Department of Obstetrics and Gynecology, Fukuoka University School of Medicine, 45-1, 7-chome, Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
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Abstract |
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Key words: cystectomy/endometriosis/histopathology/laparoscopy/ovary
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Introduction |
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In the present study, videotape records of the laparoscopic removal of 73 ovarian cysts, histologically confirmed in the endometrial epithelial lining, were reviewed. An association between easy removal of the capsule and loss of follicles was demonstrated.
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Materials and methods |
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Laparoscopic procedure
Laparoscopic cystectomy was performed under video control through a subumbilical incision and two lower abdominal incisions using 5 mm scissors and grasping forceps. Abdominal distension was maintained with a laparolift system (Origin Medsystem, CA, USA). All laparoscopic procedures were performed in the abdominal cavity. The endometriotic cysts were isolated, freed from any adhesions and the contents aspirated. The capsule of the cyst was stripped from the normal ovarian tissue where possible using two atraumatic grasping forceps pulled slowly in opposite directions; additional sharp dissection with scissors was often necessary because the capsule had adhered to the surrounding ovarian tissue in several places. The detached capsule was placed in a bag and removed from the abdominal cavity through subumbilical incision. The remaining ovarian tissue was repaired with a 20 dexon continuous suture.
Histological evaluation
Microscopic sections were obtained from the greatest tumour dimension of the cyst. A total of 65 unilateral and four bilateral ovarian cysts were histologically confirmed as ovarian endometriotic cysts because they showed the focal endometrial epithelial lining. Ten unilateral clinically suspected endometriotic cysts were haemorrhagic cysts without epithelial lining. After histological identification, the capsule wall thickness, presence of fibrosis, the number of cysts containing follicles, the number of follicles in a cyst, the depth of penetration of endometrial glands into the wall and the attachment structure of the capsule were histologically evaluated.
Statistical analysis
Statistical analysis was performed using Student's t-test (StatView, version 4.57; Abacus Concepts Inc., Berkeley, CA, USA) for patient age, size of the ovarian cyst, thickness of the capsule wall, resecting time and operating time. The 2 test was used to assess fibrosis of the cyst, presence of the follicle in the capsule and the attachment of the corpus albicans to the resected side of the capsule. P < 0.05 was considered to be statistically significant.
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Results |
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Microscopic features
The capsule wall thickness in groups 1 and 2 were 2.1 ± 0.8 and 1.8 ± 0.4 mm (mean ± SD) respectively. Attachment of the vascular-rich ovarian stroma to the resected side of the capsule was found in all cases in group 1. Primordial follicles were found in 42 (68.9%) of the group 1 capsules (Figure 2a,b). The number of primordial follicles within each capsule ranged from 125 (mean 6.6). Attachment of the corpus albicans to the resected side of the capsule was found in 30 (49.2%) cases in group 1 (Figure 3
). Corpus albicans were usually elongated by endometriotic cysts. In contrast, in group 2 no primordial follicles were found in the capsule and neither was the ovarian stroma attached to any capsule (Figure 4
). Part of the underlying normal ovarian tissue with follicles was associated with 10 capsules (eight group 1 and two group 2 cysts). Endometrial glands penetrating into the wall were found in nine cysts (eight group 1 and one group 2). The depth from the surface of the deepest penetrating endometrial glands ranged from 1.03.0 mm (mean 1.6). Extensive fibrosis of the capsule was found in 37 (60.7%) and four (33.3%) cysts in groups 1 and 2 respectively.
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Discussion |
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Nezhat et al. reported that large endometriomas may develop as a result of the secondary involvement of functional ovarian cysts in the process of endometriosis (Nezhat et al., 1992). The walls of the large cysts were easily removed, but partial removal of the ovarian cortex occurred when resecting the capsule when the wall of the cyst was adhered to underlying ovarian tissue by penetrating endometriosis. Luteal and endometrial linings were found in different areas of large endometriotic cysts. Although serial sections were not done, no ovarian endometriotic cyst showed both luteinized and epithelial lining in the present study. We could not histopathologically demonstrate the secondary involvement of functional ovarian cysts in the process of endometriosis.
Although several authors proposed that the laparoscopic treatment of ovarian endometriotic cysts should consist of drainage and coagulation (Fayez and Vogel, 1991; Brosens et al., 1994
) rather than excision, there is controversy over the recurrence and pregnancy rates when comparing the two different laparoscopic procedures (Beretta et al., 1998; Hemmings et al., 1998
). In this study, resection of endometriotic cysts was frequently associated with loss of follicles and damage to the ovarian stroma. On this basis, drainage and coagulation treatment for endometriotic ovarian cysts may well be recommended. However, the depth from the surface of the deepest penetrating endometrial glands ranged from 1.03.0 mm, whereas the maximum penetration depths for the argon (Keye et al., 1983
) and CO2 (Lasson et al., 1983
) lasers used in coagulation procedures have been reported at 0.25 and 0.3 mm respectively. This calls into question whether the complete coagulation of the penetrating endometrial glands can really be achieved under these procedures.
Most laparoscopic surgeons have achieved haemostasis with bipolar electrocautery. No suture was placed in the ovary after ovarian cystectomy (Loh et al., 1999). However, an attempt was made to mimic the laparotomy technique with carefully placed continuous sutures in the remaining ovarian tissue. Laparoscopic suture repair of the ovary is questioned as a means of preventing the periadnexal adhesion (Martin, 1991
). There are no data to suggest that suturing is more effective than bipolar electrocautery in preservation of ovarian function. The excessive use of bipolar forceps for haemostasis, especially in hilar areas, may be associated with severe damage to the remaining ovarian stroma.
In the present study, the hard stripping of the capsule from underlying ovarian tissue in group 2 was not associated with a heavy bleeding. Heavy bleeding is usually a major problem when the capsule is resected from an adhesion in hilar areas (Martin, 1991).
In conclusion, the results indicate that the resected capsule is the invaginated cortex itself and ease of removal of the capsule results from damage to the ovarian stroma between the invaginated cortex and the unaffected cortex. The surgical difficulty of group 2 probably depends on excision of the invaginated cortex and not the underlying ovarian stromal tissue. The relative ease of removal of the capsules is also associated with loss of follicles. Although the removal of the capsule has capacity to produce a good outcome (Dover and Torode, 2000), based on this study, a recommendation can be made for drainage and coagulation or a combination of stripping and coagulation when laparosocopic surgeons undertake removal of the capsule to decrease the remaining ovarian tissue.
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Notes |
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Submitted on June 8, 2000, resubmitted on June 26, 2001
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References |
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accepted on September 28, 2001.