European Journal of Obstetrics & Gynecology

ELSEVIER and Reproductive Biology 65 (1996) 81-89

Ovarian cysts

Luca Minelli*
C. Porno Hospital, Department of Obstetrics and GyMecology. Mantova, Italy

Abstract

The Author intends to compare the data available in literature on the topic of ‘iaparoscopic surgery of ovarian cysts’ to his case material. From
1985 to 1994, the author carried out 920 laparoscopic operations for the removal of ovarian cysts. Of these., 13 were converted to laparotomies,
mostly because of pet-i-adnexial adhesions. There were 22 recurrences (endometriosic and mutinous multilocular cysts), and five severe complica-
tions (two puruknt intkmmations, one intra-operative haemorrhage and one post-operative one, one post-operative acute abdomen sine causa).
In one case, an unrecognised endometrioid carcinoma was inadequately treated with laparoscopy. The author considers laparoscopy as the elective
choice for surgical treatment of ovarian cysts. Suspect malignancy is not a contra-indication to laparoscopic surgery, since the removal of the opera-
tive specimen and its subsequent histological examination can be. effected - in the large majority of cases - with the same results both
laparoscopically and laparotomically. There is a problem with undiagnosed carcinomas in fertile females, but it is equally present in laparotomy.

Keywork Laparoscopy; Ovarian cyst

1. Introduction serum and endocystic markers are the basis of many

With the advent of ultrasonography and of laparosco-
pit surgery, the approach to adnexial pathologies has
undergone major and radical changes. Clinicians could
access situations that were not evident with the manual
examination of patients [1,2]. Ultrasound dbpistages for
the study of ovarian cancer have evidenced the presence
of symptom-free, or silent cysts in 3-7% of the popula-
tion [3,4].
This may lead surgeons to operate on patients with
functional cysts that would have disappeared spon-
taneously, with the intention of distinguishing benign
from malignant turnours. Patients with ovarian car-
cinomas are sometimes treated inadequately either with
laparoscopic or laparotomic surgery.
2. Diagnosis
A protocol is necessary to exclude those patients with
functional cysts from useless surgery, and to submit to
adequate treatment those patients with organic cysts 151.
Clinical examinations, ultrasonography and a study of
*Via San Eietro, 85,25077 Rd Volciano BS, Tel. +39 337 436615,
+39 365 556104; fax: +39 365 556008.
protocols suggested in literature.
Patient age is relatively important in diagnosis. The
ratio between malignant and benign epithelial tumours
increases with age, from 4% between 20 and 30 years, to
50% between 60 and 70 years. As for borderline
tumours, the ratio remains 4% and is not age-related [6].
Ulmsonography cannot distinguish between function-
al cysts and simple organic cysts. Its sensitivity in
distinguishing between benign and malignant cysts is be-
tween 62% and lOO%,and its specificity is between 87%
and 95% [5,7-lo]. The best results are obtained by using
the endovaginal probe [ 111. The ultrasonographically
perceivable risk of ovarian carcinoma differs in meno-
pause with respect to fertile age (6% for simple cysts,
29% for solid cysts, 42% for complex cysts) 1121.Nega-
tive predictive values do not exceed 94%, with 6% of
malignancies in small, echoless cysts [12] that become
10% in totally echoless cysts larger than 5 cm [13]. Fur-
ther information could be collected by using colour-
Doppler [14-171; however, this does not seem to offer
extra advantages when compared to the concurrent use
of other diagnostic methods, such as endovaginal ultra-
sonography, CA125 and NMR [18].
Cyst volume seems to be of little importance with re-
spect to other ultrasonographic data [12]. However, it

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SSDI 0301-2115(95)02309-U
82 L. Mine&/European Journal of Obstetrics & Gynecology and Reproductive Biology 65 (19%) 81-89
becomes more important in post-menopause, from both
the diagnostic and the surgical points of view. The per-
centage of carcinomas increases from 3 to 1I%, and up
to 60%, for cysts smaller than 5 cm, from 5 to 10 cm, and
greater than 10 cm in volume, respectively 1191.
Serum markers. CA1 25 has a good predictive value in
the presence of an ovarian mass, especially if the
threshold value is raised from 35 to 65 units/ml. Sensitiv-
ity range from 75 to 78%, and specificity from 92 to 9’7%,
according to whether age is considered or not, or
whether only women in menopause are considered,
respectively. However, 50°/ of first-stage carcinomas
have a normal CA125 [20]. The use of more serum
markers in association (CA125 CA153, TAG72-4)
does not seem to improve diagnostic accuracy with re-
spect to CA125 alone, or in association with CA19.9 for
the mutinous histotype; in fact, the increase in specifici-
ty is counterbalanced by a decrease in sensitivity [21]. A
diagnostic improvement seems to come from the
association of clinical examinations, ultrasonography
and CA125 - this gives equal or better results than the
association of cytology, colour-Doppler and NMR
[22,23].
U~tr~o~d-glided aspiration allows the following:
- a macroscopic examination of the aspirated liquid,
which can decidedly indicate an organic cyst if the
liquid is fatty, chocolate-coloured or mutinous [24];
- the cytological test of cystic liquid, with diagnostic
reliability ranging from 85 to 95% [25,26], sensitivity
at about 40%, and a specilicity of 100% [27]; false
negatives account for 20-75% of carcinomas 1281,
and the negative predictive value is 77% [29];
- intracystic and hormone assays (E2, P), and tumour
marker assays can distinguish functional cysts (high
E2 and/or P) from organic cysts (high CAl25) very
well, but cannot distinguish benign organic cysts
from malignant ones [30,31].
The risks of ~trasound-~ded aspiration include the
theoretical possibility of intra-abdominal and abdom-
inal-wall dissemination of malignant cells [10,32-341,
peritoneal irritation or infection in 25% of dermoids, in
10% of lymphocoeles, and in 6% of endometriomas [35].
Ultrasound-guided needle aspiration is carried out in
case of persisting unilocular echoless cysts or of
multilocular cysts with thin septa, and with anamnestic
data that indicates the possibility of periovarian
peritoneal dystrophy (adhesion cyst). Needle aspiration
leads on to immediate laparoscopy if the liquid obtained
is oily (devoid), murky (mutinous cystoadenoma, or
- more rarely - cystoadenocarcinoma), or decidedly
bloody (vascular lesion, vessel of the cystic wall, en-
docystic tumoural mass). In other cases, the results of
the biological and cytological tests will be necessary to
distinguish between organic cysts (high CA125) and
functional cysts (high E2 or P), and will influence the de-
cision on whether to proceed with laparoscopy or to
simply wait. Needle aspiration may be therapeutic in
case of persisting functional cysts and of organic cysts
too, if their origin is adhesive, or if the productive epi-
thelium has disappeared under the effect of pressure
from the endocystic liquid [36]. If the cyst is unilocular
and echoless, or echopoor, the patient can wait and, if
necessary, follow an estrogen-progestogen therapy 1371;
another possibility is ultrasound-guided needle aspira-
tion, which enables the physician to distinguish with rea-
sonable certainty between functional and organic cysts.
If malignancy is not suspected, if the cyst is multil~ular,
or if its characteristics indicate a dermoid, or an en-
dometriosic or mutinous cyst, then laparoscopy is in-
dicated. Whenever the least suspicion of malignancy
exists, most authors suggest removing the tumour
laparotomically [38].
Diagnostic stages continue with laparoscopy, which
makes a distinction between functional and organic
cysts possible [39], but which is especially implant for
tinding signs of malignancy that may have been
suspected or excluded in pre-operative tests. Laparos-
copy as a diagnostic survey for ovarian carcinomas
seems to have very few false negatives (0.4%), but a lot
of false positives (58%) [9].
The laparoscopic examination begins with an over-
view of the whole abdominal cavity, also looking for
possible signs of metastases, then continues with the ob-
servation of the cyst surface, sampling of the peritoneal
liquid, aspiration of liquid from the cyst, and an en-
docystic view. Laparoscopic signs that lead to suspect a
carcinoma are exocystic growths, unusual colour, and
an abundant and irregular vascularisation of the ovarian
surface, together with the murky aspiration liquid and
the presence of endocystic growths.
During this stage of laparoscopy, the fundamental
issue is assessment of the risk represented by the aspira-
tion, opening and biopsying, or removal of a first-stage
malignant growth. Prognosis does not worsen in case of
intra-operative spilling of a carcinoma [40,41] and this
has induced FIG0 (the Italian society of obstetrics and
gynaecology) to consider the elimination of stage lc
from it&a-operative spilling. Case material in literature
is reassuring on this head as far as borderline tumours
are concerned [42,43]; it is contradictory as far as ovari-
an cancer is concerned [34,44-481, and seems to indicate
a real risk if malignant tumours are not removed during
a single laparoscopic session.
3. surglull teehoipue
Preparation for surgery and the patient’s position on
the surgical table present no specific difflculti~. If the
patient is not a virgin, it is best to position a
 L. ~~~eI~~~Euro~~
Journal
of Obstetrics
% Cynecoiogy
manipulator in the uterus, which becomes very useful in
case of peri-adnexial adhesions.
The basic surgical tool set-up is very simple: a Veress
needle, one lo-mm trochar and two 5-mm ones, two
large anatomical forceps (Manhes type), a needle for
cyst aspiration, one 5-mm cannula for washing and as-
piration, scissors, bipolar forceps with a large grasp and
one endoscopic bag [49,50]. Sometimes, specific tools
are useful, such as: surgical tenaculum forceps for the
extraction of the surgical specimen; a monopolar needle
for the removal of a wedge of ovary including the cyst;
a third 5-mm operative access to detach pa~i~ularly dif-
ficult adhesions; a lO-mm lavage tube with a single ter-
minal hole for the aspiration of the contents of a
dermoid cyst that breaks during enucleation; biopsy
forceps to remove suspect metastases; two needle-
holders for suturing the wall in case of a haemorrhage
that is not controllable with bipolar coagulation; fibrin
glue to approach a highly irregular ovarian breach.
The following are laparoscopic surgery techniques for
the treatment of ovarian pathologies: intraperitoneal
enucleation of the cystic wall after aspiration and en-
docystic viewing 1511; enucleation of the whole cyst
[52,53]; removal of an ovary wedge including the cyst;
Pans-parietal enucleation; adnexiectomy [5 11.
3. I. Intraperitoneal enucleation
Intraperitoneal enucleation is the technique which is
most commonly used in case of benign organic cyst [54].
After aspiration of the cystic contents, a small cut,
through which the telescope for endocystic viewing is in-
troduced, is made in the wall. If no suspect lesions are
seen, the cyst wall and the ovary wall are gripped with
two anatomical Ma&es forceps, and the enucleation of
the cyst wall from the surrounding ovarian parenchyma
begins, with traction and counter-traction movements,
while maintaining both grips close to the cleavage plane.
In case of blood loss, it becomes necessary to coagulate
the ovarian wall vessel during the enucleation proce-
dure, For a better view of any bleeding that may occur,
it is important to decrease the strength of the pulling
movements at regular intervals, since they may hide a
haemorrhage coming from small vessels that are
momentarily compressed. This is essential, especially
when the deeper layers close to the ovarian hilus are
reached. This care is amply repaid at the end of the
enucleation procedure, when the search for bleeding ves-
sels on the wall of the cavity created in the ovary is par-
ticularly difficult, and may require up to four operative
accesses (traction, counter-traction, lavage, coagu-
lation).
A variation of this method is the enucleation of the
whole cyst, either before or after aspiration of its con-
tents. Indications for this are dermoids and cysts with
ultrasonograms that indicate possible intracystic
and Reproductive
Biology
6.5(1996)81-89 83
papillae. This technique requires a limited section of the
ovary’s surface, and a successive enucleation with trac-
tion and counter-traction on the ovary and on the outer
wall of the cyst.
In case of suspect cysts or of dermoids which are not
totally intra-ovarian, it is possible to use a monopolar
needle to carry out an ovarian wedge in the point of
passage between the normal ovarian parenchyma and
the part of the ovarian wall that covers the cyst. Incision
of the wedge continues by exerting traction with the
forceps (con~olater~ly to the ovary which is being
operated upon) which grip the ovarian tissue that is
removed together with the cyst, and continuing the sec-
tion with a monopolar needle or hook in the point of
passage of an artificial cleavage plane that is created
within the ovarian parenchyma, between the ovary and
the ovarian wall that covers the cyst. This section is
made easier by traction, by the monopolar section, by
bipolar coagulation and by the delicate dissection with
the blunt tip of the closed anatomical forceps.
Closure of the ovarian breach seems useless to the
author. Approaching the edges of an incision anti-
mesially gives perfect s~ntaneous r~ons~ction of the
ovary, without adding the useless risk of adhesion
created by the sutures [55,56]. If the ovarian breach is
particularly irregular, it may be useful to invert the
edges by means of bipolar coagulation of the internal
wall, or by using fibrin glue. In such cases, but especially
when there is a slight but persistent haemorrhage, the
use of sutures may be justified.
3.2. trans-parietal enucleation of the ovarian cyst
With this technique [57], laparoscopy is the prepara-
tion and guide for a suprapubic ~~-laparotomy. Once.
the contents of the ovarian cyst have been removed by
aspiration, mobility of the ovary is assessed. If this is
considered to be sufficient, a mini-iaparotomy is carried
out, with a transversal cutaneous incision of 2-3 cm,
vertically on the ovary. By using a Faraboeuf retractor,
the fascia is exposed, and a horizontal incision is then
executed. A guidewire is positioned on the fascia. Then,
the peritoneum is opened and a second guidewire is
positioned on its edge. Once the adnexum is extracted,
cyst enucleation and ovary reconstruction are carried
out with the usual laparotomic technique. Once the
ovary is re-introduced into the abdomen, a stratified
coeliorraphy is carried out on the laparotomic cut, and
the end result is checked with a final laparoscopic view.
This method is slowly being abandoned, but it is in-
dicated in the presence of multilocular, often mutinous
cysts, to decrease the risk of early recurrence which
comes from incomplete enucleation.
3.3. tiparoscopic adnexiectomy
&mm [58] was the first to carry out a hpIrOscOpiC
a4 L. Minelli / European Journal of Obstetrics & Gynecology and Reproductive Biology 65 (19%) 81-89
adnexiectomy in 1973, and then suggested a modifica-
tion to it in 1980 [59]. In 1985, Levine [60] carried out
the first bilateral ovariectomy in the U.S. More recently,
Mann [61] published a report on laparoscopic adnexiec-
tomy in menopause.
As with laparoscopic ovariectomy [62], adnexiectomy
is a simple operation most of the time, with rare intra-
and post-operative complications. The indications are
the same as those for the laparotomic procedure, and
pre-operative selection of the cases most suitable for lap-
aroscopy is similar to that described for ovarian cysts
1631.
After exposure of the ureter, the surgical technique re-
quires haemostasis of the utero-ovarian and infundi-
bulo-pelvic ligaments, of the mesovarium, and their sec-
tion. Different methods of haemostasis may be chosen
[64]: bipolar coagulation [58,65,66], endoloop tourni-
quets [59,67], classic sutures, endoscopic suturers [67],
or mixed techniques [68].
The surgical specimen may be removed by morcella-
tion, but it should always be extracted within an endo-
scopic bag, and surgery should never cause spilling [48].
3.4. Very large cysts
If cyst size is such as to make trochar introduction im-
possible, it becomes necessary to carry out ultrasound-
guided trans-parietal aspiration; the operation can then
continue with the above-described techniques. Before
enucleation, it may be advisable to section part of the
cyst with its ovarian wall. However, one must remember
that histology often finds follicles in even the thinnest
ovarian walls. At the end of the operation, reconstruc-
tion of ovary shape must be more accurate than usual.
3.5. Infraligamentary cysts
The enucleation of infraligamentary cysts, which are
often serous or mesonephric, should always be carried
out before cyst aspiration, for a clearer view of the
cleavage plane. Once the peritoneum of the broad liga-
ment of the uterus has been incised at an adequate dis-
tance from the salpinx, enucleation can be carried out
with delicate traction and counter-traction movements.
The coagulation of small vessels may become necessary
during enucleation, especially if the starting point of the
cyst is found to be within the ovary, and if it is exposed;
at that point it is also possible to apply an endoloop
tourniquet [69]. At the end of the operation, the opening
in the broad ligament will turn out to be surprisingly
small, and will be closed completely with the aid of
fibrin glue.
3.6. Endometriosic cysts
The technique for the enucleation of these cysts differs
from the others in some points: the cleavage plane of en-
dometriosic cysts is sometimes less evident, or more dif-
ficult to separate, especially if medical treatment has
preceded surgery. Haemostasis must be accurate, and
the final closure of the ovarian breach is contra-
indicated; in fact, reports in literature [70] suggest treat-
ment by simple opening of the cyst. Great attention
must be paid to any adhesions to the ureter or the intes-
tine. It is also possible to limit surgery to the resection
of the salient part, followed by bipolar coagulation of
the internal wall, or - better yet - by vapourisation
with CO2 laser, even if enucleation seems to reduce the
frequency of recurrences [71].
3.7. Dermoid cysts
Laparoscopic treatment of dermoid cysts is routine in
many centres, but despite this, there are few reports
available in literature [72-771.
For these cysts, the risk of enucleation consists in the
possibility of granulomatous chemical peritonitis; how-
ever, recent literature contains no reports on this
[73,76,78], and the real incidence of this risk is therefore
difficult to assess [72,75,79,80].
To avoid a long and tedious final lavage, it is ad-
visable to try and enucleate the whole unbroken cyst. It
must then be placed in an endoscopic bag, aspirated,
and finally removed.
If the cyst breaks during the enucleation procedure
[73,77], it is mandatory to proceed with the immediate
aspiration of all the cystic contents that have spilled out
into the abdomen, and to an extremely accurate final
lavage. It is extremely important that the liquid in-
troduced for the lavage should not go beyond the pelvic
excavation, to avoid diffusion of dermoid contents
among the intestinal loops [72,76].
The cyst must always be removed within an endo-
scopic bag [72] to avoid wall contamination which, in
the author’s personal experience, has induced one
purulent inflammation along the area, with slow remis-
sion because of secondary peritonitis.
Suture of the ovarian breach seems superfluous to the
author, even after removal of the dermoid [56].
3.8. Ovarian haemorrhagic cysts
At ultrasonography, a haemorrhagic corpus luteum
may be confused with a carcinoma, a teratoma, an en-
dometrioma, and a torsive adnexum. Cyst enucleation is
sometimes difficult because the tissue is brittle, or be-
cause no real cleavage plane exists. Laparoscopy is in
fact often carried out to solve the diagnostic doubt, with
a PID, a tubaric or ovarian GEU, or a complex ovarian
cyst [81-831.
3.9. Ovarian aahocarcinoma
Malignant tumours of the ovary have always been
 L. Minelli/ European Journnl of Obstetrics & Gynecology ond Reproductive Biology 65 (19%) 81-89
considered as the absolute contra-indication to laparo-
scopic surgery [84]. Even a mere suspicion upon
ultrasonographic examination is, for the greater majori-
ty of authors, a contra-indication to laparoscopy. This
attitude is due to the conviction that laparoscopic sur-
gery is inadequate for the correct and complete removal
of the tumoral mass, that it is incapable of correctly
staging the tumour, and that it causes a dangerous and
practically inevitable dissemination of the tumour.
In fact, after laparoscopy, many authors report intra-
cavitary dissemination of the tumour [85], cytological
examination of the peritoneal liquid that turns from
negative to positive because of the presence of tumoral
cells, and metastatic lesions of the wall along the passage
of the trochars [85-871.
The use of the endoscopic bag, although still inade-
quate for adnexial pathologies of such purport, enables
removal of the surgical specimen without intraperi-
toneal or abdominal-wall contamination [49,50].
Recently published reports consider it appropriate to
proceed laparoscopically to surgical staging and debulk-
ing. Lymph node dissection, mobilisation of the ureter,
hysterectomy, omentectomy and appendectomy are now
well documented laparoscopic surgery techniques [88].
In young women affected by borderline tumours but
wishing to have children, simple enucleation - even
with surgical spilling - or monolateral adnexiectomy in
40 cases have not led to successive onset of disseminated
pathologies [87,89]. In 1990, Reich [90] reported one
first-stage ovarian adenocarcinoma in which he associ-
ated vaginal hysterectomy with adnexiectomy, omentec-
tomy and lymphadenectomy, all laparoscopically. In
November 1993, Alvarez reported on his experience in
diagnostic laparoscopies that had unexpectedly shown
the presence of malignant ovarian tumours [91]. At the
end of 1993, Childers considered the state of the art of
laparoscopic surgery in gynaecological oncology and
stated that, albeit with a great deal of wariness, first-
stage ovarian cancers are now being tackled laparo-
scopically [92].
3.10. Complications
A rare complication of adnexiectomy, which occurs
particularly when surgery is made difficult by the
presence of extensive peri-adnexial adhesions, is the per-
sisting presence of a thin segment of ovarian tissue, call-
ed the ovarian remnant syndrome [93]; this may cause
the onset of delayed pelvic pain, the re-appearance of
adnexial growths, dyspareunia, and urethral compres-
sion [94].
Out of 757 operations, Canis reports nine major com-
plications (granulomatous peritonitis, post-operative
bleeding, pelvic abscess, parietal endometrioma, intesti-
nal obstruction, acute pelvic pain), and 23% of post-
operative adhesions on dermoids [55]. In 1992, Chapron
coordinated a multi-centre study [95] which revealed a
85
4.83/1,000 rate of complications in major laparoscopic
surgery, of which ovarian-cyst enucleation is part of. In
a collection of 1,200 cases in literature [95], the author
found ten major complications: three abscesses, two
cases of peritonitis (one after breakage of a dermoid, the
other after perforation of the sigmoid) and three haem-
orrhagic complications after the enucleation of en-
dometriosic cysts. No gelatinous peritonitis is reported
after breakage of mutinous cysts. The incidence of adhe-
sions was studied with particular reference to en-
dometriosic cysts: in one report [96], they attain 100%
in case of enucleation, 30% after destruction of the wall
with CO, laser, and 27% after simple drainage. On the
whole, however, the figures are lower than those found
after laparotomy [55,56].
In the author’s experience, out of 920 laparoscopic
operations on ovarian cysts, there were seven severe
complications: one ovarian abscess that led to a suc-
cessive laparoscopic adnexiectomy; one inflammation of
the abdominal wall; one uncontrollable intra-operative
haemorrhage which made it necessary to follow up the
enucleation with a laparoscopic adnexiectomy; one
post-operative haemorrhage that stopped spontaneous-
ly; two early recurrences of mutinous, multilocular
cysts, treated intra-peritoneally, with a second laparo-
scopic operation and rrans-peritoneal enucleation; one
false peritonism with a post-operative acute abdomen.
Oncological complications are difficult to assess ob-
jectively (survival prognosis), although sometimes a
modification of the FIG0 staging occurs at re-
operation. In 1991, Maiman [48] reported 42 cases of
ovarian cancer operated upon laparoscopically by
mistake, but his work seems subject to criticism because
of the ultrasonographic parameters that he adopted.
Blanc coordinated a multi-centre survey [95] that found
78 malignant tumours (60 borderline, 18 carcinomas)
out of 7,122 cases treated laparoscopically. Of these neo-
plasms, 17 had not shown any sign of malignancy either
ultrasonographically or laparoscopically; in the other 69
cases, the laparoscopy had not confirmed suspicions
from ultrasonography previous to surgery. False nega-
tives at laparoscopy therefore attain 0.2%, excluding
borderline tumours. In the author’s personal case mate-
rial of 920 organic cysts operated upon laparoscopically,
there was one malignant tumour in a 36-year-old patient
in whom the ultrasound and laparoscopic diagnosis had
been that of an endometriosic cyst. During enucleation,
the area adhering to the peritoneum of the ovarian fovea
initially appeared to be solid, then with cerebroid con-
tents: it was an undifferentiated endometrioid car-
cinoma.
4. Results
A comparison between laparoscopic and laparotomic
adnexiectomy or cyst enucleation 1671 showed that -
with equal indications - laparoscopic operation times
86 L. Minetti / European Journal of Obstetrics & Gynecotogy and Reproductive Biology 65 (1996) 81-89
are similar or lower @4,97,98]; moreover, laparoscopy
has fewer post-operative complications [61,64]. Its
hospitalisation costs are similar to those of laparotomy,
but only if disposable material and endoscopic suturers
are used, and the socio-economic advantage is
remarkable, thanks to quicker patient recovery and,
therefore, to shorter absences from work; this advantage
was calculated to be about U.S.$1,200 for each one of
the 55 000 patients 1671 sub~tted to adnexiectomy
every year in the U.S. [99].
Dismissal is nearly always possible after 24 h, except
in case of extensive adhesion removal, of patients at risk
of possible haemorrhage, or of the onset of rare post-
operative complications.
In patients without other causes of sterility, the preg-
nancy rate after laparoscopic surgery for ovarian
pathology is 89-93%, which supports the fact that there
are very few damaging effects with this type of surgery
(39 100).
Currently, the rate of conversion from laparoscopy to
laparotomy is down to 3-S% for benign cysts [95] and
attains 15% overall on a case material of 13 739 opera-
tions for adnexial pathologies [ 1011.
The rate of functional cysts operated upon uselessly in
laparoscopy remains about 15%, but tends to decrease
remarkably if a correct pre-operative protocol is
observed. In the author’s experience, this rate goes down
to zero if ultraso~d-bide needle aspiration of
unilocular cysts is carried out with intracystic E and P
assay.
In the author’s survey of literature, the number of
recurrences varies from Blanc’s 1% [95] to Canis’
1l/193, with three malignancies [55].
5. Coneltions
In 1980, a Consensus Conference organised by the
American College of Obstetrics and Gynaecology [102]
judged laparoscopic surgery as being suitable for the
treatment of ovarian cysts. The diagnostic reliability of
joint ultrasonography and laparoscopy is in fact very
high; the surgical technique is relatively simple, and sur-
gical times are similar to those of laparotomy. It
therefore seems reasonable to state that laparoscopy is
the elective surgical choice for the treatment of adnexial
pathologies (70 103).
For cyst enucleation, the conservative technique is the
in&a-peritoneal one; the operative specimen must
always be removed with an endoscopic bag [72].
Conversion to laparotomy is possible in various cases,
such as intra-operative compli~tions, tenacious adhe-
sions between adnexum and intestine, laparoscopic
suspicion of malignancy.
The author feels that the problem of incompatibility
between laparoscopic surgery and malignant tumours
(in the sense of removal of the adnexial growth with im-
mediate histological examination of the specimen), al-
though certainly real, has been overestimated, for the
following reasons:
(a) the risk of inadequate laparoscopic surgery be-
cause of the unexpected presence of an ovarian car-
cinoma is 4/1,~, but the ratio is similar even if the
operation is carried out laparotomically;
(b) in menopause, when the percentage of carcinomas
is higher 11,981, bilateral adnexiectomy is carried out.
This is a radical and ‘clean’ form of surgery, both
laparotomically and laparoscopically. In this way,
useless laparotomies can be avoided in 56.8% of
unselected patients (12 104) and in 94% of the cases with
negative accurate pre-operative screening (41 105);
(c) in young patients wishing to have children and af-
fected by adnexial growths with suspicious ultrasono-
graphies, laparoscopic surgery can be suggested, with
the removal of a wedge of ovary including the suspect
cyst;
(d) the problem of the inadequate surgical approach
to carcinomas is therefore limited to young patients with
no ultrasonographic or laparoscopic signs of malignan-
cy. In these cases, the cyst is submitted to aspiration and
enucleation, with inevitable spilling. However, this is a
rare occurrence [95], and in 75% of the cases the
tumours are borderline [IO61 and, therefore, present
similar risks also with laparotomic surgery.
In the author’s opinion, even in the case of suspected
malignancy, there is no reason to convertto laparotomy
if the type of surgery to be executed laparotomically
(ovariectomy, adnexiectomy, ovarian wedge) is
t~hni~lly feasible in laparoscopy, and with the same
probability of polluting the abdominal cavity, ex-
cluding, therefore, very large cysts and extensive and
tenacious peri-adnexial adhesions. Intra-operative speci-
men ex~nation results should guide subsequent surgi-
cal policy decisions. In young patients, after radical
removal of the adnexial mass, and with no spilling, it
may be possible to wait for the final histological results
before deciding on subsequent staging and, possibly,
more radical surgery.
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