Surgical Techniques: Endoscopic 4.3.3.7 Laparoscopic Ovariopexy
Aims and Methods
Laparoscopic ovariopexy is the term for laparoscopic relocation of the ovaries with preservation of their blood supply through the infundibulopelvic ligament prior to radiotherapy in the pelvis. The aim is to remove the ovaries from the radiation field to preserve their long-term function. Functional destruction of the ovaries, which is irreversible in over 50% of cases, can be avoided, especially in patients under the age of 40. The laparoscopic technique allows a minimally invasive approach so that the oncologic treatment schedule is not altered. The available options are lateral transposition to the side wall of the pelvis and medial transposition behind the uterus, depending on the indication. Laparoscopic ovariopexy prior to (chemo) radiotherapy forms part of a wider approach, which has developed in recent years because of the improved survival times with malignant diseases overall; cure of the (young) patient is the overriding concern, but her hormonal and reproductive future is also taken into account, and this includes an attempt to preserve fertility. Like cryopreservation of ovarian tissue prior to chemotherapy, laparoscopic ovariopexy is a gynecologic oncology procedure in the widest sense.
Indications and Contraindications
Indications
Laparoscopic ovariopexy is indicated when pelvic radiotherapy is necessary in patients below the age of 40 years. The classic situation is cervical cancer, though a good or acceptable overall prognosis is implicit. Other rare indications are tumors in the pelvis that warrant radiotherapy, such as rectal and anal cancers that can occur in young patients and have a good prognosis in the early stages, or lymphomas (e.g., Hodgkin disease), for which local radiotherapy is indicated. It is important especially to think of the possibility of ovarian transposition. A nononcologic indication for lateral ovariopexy is adhesion prevention after extensive ovariolysis, for example, during surgery of endometriosis. Lateral fixation may be useful to prevent the ovary from growing back into the dissected pouch of Douglas and ovarian fossa.
Contraindications
The contraindications to ovarian transposition are a poor prognosis and, usually, postmenopausal status. Other contraindications are malignant diseases that require removal of the ovaries. The immediate premenopausal situation is a relative contraindication, and it is not indicated in patients aged over 40 as the clinical success rates do not justify the (low) risks of the procedure.
Operation Risks and Informed Consent
Besides the general intra- and perioperative risks (bleeding, infection, delayed wound healing, ureteral injury) of this not absolutely essential operation, which must be weighed in detail against the advantages of preserving hormonal activity, the specific risks such as thrombosis and infarction in the manipulated infundibulopelvic ligament must also be discussed. Atypical pain symptoms with ovulation, cyst formation, and possibly the need for later oophorectomy, should also be discussed.
Operation Planning
Planning laparoscopic ovariopexy forms part of the overall oncologic concept and is subordinate to this in every respect. The appropriate diagnostic investigations should be complete and (chemo) radiotherapy in the pelvis should be indicated
Discussion of the extent of the operation and its usefulness in the individual case
The decision rests with the patient. However, in suitable cases, the patient should be informed of the treatment options. Only an informed patient can decide
Consent to the procedure and planning with regard to radiotherapy
Anesthesiologic preoperative investigations depending on the patient′s age and local practice
Thrombosis prophylaxis: LMWH, ATS
Antibiotic prophylaxis is not absolutely necessary.
Moderately difficult surgery because rare; takes 1–2 hours; surgeon and one assistant
Anesthesia and Positioning
Special Instruments
Normal instruments for operative laparoscopy: grasping forceps, dissecting scissors, and coagulation forceps
Important: clips for exact marking of the transposed ovaries
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