy, is a procedure performed in premenopausal women who will or potentially will undergo pelvic radiation therapy. In gynecologic oncology, this is most commonly indicated for cervical cancer, although it is also performed for a wide variety of hematologic and solid malignancies in girls and young women. Preservation of ovarian function depends on a number of factors, including the reproductive age of the patient and corresponding ovarian reserve, total dose of radiation therapy, the fractionation schedule, and which chemotherapy agents are used.6 Depending on the patient’s age, ovarian irradiation doses from 12 to 20 Gy will generally cause permanent ovarian ablation, and if the ovaries remain within the radiation field, the received dose will typically exceed this. The goal of transposition is to limit the ovarian radiation exposure by surgically moving them as far as possible from the target field. Historical rates of ovarian failure after transposition have run as high as 50% and are likely a function of both radiation scatter and vascular compromise to the gonadal vessels from the transposition procedure itself. Better patient selection and minimally invasive techniques may improve these rates in the future.
Because ovarian reserve declines with age, younger patients are more likely to have successful preservation of ovarian function after radiation therapy. In patients with other risk factors for ovarian failure, it may be appropriate to evaluate gonadal function prior to ovarian transposition. Risk tables based on age and expected radiation dose are available and can be useful for providing preoperative informed consent (Table 24-1).7 The patient should also be informed that in addition to standard surgical complications, the procedure itself carries a risk of causing ovarian failure and/or chronic pain.
Table 24-1 Predicted Age at Ovarian Failure With 95% Confidence Limits for Ages at Treatment From 0 to 30 Years and for Doses of 3, 6, 9, and 12 Gy
Patients should have nothing by mouth for 6 to 8 hours before surgery. Bowel preparation is not required but may be helpful to improve exposure for minimally invasive approaches. Intravenous antibiotics prior to skin incision should be administered to decrease wound infection risk. Instruments required vary by surgeon preference, but for minimally invasive approaches should include a laparoscopic clip applier so that the lower ovarian poles can be tagged for radiographic identification.
Box 24-5 Caution Points
Limit direct cautery exposure to the ovary during mobilization.
Remove attached fallopian tube unless doing so will compromise ovarian blood supply.
How high the ovary can be fixed and the degree of angulation to the infundibulopelvic vessels can be competing concerns.
The positioning of the patient and setup for operative access are the same as described for a USO/BSO procedure. Ovarian transposition is frequently performed as part of a larger primary procedure and, if performed by laparotomy, will generally involve a midline incision extended as necessary for the primary procedure. For minimally invasive approaches, port placement will depend on the mode favored (laparoscopic or robotic) but should allow both for mobilization of the ovary in the pelvis and placement and fixation in the paracolic gutter.
Regardless of approach, the remaining steps involve safely dividing the ovary or ovaries from uterine and tubal attachments and mobilizing the gonadal vessels to prevent vessel angulation. Adnexal and other adhesions are dissected free to maximize exposure and biopsied if suspicious for malignancy. The lateral pelvic peritoneum is divided from the round ligament to the level of the IP ligament. This can be safely performed with laparoscopic scissors, harmonic scalpel, or argon beam coagulator. The medial leaf of the broad ligament is retracted medially, and the ureter is identified and separated from the IP ligament. The broad ligament is then divided medially along the superior border of the round ligament to the uterine cornua. The fallopian tube is divided at the cornua, followed by the utero-ovarian ligament.
Freed of its uterine attachments, the fallopian tube is elevated, and if an adequate plane exists within the mesosalpinx, the fallopian tube can be separated from the ovary. If a plane is not present or removing it might risk devascularization of the ovary, the tubal segment is not removed. The ovary is then elevated gently, and the gonadal vessels are separated from the underlying ureter to a level above the pelvic brim. Once this plane is developed, the gonadal pedicle can be mobilized superiorly from its peritoneal attachments, while keeping the underlying ureter in the visual field. The position of the ovary in the lateral paracolic gutter is tested to ensure that the gonadal vessels will not be placed under excessive angulation. The para-ovarian tissue is then sutured to the peritoneum in the paracolic gutter, and the inferior pole is tagged with a metal clip for future radiologic identification (Figure 24-9).8 If performed as part of an open procedure, the sutures can be placed directly. As a minimally invasive procedure, the sutures can either be placed and tied intracorpore-ally or placed, grasped with an EndoClose (Covidien) needle placed through a small lateral skin incision, and tied extracorporeally. Instrument removal and port closure procedures are the same as described for the USO/BSO procedure.
FIGURE 24-9. Diagram illustrating the location of the transposed adnexa to a nonpelvic site where they can be spared from pelvic irradiation.
Box 24-6 Complications and Morbidity
Resultant ovarian failure
Pain from subsequent benign ovarian cyst
Occult bowel or ureteral injury
Port site hernia
For minimally invasive ovarian transposition prior to definitive chemoradiation, patients are generally discharged home the same day. If performed as part of a larger open procedure, patients may be admitted for a period of time commensurate with their primary procedure. Complications related to the ovarian transposition generally develop after this period. The risk of subsequent benign ovarian cysts, often necessitating additional surgery, may be as high as 25%, and the risk of resultant ovarian failure has been reported as high as 50%.9 For patients with cervical adenocarcinoma, there is a small but significant risk of occult ovarian metastases that are now mobilized out of the radiation field. The risks of occult bowel and ureteral injury and of port site herniation are as detailed in the previous Salpingo-Oophorectomy section.
OVARIAN REMNANT SURGERY
Box 24-7 Master Surgeon’s Corner
Resection of an ovarian remnant often involves a difficult complete sidewall dissection.
Identification and mobilization of the pelvic ureter are essential. Temporary ureteral stents may be helpful.
Placing an EEA sizer in the vagina may assist in the surgical dissection by providing counter-tension and assists in identifying critical anatomy.
The ovarian remnant must be removed completely with a margin of normal tissue.
Ovarian remnant syndrome (ORS) develops in women after BSO who have ovarian tissue left behind, distinguishing these patients from women who have a residual ovary left intentionally behind after prior USO. Patients frequently present with pelvic pain, pain associated with a pelvic mass, or an asymptomatic pelvic mass. Risk factors relate to conditions that cause pelvic adhesive disease, such as endometriosis, pelvic inflammatory disease, and prior gynecologic surgery. Because of these predisposing factors, surgery for ORS is frequently a difficult procedure, requiring at least a modest pelvic sidewall dissection with a higher risk for ureteral, bowel, and vascular injury.
Preoperative evaluation includes history, examination, and imaging findings consistent with ORS. Premenopausal levels of follicle-stimulating hormone and estradiol may be present in 60% to 70% of patients but are not uniformly diagnostic.10 Because ORS often develops in the setting of prior adhesive disease, MRI may be useful to delineate the relative positions of the ovarian remnant, ureter, and bowel. Assessment of integrity of the urinary collecting system with CT urography may be helpful. Preoperative bowel preparation is helpful both for ease of exposure and reducing the risk of bowel injury.
Informed consent should convey a modest risk of injury to the bladder, ureter, and bowel.10,11 Although reported incidence for each is generally less than 5%, it is significantly higher than for standard oophorectomy. Blood loss is higher, with approximately 10% of patients requiring transfusion. With pathologic demonstration of removal, the recurrence risk should be low.
Box 24-8 Caution Points
First restore normal anatomy by freeing adhesions in the pelvic sidewall and posterior cul-de-sac.
Assume that the ovarian remnant was retained because it was initially in a difficult position. Identify the borders of the ureter, bowel, and iliac vessels early because the remnant is likely to be adherent.
In the setting of a densely adherent sidewall mass, ureteral stents may help delineate normal anatomy.
The procedure is preferably performed in the modified dorsal lithotomy position, so that manual access to the vagina and rectum is available if required. Temporary ureteral stents are placed cystoscopically if desired and inserted through the side of the Foley catheter to drain into the same bag. An oral-gastric tube is placed prior to minimally invasive procedures.
Open approaches generally involve a midline incision extended as necessary for the pelvic mass, and a fixed retractor is usually helpful. For minimally invasive approaches, port placement will depend on the mode favored (laparoscopic or robotic), but should be arranged superior to the field of dissection. Choice of instruments is determined by surgeon preference and by surgical approach. For laparoscopic procedures, endoshears with monopolar cautery, argon beam coagulator, LigaSure, and harmonic scalpel can all be used with good effect. Cold dissection without cautery is preferred for dissection in close proximity to ureter and bowel. Additional ports to improve exposure and suction may be required.
The first step is to restore as much of the normal anatomy as possible and may require extensive lysis of adhesions to free the sidewall and cul-de-sac. The ureter should be identified at or above the pelvic brim and dissected down below the ovarian mass, if seen, and down to the distal pelvis if the remnant ovary cannot yet be delineated. A retroperitoneal approach is preferred by dividing the lateral peritoneum along the iliac vessels and proceeding medially so that the position of the iliac vessels is lateral to the direction of dissection. Mobilizing the rectum medially from the mass should aid greatly with exposure; this may require sharp dissection along the rectal border, and superficial defects created in the rectal wall may require suture reinforcement. Once the ovarian remnant and normal tissue margin is dissected free from the ureter, rectum, and iliac vessels, the blood supply at the superior border can be divided and the ovarian remnant removed in an endoscopic bag or directly for open procedures. Assessment of ureteral integrity with indigo carmine and confirmation of rectal integrity with a bubble test may be helpful. Closure is determined by initial approach as detailed earlier.
Box 24-9 Complications and Morbidity
Ureteral injury at or below pelvic brim
Enterotomy during dissection or mobilization
Intraoperative or postoperative bleeding
Port site hernia
For minimally invasive procedures, patients are generally discharged home when stable with instructions and oral pain medication. If performed as an open procedure, patients may be admitted for a period of time appropriate to their incision and postoperative symptoms. Injuries recognized intraoperatively will be repaired; unrecognized injuries generally present after hospital discharge. Bleeding complications may be recognized sooner and may require transfusion or reoperation. Occult ureteral and bowel injuries generally present later as described earlier for salpingooophorectomy. Ureteral injuries will be more frequently due to devascularization if ureteral integrity was confirmed intraoperatively. Port site hernias can present after minimally invasive procedures and can be recognized early with an appropriate index of suspicion.
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