Laparoscopic-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study

doi:10.21203/rs.3.rs-4935932/v1

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Laparoscopic-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study

https://doi.org/10.21203/rs.3.rs-4935932/v1

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Objective: To evaluate the safety and feasibility of Laparoscopic-Assisted abdominal small incision for the management of adnexal masses during pregnancy.

Design: Retrospective case series.

Setting: University-based tertiary-care hospital.

Patients: 12 pregnant women with an adnexal mass during the second-trimester.

Interventions: Laparoscopic-Assisted Minimally invasive surgery with abdominal small incision.

Measurements and Main results: Surgical and obstetric outcomes were evaluated. 1. The median age was 28.5 years (range, 25-40 years), all procedures were done during the second trimester, the mean gestation week was 16 weeks (range, 12-17weeks) at operation. 2. The mean operational time was 130 minutes (range, 45-200 minutes). The median blood loss was 10ml (range, 5-200ml). The mean decrease of hemoglobin was 12g/L (range, 2-35g/L). The mean onset of flatus was 24h (range, 22-56h). The mean hospital stay was 5.5days (range, 2-7days). 3. 13 ovarian cysts and 1 mesosalpinx cyst were sent to histopathological diagnosis and the most common diagnosis is corpus luteum cyst. Cystectomy was performed for all women. 4. All patients had an uneventful recovery. The median gestation at delivery was 39.5weeks (range, 33-41 weeks), and the median birth weight was 3,227.5 g (range, 1465-4,300 g). 5. The median follow-up time was 3.5 years (range, 0.5-7years). All babies were healthy.

Conclusion: Based on these initial findings, laparoscopic-Assisted abdominal small incision appears to be a safe and technically feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy.

adnexal mass

abdominal small incision

laparoscopy

surgical outcomes

obstetric outcome

Adnexal mass is the most common indication for gynecologic surgery during pregnancy ^[1]. Expectant management is the first-choice treatment of adnexal masses, based on an increased rate of spontaneous resolution ^[2]. However, surgical management may be indicated in the presence of a persistent or symptomatic adnexal mass larger than 6cm because of major complications such as torsion, rupture, bleeding, or malignancy ^[3].

Laparoscopic management of adnexal masses in pregnancy has been demonstrated to be technically feasible ^[3–5], and laparoscopy is currently accepted as the most efficient method to manage adnexal masses in pregnancy when surgery is indicated ^[6]. Potential concerns include direct trauma to the uterus or fetus, compromise of the uteroplacental perfusion as a result of increased intraabdominal pressure, fetal acidosis caused by carbon dioxide (CO2) absorption, and carbon monoxide poisoning as a result of exposure to smoke generated by laser surgery or bipolar desiccation.

An alternative between laparoscopy and laparotomy is the minilaparotomy (ML) which can be an interesting option, thanks to the small incision ^[7]. The advantage of a ML is not only shorter operating time with less learning curve compared to laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with lower risk of rupture and in addition the possibility to preserve more ovarian tissue ^[8].

On the basis of this method, we developed a novel technique, laparoscopic-assisted minimally invasive surgery with abdominal small incision, such that it can be easily perform surgery. The objectives of the present study were to evaluate the technical feasibility and the surgical and obstetrics outcomes of the novel procedures.

From January 2015 to March 2020, a total of 12 patients diagnosed with adnexal mass during pregnancy. The indications for surgery included mass larger than 6 cm or persistent until 16 weeks of gestation or enlarging masses or suspicion of malignancy on sonography. Patients who had a viable intrauterine fetus and a desire to continue the pregnancy were included. Patients with heterotopic pregnancies or malignancy, and or with induced abortion concomitantly, and or with incomplete medical records were excluded. The hospital records were retrospectively reviewed, after approval by the institutional review board the study.

Surgical Procedure

All procedures were performed by a surgical team composed of three surgeons (Zhq. Zhang, Mh. Li and BR. Mu) with assistants. Fetal surveillance was performed by monitoring the fetal heartbeat via ultrasonography, before and after the operation.

As for the surgical technique, the patient was placed in the supine position slowly and carefully. Abdominal insufflations were done by inserting the Veress needle in the umbilical or supraumbilical area, the location of which is adjusted according to fundal height. The first Trocar which was 5-mm 30-degree was inserted below the umbilicus. Pneumoperitoneum was established with use of CO2 insufflations and was maintained at an intra-abdominal pressure of 10 mmHg. The second Trocar was then placed under direct vision to avoid injury to the uterus. After detection with laparoscopy and make sure of the side of ovarian cyst under laparoscopy, oblique incision with diameter of 2.5cm was made on the right or left side of the lower abdomen according the side of ovarian cyst, an Alexis retractor (small size, Applied Medical, Rancho Santa Margarita, CA) was placed through the 2.5cm oblique skin incision to utilize as a single access working port (Fig. 1). The cysts could be easily extracted from the abdominal cavity (Fig. 2). Sterile pads were placed around the cyst to avoid, in case of a rupture, a contamination of the abdominal cavity. The ovarian lesions were treated with cystectomy in general manner. Incision was sutured interrupt (Fig. 3,4).

After surgery, the patients were not commonly given acetaminophen as analgesia. A case-by-case administration of prophylactic antibiotics preoperatively or postoperatively was done, and not routinely. Fetal well-being was assessed again routinely before discharge. Patients were allowed to discharge when they were fully mobile, passing urine satisfactorily, and not requiring narcotic analgesia.

Follow-up was done for all patients. For those patients who delivered in our institution, pregnancy outcome was obtained from their medical records. For those patients who delivered elsewhere, three attempts were made to collect that information by telephone. Those cases in which information was received by telephone, the patients were asked to deliver the information from the official birth documents to minimize the effect of recall bias.

A total of 12 patients have been identified, and their median age was 28.5 years (range, 25–40 years) old. The median gestational age was 16 weeks (range, 12-17weeks) at the time of operation. All the procedures were done during the second trimester of pregnancy. None of our patients underwent procedures in the third trimester. The median interval between diagnosis of ovarian cyst to surgery was 11weeks (range, 1-208weeks). Cystectomy was performed for all women. No cases were conceived by In Vitro Fertilization and Embryo Transfer (IVF-ET).

All the operations were performed successfully with no complications and minimal blood loss. The median operational time was 130minutes (range, 45–200 minutes). The median blood loss was 10ml (range, 5-200ml), the median decrease of hemoglobin was 12 (2-35g/L), and the median flatus time after operation was 24h (range, 22-56h). All of the patients had an uneventful recovery, and the median hospital stay was 5.5 days (range, 2–7 days). 13 ovarian cysts, 1 mesosalpinx cyst, including 2 cases with bilateral ovarian cysts, were sent to histopathological diagnosis, including 5 corpus luteum, 4 mature teratoma, 2 endometrioma, 1 serous cystadenoma, and 1 mucinous cystadenoma.

Pregnancy was continued to term in all patients. 8 patients delivered normal term babies vaginally. 4 patients underwent cesarean section because of obstetric indications, including fetal distress, and labor progress failure, and severe eclampsia. The median gestation at delivery was 39.5weeks (range, 33-41weeks), and the median birthweight was 3227.5g (range, 1465-4300g). 1 preterm labor was reported because of severe eclampsia. All patients and their babies were followed up. The median time was 5 years (range, 2.5-9years). All the babies were healthy.

Our results, show that, laparoscopic-Assisted abdominal small incision is a safe and feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy, with the less risk of potential negative effects of carbon dioxide gas insufflations on mother and fetus. These operations represent another possible alternative between laparoscopy and laparotomy, and are safe, reliable and associated with a decreased risk of maternal and fetal post-operative complications, and with an improvement in post-operative course.

The advantage of this approach which we recommend, also considered in literature as a minimal invasive procedure, is not only a shorter operating time with a less learning curve than with laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with a reduced risk of rupture and subsequent the possibility to preserve more ovarian tissue with lower risk for complications, and it represents an interesting option because of a small incision (2.5cm). Secondly, it not only will prevent the hazardous consequences that result from a delay in intervention, but also will allow for surgical treatment of any problem found in the abdomen. Thirdly, the panoramic view of the pelvic organs obtained at laparoscopy may reduce the need for intraoperative uterine manipulation. Fourthly, in special cases if the cyst is bilateral, multi-cystic, very large with a high risk of rupture and childbearing is not completed, laparoscopic-Assisted Minimally invasive surgery with abdominal small incision can be a good option also because each tumor can be easily extracted from the abdominal cavity reducing complications and, in this way, giving the chance to preserve more ovarian tissue. In addition, combined with no use of electro-surgery in the proximity of the uterus, the risk of uterine irritability may be reduced, translating into a decreased incidence of postoperative miscarriage and premature labor, the last but not least, is that an upper abdomen exploration through laparoscopy could be performed, especially when necessary, such as in the case of an unexpected borderline malignant or ovarian tumor diagnosed by frozen section analysis.

For treatment of adnexal masses during pregnancy, several surgical approaches have been described, including single-port laparoscopic surgery (SPLS) ^[9], gasless laparoendoscopic single-site surgery^[10], minilaparotomy^[8] and robotic-assisted laparoscopic surgery (RALS) ^[11], have also been introduced and appears to safe and less invasive alternative to laparotomy or conventional laparoscopy. Laparoscopic-Assisted abdominal small incision is another safe and feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy, with the less risk of potential negative effects of carbon dioxide gas insufflations on mother and fetus.

The main limitation of this study was that it was not a comparative study of 2 different techniques and the small sample size. The pregnancy and neonatal outcomes in our series patients are promising. Because of the limited cases in our case series, further studies addressing the efficacy and safety of this novel technique with those of other approaches are warranted. In conclusion, the present study suggests that this procedure combines advantages of laparoscopic and abdominal approaches, and generate satisfactory surgical and obstetrics outcomes, and should become a valid alternative to all approaches described so far for patients with adnexal mass during pregnancy.

Conflict of interest

We declare that we have no conflict of interest.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Funding
This work was supported by fund from National key R&D Program of China Number: 2017YFC1001200.

IRB Ethical approval

The study protocol was approved by the Institution Review Board.

Consent to participate declaration: not applicable.

Authors' contributions

M.H.Li performed the surgery, conceived and designed the study, analyzed the data, contributed materials/analysis tools, and wrote the paper. Zh.Q.Zh performed the surgery, collected analyzed the data, contributed materials/analysis tools, and wrote the paper. B.R.M recruited the patients, performed the surgery, collected the data, and wrote the paper.

Acknowledgements

The authors wish to thank all of the surgeons who participated in the investigation and Dr Zhan Li for her assistance in the writing of this texts.

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No competing interests reported.

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Laparoscopic-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study

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