Video Clips on DVD
- 9-1
Techniques in Vaginal Oophorectomy
- 9-2
Vaginal Bilateral Salpino-oophorectomy
The fate of the ovaries in a woman considering an indicated hysterectomy is a common question in the practice of gynecology. The approximately 600,000 hysterectomies done annually in the United States attests to the number of times this decision is weighed by patient and physician. The decision balances cancer prevention with surgical menopause and varies with the woman’s inherited and acquired risks for each of these issues. Risk assessment lies behind many of the choices made by patient and provider in the matter of oophorectomy. The decision to remove or not remove ovaries at hysterectomy should not be made lightly. For the patient, risk (and fear) of cancer and repeat surgery is contrasted with surgical menopause and the associated quality of life, bone, cardiovascular, and other risks. For the provider the method and risk of operative complications are contrasted between abdominal, laparoscopic, and vaginal approaches to hysterectomy. Fear may sway decision making by patient (in the form of inflated cancer fears) and physician (in the form of overstated risks). The good physician practices medicine with competence and compassion; hence, it is requisite that the best evidence for and against oophorectomy in a given patient be known and communicated to the patient in an unbiased manner . That evidence, however, is often inadequate and nearly always incomplete. Passions therefore will often carry the patient to her final decision.
Patient Case Presentations
It is worthwhile to consider three women facing the question of prophylactic oophorectomy at the time of hysterectomy. The first woman is 37 years old and has had three vaginal deliveries, the last of which left her with stage III uterovaginal prolapse. The woman reports significant bowel, bladder, and sexual issues related to her pelvic organ prolapse. Having tried and disliked a pessary, the woman now seeks a definitive surgical prolapse repair. As part of her repair a hysterectomy is planned and the woman asks about the fate of her ovaries.
Next is a 72-year-old woman who, having used a pessary for 5 years to manage her stage IV uterovaginal prolapse, develops significant vaginal ulcerations prompting her, among other reasons, to seek a definitive surgical repair. Like the 37-year-old woman, this woman is scheduled to have a hysterectomy and also ponders the fate of her ovaries.
Finally, a 47-year-old woman with a 3-year history of distressing menorrhagia, failing all conservative managements, is considering a hysterectomy. She has no personal or family history of ovarian disease. Her medical history is unremarkable; however, she has had two prior cesarean sections. Her body mass index is 28 and on physical examination she has a 10-week-size anteverted, smooth, mobile uterus with no remarkable uterine prolapse.
Discussion of Cases
These three women could be seen to span the decisional spectrum for prophylactic oophorectomy. All things being equal, the first two women have somewhat more obvious decision processes to consider. For the youngest woman the scale tips sharply toward keeping her ovaries while for the much older woman the reverse is true. Either woman, however, may weigh the evidence differently and choose contrary to scales of evidence. It is further recognized that present neoplasm, family history, pelvic pain, endometriosis, or history of significant pelvic infection could modify the certainty of keeping the ovaries in the younger woman. Oophorectomy does increase the operative risk for the older woman, although the magnitude of this risk is unknown and variable between patients and hysterectomy approach. Beyond this operative risk there are few clear benefits to keeping the ovaries at age 72. Therefore, it is often the patient risks that drive the decision for oophorectomy in the younger woman and surgical risks that drive the decision against oophorectomy in the older woman. More to the point, surgeon skill may often dictate ovary removal in the older woman (particularly in this 72-year-old woman who should have a vaginal hysterectomy for her stage IV uterovaginal prolapse).
The decision regarding the 47-year-old woman more delicately balances the risks and benefits of oophorectomy. For the 47-year-old woman age, family history, surgical history, habitus, and uterine support all impact the decision and technique of oophorectomy. Given that the mean age of menopause for U.S. women is approximately 51 years, this woman has approximately 4 years of remaining ovarian function. The patient’s family history (with or without Ashkenazi Jewish heritage) renders no mandate to remove the ovaries or to test for high-risk genetic factors ( Table 9-1 ). The patient’s cesarean history should cause the physician to pause in considering the vaginal approach to hysterectomy but this too is debatable. On prophylactic oophorectomy, the American College of Obstetricians and Gynecologists ( ) offers no mandate on whether this woman’s ovaries should be removed nor how best to remove them. In what follows we will consider this woman intermittently and discuss how her situation might be approached as to both the decision and potential techniques of prophylactic oophorectomy.
For non–Ashkenazi Jewish women
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* Based on the U.S. Preventive Services Task Force recommendations for genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility.
Surgical Technique
Planned removal of the ovaries at the time of hysterectomy considerably influences the route of surgical access. In a study by over 40% of abdominal hysterectomies appeared to have been justified on the basis of planned oophorectomy. This is not a surprising finding. Yet there does not appear to be any credible evidence to support the decision to pursue an abdominal approach solely on the basis of the need to remove ovaries. Indeed, , in a randomized study comparing vaginal versus laparoscopically assisted hysterectomy, both with concurrent prophylactic bilateral oophorectomy, concluded the laparoscopic approach resulted in more injury. The complications noted to be higher among the laparoscopic group included blood loss greater than 500 mL, hematoma at the trocar and vaginal cuff sites, and postoperative fever. Irrespective of the evidence, surgeon skill and confidence will undoubtedly influence whether the ovaries will be pursued vaginally. devised a system to grade the accessibility of the ovaries based on their relative proximity to the ischial spines, midvagina, and hymen ( Fig. 9-1 ). The system is largely valuable only to testify that the lower the grade (closer to the ischial spines; higher in the pelvis), the lower the incidence and lower the success rate with vaginal ovarian removal.
Abdominal Approach to Oophorectomy
Abdominal removal of the ovaries can be performed during laparotomy or laparoscopy and the latter may include robotic assistance. The steps to remove the ovaries from this vantage are the same irrespective of surgical approach. Avoidance of ureteral injury is always paramount when operating in the pelvis. Understanding the course of the ureters and their relation to the ovarian blood supply is essential for safe resection of the ovary. Ligation of the ovarian blood supply can be accomplished using a variety of techniques including suture, electrocautery (e.g., bipolar vessel sealing), and stapling. Each of these techniques is used with obvious differentials in cost and with minimal (but unknown) differences in operative risk.
Once the surgeon has entered the abdominal cavity the ovaries and fallopian tubes should be inspected and any abnormalities noted and recorded in the operative dictation. With the ipsilateral ureter identified, the infundibulopelvic ligament is put on tension and the overlying peritoneum between the round and broad ligament cut ( Fig. 9-2 ). Next, careful dissection isolates the ovarian blood supply for ligature or vessel sealing, taking care to assure that the ipsilateral ureter is not within the surgical field. The ligated infundibulopelvic ligament with the ovary and tube are next reflected toward the uterus; and visually away from the ureter. Ultimately the line of dissection incorporates the round ligament and opening the opposing leaves of the broad ligament to begin the hysterectomy. Of note: some surgeons do not fully expose the blood supply of the infundibulopelvic ligament, choosing instead to ligate these vessels through the peritoneum. This practice is quicker and may reduce blood loss encountered with the more extensive dissection but potentially puts the ureter at increased risk. This difference may be less in laparotomy or robotic surgery possibly attesting more to surgeon skill and confidence than to any real differences in surgical approach. Irrespective of abdominal surgical approach, injury to the ureter in association with oophorectomy is most often encountered with the first pedicle across the infundibulopelvic ligament as all abdominal techniques (open, laparoscopic, and robotic) remove the ovaries from the pelvic brim toward the uterus.
Vaginal Approach to Oophorectomy
The most challenging and necessary task in vaginally removing the ovaries is securing the ovarian vessels contained within the infundibulopelvic ligament. There are several basic techniques used to accomplish this task (see Videos 
). Both techniques follow transvaginal removal of the uterus. The first technique identifies the infundibulopelvic ligament by downward traction on the ovary (via Babcock or Allis clamp) prior to clamping and ligation ( Fig. 9-3 ; Video 9-1 
). Packing the bowel free of the operative field is recommended. Exposure of the operative field is facilitated with placement of retractors at 12 and 6 o’clock and either 3 or 9 o’clock, depending on the ovary being removed. Gentle downward traction on both the ovary and fallopian tube is necessary to safely pass a heavy clamp (e.g., Heaney clamp) across the blood supply of the infundibulopelvic ligament (see Fig. 9-3 ). The ovary and tube are removed and the ovarian vessels ligated with a free tie if desired, and then a second suture ligature is placed inside the free tie. Stapling devices or bipolar vessel sealing technologies such as Ligasure (Valleylab, Boulder, CO) can also accomplish the above tasks. In those cases in which the infundibulopelvic ligament is not easily accessible from the vagina an Endoloop (Ethicon, Somerville, NJ) ligature can facilitate isolation and ligation of the infundibulopelvic ligament (see Video 9-1 
). The Endoloop is passed through an ovary-suspending clamp onto the isolated infundibulopelvic ligament allowing ligation and ultimately division and removal of the ovary.
In the second technique for vaginal oophorectomy described by and and featured in Video 9-2, stepwise dissection between the round ligament and the infundibulopelvic ligament isolates the ovarian vessels for ligation and division ( Fig. 9-4A to C ; see Video 9-2 
). In this technique the uterus need not be completely severed prior to the oophorectomy on one side. On the other side, however, the uterus is divided from the adnexa. The round ligament is clamped separately, cut, and ligated and the suture is held long and retracted laterally for better visualization (see Fig. 9-4A, B ). An alternative technique featured in Video 9-1 is to use electrocautery to cut away the round ligament from the infundibulopelvic ligament. Care must be taken in using electrocautery to keep the plane of dissection in the broad ligament between the round ligament and the ovarian vessels and to avoid large veins. Following these steps the infundibulopelvic ligament on one side tethers the uterus with the tube, ovary, and mesovarium. An angled Sheth adnexal clamp ( Fig. 9-5 ), or a Heaney or long Kelly clamp, is applied to include only the infundibulopelvic ligament. Gentle handling of tissue is essential at this time to prevent tearing and bleeding in the broad ligament or ovarian vessels. The operative field is carefully inspected (to assure that bowel or the gauze pack is not in the clamp), the tube and ovary are removed, and sutures are placed (see Fig. 9-4C ). The infundibulopelvic ligament is singly or doubly ligated with No. 0 absorbable suture. With exposure and isolation of the contralateral round ligament, the contralateral ovary is removed in the same manner, without the uterus present. Retraction of the bladder and vaginal walls during the oophorectomy can be accomplished with Heaney, Deaver, Breisky-Navratil, or other similar retractors. Trendelenburg patient positioning is recommended at the start, both to improve exposure and to limit bowel injury.
Outcomes and Complications
Surgical outcomes for prophylactic oophorectomy largely fall into predictable categories. The clinical significance of potentially more blood loss and longer operative times with oophorectomy may be insignificant but it does pose the usual risk dichotomy—immediate operative risk versus long-term outcomes. The long-term outcomes include the matters of cancer prevention and menopause and will be considered later in this chapter. In Table 9-2 from the complications listed between vaginal hysterectomy with and without vaginal oophorectomy are similar, but tubal tear and fallopian tube prolapse can occur only with and without oophorectomy, respectively. Surgical time was longer among women undergoing a vaginal oophorectomy by about 45 minutes and no differences were noted in length of hospitalization or rate of blood transfusion. Inability to remove the ovaries vaginally was associated with obesity, nulliparity, reduced pelvic space, and absent uterine descent, but not uterine size.
| Complication | Number of Affected Patients (%) | |
|---|---|---|
| With Oophorectomy ( n = 740) | Without Oophorectomy ( n = 700) | |
| Pyrexia | 32 (4) | 34 (5) |
| Urinary tract infection | 224 (30) | 214 (31) |
| Wound sepsis | 9 (1) | 7 (1) |
| Primary hemorrhage | 7 (1) | 8 (1) |
| Paralytic ileus | 1 (<1) | 1 (<1) |
| Secondary hemorrhage | 0 (0) | 1 (<1) |
| Granulation tissue | 40 (5) | 86 (12) |
| Fallopian tube prolapse | 24 (3) | 92 (13) |
| Peritonitis | 1 (<1) | 1 (<1) |
| Resuturing of wound | 0 (0) | 1 (<1) |
| Shock | 10 (1) | 8 (1) |
| Tubal tear | 226 (31) | — |
| Blood transfusion | 30 (4) | 26 (4) |
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