Laparoscopy for Ovarian Tumours in Pregnancy- my 8 years journey of experiences unfolded ..! presented at Endogyn Kolkatta 10th MArch 2018

1. LAPAROSCOPY FOR OVARIAN
TUMORS IN PREGNANCY -
A Journey of 8 years experience
Unfolded..!!

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. INDICATIONS

4. OBSTETRIC INDICATION
 Ectopic pregnancy
 Heterotopic pregnancy
 Excision of Rudimentary Horn

5. GYNECOLOGICAL INDICATION
 Adnexal mass
 Ovarian tumor
 Torsion

6. ADNEXAL MASS
NON OVARIAN
Paraovarian cyst
Leiomyoma
Hydrosalpinx
Tubo ovarian
abscess

7. OVARIAN TUMOUR
BENIGN
Functional cyst
Follicular cyst
Corpus luteal cyst
Theca lutein cyst
Luteoma
Hemorrhagic cyst
Benign cystic teratoma
Serous cystadenoma
Mucinous cystadenoma
MALIGNANT
Epithelial
Germ cell
Sex cord / Stromal
Granulosa cell
Metastatic

8. SURGICAL
 Appendicitis
 Pelvic kidney
 Peritoneal Inclusion Cyst
 Diverticular abscess

9. Laparoscopic cystectomy

10. Laparoscopic Management of Torsion of
Adnexal Mass

11. CASE REPORT
• 25 year, G4P3L3 patient was
referred from peripheral hospital
i/v/o pain in abdomen with 4
months of amenorrhea
• On further examination, it was
found to be ovarian mass with 15
weeks of pregnancy

12. Patient was c/o mild abdominal pain
O/E-
• P/A- Soft, 28-30 weeks soft cystic mass
arising from pelvis, non tender, soft ,
cystic, mobile
• P/V- findings confirmed.
• Uterus felt separate from the mass , 14-16
weeks size
CLINICAL PICTURE

13. INVESTIGATIONS
• USG - 13 x 8 x 6 cm left sided ovarian
Cystadenoma
• MRI- Benign 13 x 8x 6 cm left ovarian
Cystadenoma
• Ca-125- WNL

14. SURGERY
• Laparoscopic Cystectomy
• Ovarian cyst fluid aspiration done
• Around 300cc serous fluid was aspirated
• Patient withstood procedure well
• Immediate Post op USG for FHS.

15. PERINATAL OUTCOME
• Patient had regular ANC visits
• Put on progesterone support
• And delivered full term 2.8 kg
female child normally

17. STUDY IN ADNEXAL MASSES IN PREGNANCY
• An observational study of 42 cases of Adnexal Masses in
Pregnancy was done in the department of Obstetrics and
Gynaecology LTMMC and LTMGH, Mumbai a tertiary
reference centre, during Year 2013-2015.
• INCLUSION CRITERIA: Antenatal patient with adnexal mass
irrespective of time of detection whether, antenatal or
incidental at the time of surgery.
• EXCLUSION CRITERIA: Non pregnant patient with adnexal
mass, Ectopic pregnancy, Heterotopic pregnancy, Patient
not keeping follow-up

18. AGE WISE DISTRIBUTION
In present study (n=42), the
mean age group for adnexal
mass with pregnancy was 26-
30 years.

19. PARITY WISE DISTRIBUTION
Parity No. of cases Percentage
(%)
Nullipara 13 31
Para 1 16 38
Para 2 11 26
Para 3 02 5
In the present study, Adnexal
Masses were found more
commonly in Multiparous
patients.

20. ACCORDING TO THE SIZE OF ADNEXAL MASS
9
17
13
3
0
2
4
6
8
10
12
14
16
18
<5 Cm 6 - 10 Cm 11 - 15 Cm 16 -20 Cm
NOOFCASES
SIZE IN Cm
ACCORDING TO THE SIZE OF ADNEXAL MASS
In the present study, 40%
cases were found to have
adnexal mass between 6–
10 cms and 31% cases in
the range of 11–15 cms.

21. ACCORDING TO THE COMPLICATIONS
Complications No. of cases
Torsion 06
Haemorrhage 02
Rupture 00
Infection 00
Malignancy 00
In this study, 6 out of 42 (14%)
cases had torsion and two
patients (5%) had haemorrhage;
who underwent emergency
exploratory laparotomy.

22. MANAGEMENT OF THE CASES
11
24
7
0
5
10
15
20
25
30
CONSERVATIVE ELECTIVE EMERGENCY
NOOFCASES
MANGEMENT WISE
In this present study, 11 (26%) cases
were managed conservatively. Rest
of 31 (74%) cases were managed
surgically.
2 patients (5%) were operated
laparoscopically and 29 cases (95%)
underwent exploratory laparotomy.
There was no difference in adverse
pregnancy outcome in both elective
and emergency groups

23. ACCORDING TO HISTOPATHOLOGY REPORT
HPR No. of
cases
Percentage (%)
Simple / follicular
cyst
05 16
Mucinous
cystadenoma
09 29
Serous
cystadenoma
06 19
Teratoma 09 29
Others 02 07
In present study, the most
commonly found adnexal mass
during pregnancy are mucinous
cystadenoma and dermoid cyst
accounting for 29 % each.
None of the histopathology
report was suggestive of
malignancy.

24. REVIEW
OF
LITERATURE

25. OVARIAN CYSTECTOMY DURING PREGNANCY

26. ADNEXAL TORSION DURING PREGNANCY

27. ADVANTAGES
LAPROSCOPY VS OPEN
 Small abdominal incision
 Rapid postoperative recovery and
 Early mobilization
 Decreased risk of thromboembolism associated with
pregnancy.
 Smaller scars.
 Fewer incisional hernias.

28. ADVANTAGES
LAPROSCOPY VS OPEN
Early return of gastrointestinal activity due to
less manipulation of the bowel during surgery,
which may result in fewer postoperative adhesions
and intestinal obstruction.
Decreased rate of fetal depression due to
decreased pain and less narcotic use.
Shorter hospitalization time and prompt return to
regular life

29. SAFETY
 A retrospective study performed by Swedish health registries
on the safety of laparoscopy during pregnancy.
 Compared the outcome of 2181 laparoscopies performed on
pregnant patients prior to 20 weeks of gestation with the
outcome of 1522 laparotomies performed in a similar
population.
 Conclusion that there were no significant differences in any
measured outcome among the two groups:
 Intrauterine growth restriction,
 Congenital malformations,
 Stillbirths, or neonatal deaths.
 No adverse long-term effects have been reported.

30. TIMING
 There is no absolute maximum gestational age for performing
laparoscopy, the operation can be performed in any
trimester.
 Optimal time to operate is the early second trimester.
 Laparoscopy during the last trimester can be difficult to
perform due to the enlarged uterus that can interfere with
adequate visualization.

31. THROMBOPROPHYLAXIS
 In Laparoscopic procedure the duration of the
intervention is longer.
 The use of pneumoperitoneum contribute to venous
stasis and, possibly, thrombosis.
 Society of American Gastrointestinal and Endoscopic
Surgeons (SAGE in 2008), recommended placing
pneumatic compression devices on the lower limbs
of pregnant women undergoing laparoscopic
procedures for surgical problems.

32. PROPHYLACTIC TOCOLYSIS
 There is no evidence to support the use of
prophylactic tocolytics or glucocorticoids.
 These drugs may be indicated in management of
threatened preterm delivery in patients that are
presenting premature contractions.
 The use of monopolar electrocautery must be
avoided in order to minimize the uterine
contractility.

33. PREMEDICATION
1. NBM
2. NO ENEMA
3. Antibiotics
4. Written informed consent for SOS laparotomy
6. Anxiolytics/ Antiemetic/ H2 receptor
antagonist/analgesic
7. DVT prophylaxis
Above all Informed Consent and explaining the
Complications

34. PATIENT POSITION
 Depending on the operation that is to be performed , the
patient is placed in the
 Low lithotomy position with a leftward tilt (after 16 weeks
of gestation)
 To avoid significant compression of the gross abdominal
vessels.

35. GUIDELINES FOR LAPAROSCOPY
American Gastrointestinal and Endoscopic Surgeons,
published in 2011, makes the following
recommendation:
• Nasogastric intubation is a must in all case as there is
a high risk of aspiration into the lungs.
• Patients Positioning: dorsal lithotomy position in the
first half of pregnancy, but in second half lateral
recumbent position.
• Hypotension should be avoided; proper fluid
replacement should be done.
• Open Hasson trocar method

36. GUIDELINES FOR LAPAROSCOPY
• Pneumoperitoneum: Lower CO2 insufflations
pressure of < 12 mm Hg should be used to avoid
foetal acidosis.
• Trocars: VersaStep trocars or other nonbladed
trocars should be used under direct visualization.
• Instrument size: Laparoscopes as small as 3mm
are recommended.
• Bowel Retractor Fan: The upgraded 5-mm bowel
retractor fan has become indispensable in the
larger uterus.

37. GUIDELINES FOR LAPAROSCOPY
• Laparoscopic Ports in Pregnancy: If the
uterus is <18 weeks, the initial trocar
placement is in the umbilicus, not
subumbilical. CO2 pneumoperitoneum is
obtained with open placement of the
laparoscopic trocar that ranges from a
10-mm to 3-mm diagnostic
laparoscope. In pregnancies associated
with a uterine size ≥18 weeks, the initial
trocar is placed above the navel with the
lateral ports being placed under direct
visualization.

38. GUIDELINES FOR LAPAROSCOPY
• Electrocautery should be used with care; the
smokes containing carbon monoxide should be
evacuated promptly to avoid toxic effect to
foetus.
• All specimens should be removed with endobag to
avoid spillage.
• Tocolysis is indicated if signs of uterine irritability
are present.
• Venous Thromboembolic (VTE) Prophylaxis:
intermittent pneumatic compression devices or
intermittent electric calf stimulators should be
used to prevent stasis due to decreased venous
return.

39. FETAL ASSESSMENT
 Fetal heart rate should be confirmed and documented before
and after the procedure, and is usually done with a hand-held
Doppler device.
 If fetal monitoring is necessary during the procedure,
transabdominal fetal monitoring may be possible through the
left abdominal wall.
 If maternal acidosis is suspected and confirmed, it can be
reversed by immediately hyperventilating the mother and
decreasing intraabdominal pressure.
 These measures can help to resuscitate the fetus by improving
placental blood flow and fetal oxygenation.

40. POST-OPERATIVE CARE
 A CTG (non stress test) should be done in the recovery room,
if the gestational age is appropriate .
 Opioids pain killers and antiemetics can be used to control
pain and nausea.
 NSAID should be avoided, especially after 32 weeks of
gestation.

41. COMPLICATIONS AND RISKS
 Laparoscopy is not a risk – free procedure.
 Laparoscopy seems to be associate to low weight to the birth
and IUGR.
 The risk of spontaneous abortion is high especially in the first
trimester.
 The risk correlated to anesthesia, that is directly proportional
to the duration of the intervention.


42. COMPLICATIONS
Intraoperative
Pneumoperitoneum
Gas
Extravasation
Positioning Nerve injury
Endobronchial intubation
Thermal injuries
s/c emphysema
Pneumothorax
pneumomediastinum
Hycercarbia
Gas embolism
Arrythmias
Hyper/hypotension

43. Postoperative
Pain
PONV
1. visceral
2. Parietal – port site infiltration
3. Shoulder tip- d/t residual co2 and HCO3
-
T/T-complete co2 desufflation
-Rt subdiaphragmatic LA infiltration
-NSAIDS / opioids ,
Cause- co2 insufflation
bowel manipulation
Treatment -propofol induction, hydration
NG tube
Ondansetron
Periop O2 supplementation
Low dose dexamethasone
COMPLICATIONS

44. RISKS RELATED EXCLUSIVELY TO THE
LAPAROSCOPIC INTERVENTION
 Risk of penetration of the uterus by the Veress needle or the
trocar
 Bleeding
 Uterine rupture
 Loss of amniotic fluid
 Direct fetal damage
 Creation of a pneumoamnion
 Consequent spontaneous rupture of the membranes
 Fetal distress and
 Stillbirth

45. RISKS RELATED TO THE PNEUMOPERITONEUM
AND THE INSUFFLATION OF CO2.
 The increased intraabdominal pressure determines important alterations
of the materno-fetal hemodynamics.
 The reduction of the blood flow in the vena cava and the limitation of
the maternal diaphragm excursion can compromise uteroplacental
perfusion.
 The greatest risk seems to be maternal acidosis, caused by CO2, and a
consequent fetal hypoxia.

46. RISKS RELATED TO THE ELECTROSURGERY
 Harmful potential of the gas developed in abdomen because
of the use of laser and bipolar electrocautery during the
laparoscopic procedures seen.
 Increase in the levels of fetal carboxyhemoglobin in the
peripheral blood
 Increase of the maternal intrabdominal concentration of
CO2
 RECOMMENDATION: to minimize the harmful potential of the
gases freed in the peritoneal cavity through a suitable
elimination of the CO by ventilation at high concentrations of
oxygen.

47. LAPAROSCOPY
Vs
LAPAROTOMY IN PREGNANCY
 Both approaches seem to be reasonably safe.
 Laparoscopic approach is safer for operations on HIV
positive pregnant patient , as there is less risk of needle
injury.
 Acute abdomen in pregnancy represents a sure and
advantageous approach – preferable - both for the mother and
the fetus.

48.  Prompt Diagnosis Better Prognosis
 Treatment laparoscopy / Laparotomy.
 Post op USG.
 Bed Rest
 Tocolytics
 Progesterone
 Haematinics
 Regular ANC Follow up
 Delivery: Spontaneous Labor or Induced depends on
Obstetrician.
 Individualization of case to be done.
 Normal delivery or OVD /LSCS.
TAKE HOME MESSAGE

49. REFERENCES
• Kumari I, Kaur S, Mohan H, Huria A. Adnexal masses in pregnancy: A 5 year review. Aust N Z Obstet
Gynecol. 2006;46:52–4.
• DePriest PD, deSimone CP. Ultrasound screening in the detection of ovarian cancer. J Clin
Oncol.2003;21(Suppl):194s–9s.
• Whitecar P, Turner S, Higby K. Adnexal masses in pregnancy: A review of 130 cases undergoing
surgical amangement. Am J Obstet Gynecol. 1999;181:19–24.
• Bromley B, Benacerraf B. Adnexal masses in pregnancy: Accuracy of sonographic diagnosis and
outcome. J Ultrasound Med. 1997;16:447–52.
• Lerner JP, Timor-Tritsch IE, Federman A, Abramovich G. Transvaginal ultrsonographic
characterization of ovarian masses with improved, weighted scoring system. Am J Obstet
Gynecol. 1994;170(1Pt1):81–5.
• Timmerman D, Schwarzler P, Collins WP, Claerhuut P, Coenen M, Aman F, et al. Subjective
assessment of Adnexal masses using ultrasonography: An analysis of intra observer variability and
experienced. Ultrasound Obstet Gynecol. 1999;13:11–6.
• Granberg S, Wikland M, Jansson T. Macroscopic characterization of ovarian tumours and the
relation to the histological diagnosis criteria to be used in ultrasound evaluation. Gynecol
Oncol. 1989;35:139–44.
• McCarthy A. 7th ed. United States: Blackwell Publishing; 2007. Miscellaneous medical disorders
Dewhurst's textbook of Obstetrics and gynaecology; pp. 283–8.