Laparoscopic Managment of Adnexal Mass Prof. Dr. Fuat Demirkıran I.U Cerrahpaşa School of Medicine. Department of OB&GYN Division Of Gynocol Oncol TJOD 2012 Antalya,

%80 benign masses %10-15 malignant masses %5 Metastatic masses Adnexal Masses

Ultrasonography Tumor Markers Conventional Doppler 3D-4D Other Imaging Techniques BT MR PET-CT

Management of Adnexal Mass USG-guided Cyst Aspiration Laparoscopic Surgery Open Abdominal Surgery Follow-Up

Laparoscopy is associated with a reduction in the following: febrile morbidity, urinary tract infection, postoperative complications, postoperative pain, days in hospital, and total cost.

Low risk masses for malignancy

Many studies document that, after careful preoperative screening, the relative frequency of encountering a malignancy during laparoscopic evaluation is low(2%).

Cystadenomas

Endometrioma

Solid Mass

Dermoid cysts

There were no operative or postoperative complications related to cyst content spillage, regardless of the surgical approach.

Adneksiyal kitlelerin morfolojik sınıflandırılması ve malignite riski (IOTA) Timmerman D, Valentin L, Bourne TH, Collins WP, Verrelst H, Vergote I, International Ovarian Tumor Analysis (IOTA) Group: Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA)Group. Ultrasound Obstet Gynecol 2000; 16:500–505.

papillary projections

Frozen –section evaluation

Malignant masses

What about laparoscopic surgery for malignant adnexal mases

Laparoscopic surgery for Ovarian Cancer The adequacy of minimally invasive surgery compared to traditional laparotomy for staging. The risk of tumor cyst rupture. The incidence and long-term implications of port-site metastases. The effect of CO2 pneumoperitoneum on tumor growth.

results suggest that laparoscopic comprehensive surgical staging of EOC is as safe and adequate as the standard surgical staging performed via laparotomy. Gynecologic Oncology 105 (2007) 409–413

33% 75% Cyst rupture

Prognostic Effect of Cyst Rupture increase stageUn-change stage authorn n Gleeson NC23 Sevelda P60 Lehner R70 Kruitwagen RF219 Leminen A154 Ahmed FY194 Vergote I1545 Abu-Rustum NR289 Gleeson NC, Am J Obstet Gynecol, 2001; Sevelda P, Gynecol Oncol, 1989 Lehner R, Obstet Gynecol, 1998; Kruitwagen RF, Gynecol Oncol, 1996 Leminen A, Gynecol Oncol, 1999; Ahmed FY, J Clin Oncol, 1997 Vergote I, Lancet, 2001; Abu-Rustum NR, Gynecol Oncol, 2003

Port-site metastases

Minimize tissue trauma and the number of instrument transfers Rinse trocars in 5% povidine-iodine before insertion Perform trocar fixation Rinse tip of instruments in 5% povidine-iodine when interchanging instruments Resect tumor with adequate margins Use protective bags to retrieve tumor Remove all intraabdominal fluid before trocar removal Deflate the abdomen with trocars in place Irrigate site of trocars with 5% povidine-iodine Close peritoneal trocar sites (10- to 12-mm trocars) Preventive measures for reduction of port-site metastases

Effects of CO2 pneumoperitoneum There have been limited human studies evaluating this effect.

The accuracy and adequacy of laparoscopic surgical staging were comparable to laparotomic approach, and the surgical outcomes were more favorable than laparotomic approach. However, the oncologic safety of laparoscopic staging was not certain.

Surgical approach to adnexal masses Low intermediate high Laparoscopic surgery diagnostic laparoscopy laparotomy laparoscopic surgery Laparotomy Malignancy risk with USG and others