Ovarian and Fallopian Tube Procedures
Box 24-1 Master Surgeon’s Corner
Identify the ureter before dividing the infundibulopelvic (IP) ligament.
Divide the IP ligament at least 2 cm from the proximal ovarian border.
For prophylactic bilateral salpingo-oophorectomy, cauterize the uterine cornua to ablate the tubal remnant.
Unilateral salpingo-oophorectomy (USO) and bilateral salpingo-oophorectomy (BSO) are performed for a wide variety of indications. In gynecologic oncology, there is a fundamental distinction between USO/BSO performed for an identified lesion (eg, pelvic mass, ovarian cyst) and risk-reducing salpingo-oophorectomy (RRSO) performed to decrease the risk of subsequent ovarian and breast cancer in women at increased genetic risk. Indications for USO/BSO for symptoms or suspected ovarian malignancy are detailed more completely in Chapter 11. Recommendations for RRSO should be based on the individual woman’s risk for ovarian cancer. In the recent report of the Society of Gynecologic Oncologists Clinical Practice Committee, Berek et al1 detail these risk groups. Women with BRCA1 and BRCA2 mutations may reduce their risk of an associated gynecologic cancer by 96% and their risk of an associated breast cancer by 50% to 80% by undergoing RRSO after completion of desired childbearing. Women without a germline mutation who are at higher than average risk because of a strong family history of breast or ovarian cancer may also benefit from RRSO, but the absolute risk reduction is less clear. In premenopausal women at average risk for ovarian cancer undergoing hysterectomy for benign disease, the decision for oophorectomy should be individualized based on the patient’s personal risk factors.
Clinical outcomes after salpingo-oophorectomy as an isolated procedure are determined by both the surgical approach and menopausal status of the patient. Minimally invasive USO/BSO is generally an outpatient procedure with a short recovery period and low complication rate, whereas recovery after USO/BSO requiring laparotomy is longer as determined by the larger incision. Oophorectomy in premenopausal women results in menopausal symptoms in the majority of patients. Subsequent therapy for surgical menopause is determined by the severity of symptoms, specific risks related to hormone therapy, and patient choice. There are several studies suggesting an overall negative health impact when BSO is performed before the age of menopause. Among other findings, an observational study from the Nurse’s Health Study found that women younger than 50 years who had BSO and never used estrogen had increased rates of all-cause mortality, coronary heart disease, and stroke.2
Preoperative evaluation for most patients consists of physical examination and radiologic and/or serologic studies. Pertinent examination findings include the size and mobility of a palpable mass, associated or referred pain symptoms, or the presence of adjacent cul-de-sac nodularity. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can each play a role in preoperative characterization of adnexal findings and associated abnormalities within and outside of the pelvis. Serologic studies can include both standard preoperative testing (eg, complete blood count, chemistry, type and screen, and pregnancy test, as appropriate) and testing directed toward the risk of malignancy (eg, tumor markers, as detailed in Chapter 11). Preanesthesia risk assessment should be individualized by cardiopulmo-nary risk factors and other relevant medical issues.
Considerations for informed consent include those specific to the surgical approach, as well as those determined by menopausal status and hereditary risk factors. Blood loss is generally minimal, but may be higher for large masses or those associated with endometriosis. Wound infection risk is low for both minimally invasive and open approaches, but may be increased by obesity, diabetes, and other risk factors. Because several studies have suggested an overall negative health impact when BSO is performed before menopause, clear discussion of expected benefits and risks should be held before surgery. Finally, women with BRCA1 and BRCA2 mutations should be informed that despite the substantial ovarian and breast cancer risk reduction, the risk of peritoneal carcinoma after RRSO remains approximately 1%. A small tubal remnant remains in the uterine cornua after the fallopian tube is divided medially. However, fallopian tube cancers generally originate in the fimbriated portion, and the risk for subsequent cancer developing in this retained segment is uncertain but probably low.3
Patients should have nothing by mouth for 6 to 8 hours before surgery. Bowel preparation is not required but may be preferred by some surgeons to improve exposure for minimally invasive approaches. Intravenous antibiotics prior to skin incision should be administered to decrease wound infection risk. The myriad tools available to perform USO/BSO result in similar outcomes and are determined by availability and preference, but should be requested when the case is scheduled to limit delays on the day of surgery.
Box 24-2 Caution Points
The position of the ipsilateral ureter varies, but generally passes under the infundibulopelvic (IP) vessels to descend over the pelvic brim medial to the IP.
Ovarian tissue may extend into the IP ligament up to 1.5 cm from the visible margin.
A small tubal remnant remains in the uterine cornua after the fallopian tube is divided medially.
The patient may be positioned in modified dorsal lithotomy in Allen stirrups if vaginal access is required for dilation and curettage or if use of uterine manipulator is preferred. Alternatively, supine positioning is appropriate if these procedures are not required. A Foley catheter should be placed, and an oral-gastric tube is preferred before minimally invasive port placement to decrease the risk of gastric injury. Open approaches generally involve a midline incision extended as necessary for the pelvic mass, and a fixed retractor may be helpful. For minimally invasive approaches, port placement will depend on the mode favored (laparoscopic or robotic) but should be arranged superior to the known ovarian mass. At a minimum, these approaches require a camera port and at least 2 instrument ports, and ports should be spaced to allow instruments to be moved independently. The diameter of the ports is determined by preference and availability; cameras, instruments, and cautery devices can range from 3 to 10 mm. Incorporating at least one 10-mm port facilitates removal of the surgical specimen. The camera port is placed first, and either open placement of a Hasson cannula or closed insufflation with a Veress needle may be used. The remaining ports are placed under direct visualization. Recently, successful outcomes have been reported after laparoendoscopic single-site RRSO.4 This approach involves multiple ports closely placed within a single 2-cm umbilical incision and is a viable approach worthy of further study.
Regardless of approach, the remaining steps involve safely dividing the ovaries and tubes from their supportive and vascular attachments. Peritoneal washings are taken and sent for cytology. Adnexal and other adhesions are dissected free to maximize exposure and biopsied if suspicious for malignancy. The lateral pelvic peritoneum is divided from the round ligament to the level of the infundibulopelvic (IP) ligament (Figure 24-1). At laparotomy, the broad ligament is opened using sharp scissor dissection or the electrosurgical unit. At laparoscopy, laparoscopic scissors, harmonic scalpel, or argon beam coagulator can be used. The medial leaf of the broad ligament is retracted toward the midline, the para-rectal space is developed toward the pelvic floor, and the ureter is identified at the pelvic brim and traced distally along the broad ligament or vice versa (Figure 24-2). It is important to determine the proximity of the ureter at the pelvic brim to the IP ligament and the proximal ovarian border. Because ovarian tissue can be extended within the IP up to 1.5 cm from the visible ovarian border, the IP should be divided approximately 2 cm from the ovary.5 Identifying the ureteral position at the pelvic brim ensures that this can be done safely. The IP ligament is then mobilized from the pelvic sidewall vessels and isolated by creating a window in the medial leaf of the broad ligament between it and the ureter. The ovary can be elevated and the IP safely divided between clamps (Figure 24-3). A single or double suture ligature of 0 or 2-0 delayed absorbable suture is used to secure the infundibulopelvic ligament pedicle (Figure 24-4). Laparoscopic options for dividing and sealing the IP include bipolar cautery, LigaSure (Covidien, Mansfield, MA), harmonic scalpel, stapling devices, and laparoscopic or open ties (Figures 24-5 and 24-6).
FIGURE 24-1. Peritoneal incision with identification of ureter and infundibulopelvic ligament.
FIGURE 24-2. Salpingo-oophorectomy. Development of para-rectal space and relationship of ureter and infundibulopelvic ligament.
FIGURE 24-3. Salpingo-oophorectomy. Clamping of infundibulopelvic ligament (ovarian vessels).
FIGURE 24-4. Salpingo-oophorectomy. The infundibulo-pelvic ligament is secured with a suture ligature.
FIGURE 24-5. Salpingo-oophorectomy. The infundibulopelvic ligament is divided using a vessel-sealing device (LigaSure).
FIGURE 24-6. Salpingo-oophorectomy. Infundibulopelvic ligament is divided by a vessel-sealing device.
The broad ligament is then divided medially along the superior border of the round ligament to the uterine cornua. The fallopian tube and utero-ovarian ligament are divided individually when using a minimally invasive surgical approach or divided as a combined unit if approached via laparotomy and secured with a Heaney transfixion stitch of 0 or 2-0 delayed absorbable suture (Figures 24-7 and 24-8). Any of the previously mentioned laparoscopic instruments can be used for this purpose. Consideration should given to cauterizing the tubal remnant in the uterine cornua for all women at increased genetic risk; this is most easily performed with the bipolar cautery or LigaSure. For minimally invasive procedures, the specimen is placed in an endoscopic bag and delivered through the 10-mm port site. Larger cystic ovarian masses can be decompressed once the open end of the bag is brought out through the incision. Solid masses may require extending the skin and fascial incisions for removal. Instrument ports should be removed under laparoscopic visualization to prevent bowel or omentum being drawn up into the defect. The fascia at all port sites larger than 8 mm should be closed laparoscopically or directly to decrease the risk of port site hernia, and the skin should be closed with subcuticular suture, skin adhesive, or both.