The steps of surgical removal of the ovary will be informed by the anatomy. Although it seems obvious, the anatomic relationships of the ovary to the uterus, ureter, iliac vessels, and bowel will to one degree or another become altered in pathologic situations. The degree of aberration will vary from case to case and across pathologic conditions; however, the basic surgical approach needs not vary. A detailed understanding of the normal anatomy of the adnexa and the surrounding structures is essential and will inform the surgeon on how to best approach the particular pathology at hand. The first step in any surgery is to restore the anatomy to normal. This can be especially important when preforming difficult surgery to remove the adnexa. Once adhesions are lysed and normal anatomic relationships re-established, the level of complexity has been reduced allowing the surgeon to more easily remove the ovary.

The ovary is a retroperitoneal organ that resides in the pelvis. It is attached by a vascular pedicle to the uterine cornua (Fig. 11.2.1). Its arterial blood supply, however, originates off the aorta just distal to the renal vessels. The venous return runs adjacent to and inferior to the gonadal artery. These veins can become engorged in some pathologic conditions and often have multiple tributaries. The right gonadal vein empties into the vena cava directly; however, the left ovarian vein empties into the left renal vein (Fig. 11.2.2). The gonadal vessels travel toward the pelvis parallel to and adjacent to the ureter. Just like the ureter, the gonadal vessels cross the pelvic brim at the level of the bifurcation of the iliac vessels. The gonadal vessels are lateral and superior to the ureter at the pelvic brim. This relationship is difficult to appreciate unless the retroperitoneum overlying the gonadal vessels is opened (Fig. 11.2.3). The gonadal vessels insert into the ovary and, after passing by the ovary anastomose into the utero-ovarian pedicle at the cornua. The utero-ovarian pedicle contributes blood supply to the ovary and fallopian tube along its course. Again, while it may be difficult to appreciate, a layer of peritoneum covers the ovary and its blood supply, tube, and uterus.¹

The concept of “restoring anatomy to normal” is predicated upon a complete understanding of these anatomic relationships. Expert pelvic surgeons understand and use the relationship between the gynecologic organs, the rectum, and the genital urinary system to inform their surgical decisions. The most important anatomic concept to recognize is that the bladder, ureters, and rectum, as well as the ovaries, tubes, and uterus are NOT located in the pelvis but in the retroperitoneum (Fig. 11.2.4). The
rectosigmoid and ileum are the only true pelvic organs once we understand this anatomic relationship. In reality, for many operations this distinction is irrelevant. However, for complex ovarian surgery, it is critical to perform the operation quickly, safely, and with assurance that there has been no unintended injuries.

While this is a subtle distinction, it is an important one. When tackling a complex pelvic surgery with multiple adhesions and perhaps a pelvic mass adherent to the pelvic sidewall, recognizing this relationship will enable the surgeon to proceed judiciously. Lysing adhesions becomes easier when one recognizes that adhesions between loops of small bowel and to the rectosigmoid are inherently different than those to the adnexa or uterus. In fact, since there are no normal attachments of the ovaries to the true pelvic organs, these can be easily managed by following the course of bowel loops and sharply lysing adhesions free from the ovarian tumor or uterus. A systemic approach is often the best, beginning where the anatomy is normal and proceeding toward areas of complexity. With this approach, the surgeon continues until the anatomy becomes confusing, at which point the focus changes to another area where the adhesions are less complex. With this approach, areas of adhesions that were initially difficult to lyse successfully, can more easily be managed (see Video 11.2.1, Part A). Careful dissection is important with attention to hemostasis as the planes between loops of bowel and the adnexa can be easily masked by blood. Sharp dissection offers some advantages over cautery because when the surgeon is in the correct anatomic plane there is little if any bleeding. In addition, there is no concern of thermal spread from cautery. Energy devices, such as harmonic or ligasure seal peritoneal edges together, are generally counterproductive when tackling adhesions.

Nonoperative management of an adnexal mass is appropriate in certain situations and should be individualized based upon the patient. While conservative management of adnexal masses can occupy an entire chapter, a few guiding principles are worth discussing. In general, symptomatic or complex lesions should be managed surgically. In addition, an adnexal mass of 8 cm or larger is unlikely to resolve spontaneously and is at higher risk of torsion, making observation in these situations of questionable benefit. The risk of surgical intervention to manage the patient’s symptoms and assess for malignancy must always be balanced by medical comorbidities, desire for future fertility, and to some extent loss of hormonal function. Repeat imaging at 6 weeks in premenopausal woman is reasonable when the adnexal mass is thought to be a hemorrhagic or functional cyst. If this lesion is still present at that point, it is less likely to resolve and surgical intervention is generally warranted.