Introduction
Adnexal cell masses are frequently found in women of all age groups. Most adnexal masses arise from ovaries. Other pathologies that cause an adnexal mass include ectopic pregnancy, leiomyoma, tuboovarian abscess, or subserosal fibroids. Laparoscopic management of adnexal masses is common and has become the gold standard for treating benign adnexal masses.
What Are Adnexal Masses?
An adnexal mass or adnexal tumors are growths that form around the uterus region, usually in the fallopian tubes, ovaries, or the neighboring connective tissues. The term "adnexa" refers to the fallopian tube, ovaries, and ligaments, which are part of the female reproductive organs. Adrenal masses can either be borderline, benign, or malignant neoplasm, metastasis (cancer spreading to different parts of the body rather than from where it has started) from a distant site, or a nonneoplastic process (noncancerous lesion). These masses are usually diagnosed accidentally. The most commonly found adnexal masses are the benign functional cysts of ovaries. This includes polycystic ovarian cysts, follicular cysts, and corpus luteum cysts (a normal cyst formed in the ovaries after ovulation).
What Causes Adnexal Masses?
Adnexal masses originate mostly from the female reproductive system. They can also originate from the digestive or urinary systems. Numerous gynecological and nongynaecological factors can cause them.
Gynecological Adnexal Tumors:
Most adnexal masses are caused within the female reproductive system. Some of the most common causes include:
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Ovarian Cysts - Ovarian cysts are fluid-filled cysts formed inside the ovaries. They are usually painless, and most people never develop any symptoms.
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Noncancerous Ovarian Tumors - Abnormal cells become solid masses with occasional cystic components as they grow and multiply in the ovaries. A benign or noncancerous tumor does not spread to other body parts or nearby tissues.
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Broad Ligament Leiomyoma - Broad Ligament leiomyoma is a smooth muscle tumor located near the fallopian tube and ovary and could be mistaken for an adnexal mass.
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Tubo Ovarian Abscess - When a genital tract is infected, it can lead to inflammation of the ovary, fallopian tube, and surrounding structures, including the bladder or bowel.
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Ectopic Pregnancy - When an embryo (fertilized egg) implants in areas other than the uterus, it is called an ectopic pregnancy. When the egg grows outside the uterus, it causes severe pain and internal bleeding. If left untreated, ectopic pregnancies are fatal for the pregnant person.
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Ovarian Cancer - Ovarian cancers are the most common type of cancer seen in women. The ovarian tumor grows and spreads to other body areas when it is cancerous.
Non-Gynaecologic Adnexal Tumors:
Non-gynecologic adnexal tumors usually originate from the gastrointestinal or urinary systems. Some of the most common types include adnexal tumors of the appendix and colon. Colon and breast cancers can also spread to the pelvic region resulting in adnexal tumors.
What Is a Laparoscopy?
Laparoscopy is a surgical procedure that allows the surgeon to access and visualize the abdomen and pelvis area with a laparoscope's help without making large incisions in the skin. This procedure is also known as minimally invasive surgery or keyhole surgery. Laparoscopy is done using a laparoscope. A laparoscope is a small tube-like instrument with a camera and a light source. This camera and light source produce images inside the abdomen or pelvic region and transmit them to the television monitor inside the operating room.
What Are the Benefits of a Laparoscopy?
Laparoscopic surgery is minimally invasive and has been associated with a shorter hospital stay, early recovery, decreased cost, and significant patient satisfaction. It also has lesser adverse effects, less blood loss, mild postoperative pain, decreased need for painkillers, and better panoramic vision. Laparoscopy treatment prevents adhesion, is safe, is nontraumatic, and helps preserve ovarian tissue and its fertility.
What Are the Limitations Associated With Laparoscopy?
Some of the limitations associated with laparoscopy include the following.
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Difficulty in inserting trocars (a medical device used for laparoscopy).
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Risk of ovarian rupture leading to the spread of cyst fluid into the abdominal cavity.
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Chances of misdiagnosis of ovarian malignancy.
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An inability to perform a complete staging procedure in case of malignancy.
What Role Does Laparoscopy Play in the Management of Adnexal Masses?
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Most adnexal cell masses are benign, and malignancy is found in only 7 to 13 % of premenopausal and 8 to 45 % of postmenopausal patients.
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During laparoscopy examination, a careful inspection should be done on all peritoneum surfaces, pelvis, diaphragm, pouch of Douglas, and bowel surfaces.
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For benign adnexal masses like ovarian cysts, procedures like oophorectomy, adnexectomy, and ovarian cystectomy were performed.
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Endometriosis and uterine fibroid mass in postmenopausal women always tend toward malignancy.
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Combining ultrasonographic techniques with serum tumor markers can establish the criteria for differentiating benign and malignant masses. This can help physicians decide on the surgical procedure.
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The following intraoperative findings were considered suspicious signs of malignancy. They are the diameter of the ovarian cyst, the presence of a unilocular or bilateral ovarian cyst, the existence of septa, and particles of papillomatous projections on the outer surface or projections protruding into the cystic cavity. The mass usually appears solid.
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Immediate conversion to laparotomy will be conducted if a malignancy is revealed during laparoscopy. It will further be treated by postoperative chemotherapy.
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A proper selection of cases through preoperative workup and detailed imaging like ultrasound can reduce the risk of conversion laparotomy.
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Surgical staging is performed laparoscopically if malignancy is diagnosed, which is safe and accurate in a borderline or invasive early-stage disease.
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Frozen section evaluation is essential for patients suspected of malignancy during laparoscopy.
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Laparoscopy does not just rule out malignancy. It is also used to relieve compressive and pain symptoms of benign or malignant adnexal masses.
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The potential malignant tumor should be excluded from laparoscopic options. This is performed using Trans vaginal ultrasonography combined with Doppler and 3D ultrasound.
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Good histopathologic reporting is also needed for successful operative management. Malignant tumors are staged, and benign tumors are treated using ovarian preserving procedures.
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Older adults are at increased risk of diseases like diabetes mellitus and cardiovascular disease, and when elderly patients require surgery, the surgical morbidity and mortality (death) rates increase. Therefore, it is important to establish the risk profile of patients with adnexal mass to reap the benefit of laparoscopy.
Conclusion
A laparoscopic approach is safe and effective in managing patients with adnexal masses of unknown pathology.Proper selection of cases, adequate surgical skills, and an expert laparoscopic and surgical team will result in good patient outcomes.
