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Re: 'scoping dermoidsFrom: Peter V. Weston, M.D. (weston@ICSI.Net)Wed Dec 6 16:24:18 1995
>To the more laparoscopically athletic on our list: > >I would appreciate a few literature references (including review articles, if >possible) dealing with laparoscopic surgery for dermoid cysts. If these contain >info on 2nd look 'scopes to assess risk of adhesiogenesis, so much the better. If this is a repeat post please excuse me but I suspect that my original post went to cyber neverland. In my opinion we should look upon endoscopic surgery as an approach and not as surgery in and of itself. Hysterectomy is hysterectomy regardless of whether the approach is vaginal, abdominal, endoscopic or a combination of the above. Oophorectomy, ovarian cystectomy, surgial sterilization, presacral neurectomy, bladder neck suspension etc etc are all operations for which there are indications and the approach should be the one that is best for the patient and the one that is within the competence of the surgeon. What is of paramount importance is that basic surgical principles MUST be adhered to. The basic principles governing ovarian cystectomy whether for mature cystic teratomata or for as yet undetermined pathology are as follows: Adequate visualization of the peritoneal cavity including the liver and diaphragm. Ability to take call washings. Removal of the cyst or ovary intact without contamination of the peritoneal cavity with cyst contents. I hate to make this a dogmatic statement because in some institutions it is not possible to have a pathologist standing by to perform frozen section analyses. In my opinion it is in the patient's best interest to have a rapid diagnosis available so that if a malignancy is found definitive staging surgery can be performed under th same anesthetic. Spillage of cyst contents can be avoided with the use of containment bags. With that preamble out of the way let me present our technique of ovarian cystectomy. Ovarian cystectomy can best be performed using 3 operationg ports. The 2 lateral ports are 5mm and the subumbilical port is 10mm. Two of the ports are for grasping instruments (for traction and countertraction) and the other for scissors. One can usually differentiate ovarian tissue from the cyst by the presence of follicles, corpora lutea and or corpora albicantes. An incision is made in the cortex, the cut edges grasped and pulled apart and the scissors passed between the cortex and the cyst. The scissors are open and withdrawn, the capsule cut and this process repeated until the entire ovary os circumscribed. If the ovary needs to be stabilized it can be supported against the pelvic wall with the uterine manipulator. After the ovary has been circumscribed the cyst can be separated for the ovary with sharp dissection taking advantage of the magnification that laparoscopy affords. It is very unusual to have bleeding. If the ovary is no greated than 5 or 6cm in diameter it can be inserted into a bag such as the Endopouch by US Surgical. The Endopouch is passed through the 10mm port. The advantage of the Endopouch is that the mouth of the bag stays open because of a "memory metal" ring. The cyst can then be scooped into the bag and the bag closed with the purse string suture. The memory ring is closed and the instrument removed. Next remove the endoscopic cannula and use the purse string to bring the mouth of the bag into the incision. Grasp the bag with hemostats, cut off the purse string and expose the cyst in the bag. Under direct vision puncture and drain the cyst. Avoid the temptation to pull on the bag - it can break! When the cyst is deflated or morcellated grasp it with a Kocher clamp and remove it still in the bag. If the cyst is too big to fit into an Endopouch one can use a gas sterilized 1 quart Glad bag. Roll this into a tight pencil and pass it through the 10mm port. Once in the peritoneal caavity unroll it, hold the 2 sides apart with graspers and insert the cyst. Pass a toothed grasper through the 10mm port and grasp a corner of the bag. Remove the cannula, pull the bag upto the skin edge, grasp with a hemostat and decompress the cyst as before. If necessary the incision can be enlarged. If the abdominal wall is thick an operating laparoscope with a camera attached can be passed into the bag and using scissors the cyst can be opened under direct vision. On review of the literature some surgeons remove the cyst through a colpotomy incision and do not appear to be concerned about soillage. The sebaceous material in benign cystic teratomata is extremely caustic and copious lavage is recommended. Harry Reich states "Vigorous peritoneal cavity irrigation withat least 10 litres of Ringer's lactate ........ is recommended .......". A couple of references: Clinical Obstetrics and Gynaecology Volume 3 Number 3 September 1989 Pages 655-681 Obstetrics and Gynecology Volume 86 Number 6 December 1995 Pages 964-968 I this is not clear feel free to call me at home (210) 493-5042 any evening Central Time. I think that is GMT -7.
-- Peter V. Weston, M.D. Private Practice, Gynecology, San Antonio. weston@icsi.net
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