1 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Medical School and 2 Northwestern University Medical School, Chicago, Illinois, USA
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Abstract |
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Key words: dermoids/laparoscopy/mature cystic teratomas/ovarian cysts/surgeon experience
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Introduction |
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This study was undertaken to identify the risk factors associated with the intra-operative leakage of benign cystic teratomas. Specifically, we sought to determine whether surgeons' experience, surgical technique, presence of adhesions and cyst size predisposed to intra-operative leakage.
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Materials and methods |
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Each surgeon's experience was estimated by calculating the average number of laparoscopic cases per year performed from 1993 to 1997. Number of years as a physician was determined based on the year of graduation from medical school as reported to the American Medical Association. Patients under the resident service were cared for by physicians undergoing training under the supervision of an experienced surgeon. Statistical analysis was performed using SPSS Version 6.1.1 (SPSS Inc., Chicago, IL, USA). Dichotomous variables were compared by 2 test. Continuous variables were compared with two-sided sample t-test and for non-parametric analysis the MannWhitney U-test. Multiple logistic regression was also performed.
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Results |
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Surgeon laparoscopic experience was distributed in a bimodal pattern, with 39 surgeons performing <20 laparoscopic cases per year and five surgeons performing >35 cases per year. No surgeon averaged between 20 and 35 laparoscopic cases per year. Patients who underwent laparoscopic cystectomy by experienced laparoscopic surgeons (>35 laparoscopies/year) were less likely to have intra-operative leakage (relative risk: 0.5, 95% confidence interval: 0.21.2) (Table III). Among patients undergoing unilateral cystectomy without concurrent procedures, estimated blood loss and operating time were not different between women (leakage, no leakage, laparoscopy, laparotomy; data not shown). The phase at which leakage occurred during cystectomy did not statistically differ for laparoscopy and laparotomy, including respectively at ovarian capsule incision (14.1 versus 11.3%), cyst dissection (17.2 versus 22.5%) and during cyst removal (9.4 versus 3.8%). A backward likelihood ratio logistic regression analysis was performed on the entire dataset to assess further factors related to intra-operative benign cystic teratoma leakage including surgeon years of experience, surgeon laparoscopic experience, preoperative size, laparoscopy, and presence of adhesions. In the final logistic model, only laparoscopic experience was found to protect against intra-operative leakage (P = 0.058).
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Discussion |
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With the introduction of high-resolution transvaginal ultrasonography, the diagnosis of a benign cystic teratoma can be made with greater accuracy. Cystic teratomas are suspected if any one of the following three sonographic findings is present in a woman of reproductive age: a densely echogenic tubercle associated with a cystic echo pattern, a thin, echogenic, band-like echo or a dense echo pattern with or without a cystic component (Cohen and Sabbagha, 1993). In a prospective series, a diagnostic accuracy of 97% was noted in predicting cystic teratomas (Caspi et al., 1996
). Unfortunately, malignancy complicates 0.173% of cases (Commerci et al., 1994
) and cannot be completely excluded on the basis of ultrasound findings, even with colour Doppler flow imaging (Luxman et al., 1996
). Also, benign cystic teratomas may be at risk for chronic leakage (1%), acute rupture (13%) or torsion (3%), and as a result surgical intervention is often recommended (Commerci et al., 1994
). Careful observation (Caspi et al., 1997
) or cystectomy should be considered in patients who desire future fertility.
The rate of bilateral mature cystic teratomas was 11% in this study, consistent with other studies (Commerci et al., 1994). In the past, sampling of the contralateral ovary was recommended to rule out a second mature cystic teratoma. Unfortunately, indiscriminate removal of ovarian tissue rarely leads to the identification of a teratoma. In addition, potential complications of ovarian biopsy include haemorrhage, infection, adhesion formation and possible reduction of follicles (Toaff et al., 1976
). For these reasons, careful inspection of the contralateral ovary is recommended with diagnostic cyst aspiration followed by cystectomy if indicated.
Although several studies have emphasized the importance of experience (Howard, 1995; Nitke et al., 1996
), this is the first paper to study the effects of surgeon experience on leakage from mature cystic teratomas. The current study suggests that cystectomy by laparotomy is highly insensitive to surgeon experience as measured in years. Postgraduate years offer no relative benefit to preventing benign cystic teratoma leakage at laparotomy. However, laparoscopic experience is highly predictive of success at laparoscopic cystectomy. Those surgeons performing <20 cases per year are more likely to have inadvertent leakage at laparoscopic cystectomy. In light of the concerns of chemical peritonitis from benign cystic teratoma cyst fluid, less experienced laparoscopic surgeons are advised to involve more experienced surgeons during endoscopic management, or to consider laparotomy. This finding also helps to validate the Society for Reproductive Surgeons' recommendation that laparoscopic cystectomy be considered a level II procedure (Keye, 1994
).
In the only randomized prospective study reporting leakage rates (Yuen et al., 1997) during the management of benign ovarian cysts, the overall frequency of inadvertent leakage was similar for laparoscopy (27%) and laparotomy (30%). Unfortunately, only 20 benign cystic teratomas were managed by cystectomy. In that study, the benign cystic teratoma rupture rate during cystectomy at laparotomy was 44% compared to 18% in the laparoscopy group. This was similar to the current findings, with cystectomy leakage at laparotomy (39%) occurring more frequently at laparoscopy than by experienced surgeons (26%). Other observational studies have reported leakage rates at laparoscopic resection of anywhere between 13 and 100% (Nezhat et al., 1989
; Bollen et al., 1992
; Reich et al., 1992
; Chapron et al., 1994
; Howard, 1995
; Lin et al., 1995
; Teng et al., 1996
; Ulrich et al., 1996
; Shalev et al., 1998
).
Granulomatous chemical peritonitis has been previously reported in at least 100 patients (Wolfe et al., 1984). Peritonitis associated with the leakage of benign cystic teratomas is characterized by multiple small yellowwhite implants and dense adhesions (Stern et al., 1981
). Microscopically, these lesions are granulomas with lipoid-laden macrophages, lymphocytes, plasma cells and foreign-body giant cells present (Kistner et al., 1952
; Stuart and Smith, 1983
). Chronic peritoneal irritation secondary to leakage can mimic pelvic inflammatory disease, carcinomatosis or tuberculous peritonitis. Keratin and sebum are considered potent irritants (Kurrein and Fothergill, 1961
).
At laparotomy, intraperitoneal leakage during ovarian cystectomy can be minimized by exteriorizing the ovary and placing packs prior to ovarian capsule incision. A similar approach can be taken at laparoscopy with placement of the ovary into a bag prior to cystectomy. Some authors argue that copious irrigation will reduce or prevent the risk of peritonitis at laparoscopic cystectomy. For this reason, benign cystic teratoma cysts have been managed laparoscopically without regard to cyst leakage (Hessami et al., 1995; Howard, 1995
). Although we agree that irrigation is an important component of any surgery, it is not a substitute for experience. As demonstrated by this study, laparoscopic experience can reduce benign cystic teratoma leakage to a minimum. Also, benign cystic teratoma fluid is commonly viscous and may contain other potentially inflammatory products, including hair, sebum, bone, cartilage and fat. If these contents are allowed to escape, they may be difficult to remove manually or with irrigation. Irrigation in the Trendelenberg position may also displace these products into the upper abdomen or other areas not easily visualized. Also, lavage failed to reduce the level of inflammation and adhesion formation down to control levels as assessed histologically in the rabbit model (Fiedler et al., 1996
).
The laparoscopic approach to large benign cystic teratoma cysts (>10 cm diameter) may provide some technical difficulties to specimen removal. Commercially available endoscopic bags often do not open to beyond 610 cm in diameter. To facilitate removal of large specimens, some authors suggest the use of laparoscopic assisted vaginal resection (Pardi et al., 1995; Teng et al., 1996
), extending the abdominal incision (Shalev et al., 1998
) or aspirating and irrigating the cyst fluid until the fluid clears, followed by cystotomy closure and subsequent cystectomy (Ulrich et al., 1996
). In our series, none of the benign cystic teratomas exceeded 10 cm in diameter.
This is the largest observational study to date comparing the management of benign cystic teratomas by laparoscopy and laparotomy. We were able to examine the role of cyst size, adhesions and experience on leakage rate. As with all observational studies, we are limited in our conclusions. It is possible that a residual confounding factor was unmeasured. For example, we did not subdivide the number of advanced laparoscopic cases performed by each surgeon when estimating laparoscopic experience. We could have also attempted to quantify surgeon experience using the average number of cystectomies of all types for laparotomy and laparoscopy. This would have required reviewing thousands of charts. Despite these limitations, we were able to demonstrate a trend with overall laparoscopic experience.
In conclusion, benign cystic teratoma leakage at surgery can be significantly reduced if an oophorectomy is performed. However, oophorectomy should only be considered in patients who are not interested in preserving ovarian function. The method of access (laparoscopy versus laparotomy) does not influence the overall rate of benign cystic teratoma leakage at cystectomy. However, if cystectomy is attempted by laparoscopy, benign cystic teratomas are less likely to leak when the operation is performed by an experienced endoscopic surgeon.
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Notes |
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References |
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Submitted on January 26, 1999; accepted on May 28, 1999.