Removal of one or both ovaries, with or without the adjacent fallopian tube, has evolved in recent years beyond the management of acute conditions such as ovarian malignancy or torsed adnexa to encompass prophylactic surgery for women seeking to reduce their future risk of breast and ovarian cancer. Consequently, laparoscopic approaches to adnexal removal in isolation, or in conjunction with hysterectomy need to be well understood by most gynecologic surgeons. In addition to the above-listed indications, women with persistent lateralized abdominal or pelvic pain will often request removal of one or both ovaries, although limited evidence exists to confirm a long-term decrease in pain symptoms, even when a persistent mass, such as an endometrioma, or recurrent painful functional ovarian cysts are present. This is primarily due to current limitations in preoperatively diagnosing the root cause of chronic abdominal-pelvic pain. Similarly, removal of both ovaries to achieve permanent hypoestrogenism as a treatment for endometriosis in young women with multiple prior surgeries remains controversial, as some postmenopausal women continue to develop recurrent disease.

The technique of laparoscopic oophorectomy or salpingo-oophorectomy when done safely poses minimal surgical risks (see Complications box on page 72). The opening of the pelvic side wall in order to distance the ureter from the infundibulopelvic (IP) ligament prior to ligation should largely eliminate the risk of ureteral injury. If the entire ovarian cortex is not removed at the time of oophorectomy, particularly in patients with endometriosis, functionally active ovarian remnants may subsequently cause symptoms including pain, and can be challenging to remove. Complete removal of both ovaries, of course, induces surgical menopause with all attendant issues, including potential bone loss, hot flashes, and increased cardiovascular morbidity, some of which may be mitigated by the use of hormone replacement therapy. The decision to remove both ovaries must be individualized by patient, but computer models suggest that women under the age of 65 likely benefit more from ovarian preservation then bilateral oophorectomy, primarily due to reduced cardiovascular disease. Alternatively, women testing positive for BRCA1 or BRCA2 mutations have a 15% to 40% lifetime risk of developing ovarian cancer. In these patients prophylactic salpingo-oophorectomy reduced the risk of ovarian cancer by 80% (95% confidence interval, 42% to 93%) in one prospective study.

An initial workup of a pelvic mass generally will include a history, physical exam, and pelvic ultrasound. Certain findings (Table 8.1) are more frequently associated with an increased risk of malignancy. Unfortunately, recent studies still indicate that current markers are inadequate to predict the risk of an ovarian malignancy, and generally between 20 and 30 surgeries for benign disease are performed for every one ovarian cancer that is identified, if routine screening of asymptomatic
postmenopausal women is performed. Certain laboratory tests may suggest particular malignancies (elevated CA-125 is associated with an epithelial ovarian malignancy in postmenopausal women; elevated lactic dehydrogenase, α-fetoprotein, and human chorionic gonadotropin levels are associated with the presence of germ cell tumors in younger women; elevated levels of inhibin, estrogen, or testosterone are associated with sex-cord tumors at any age—see Chapter 18 for more details).