Volume 108, Issue 1 , Pages 12-15, January 2010
Factors influencing the choice of laparoscopy or laparotomy in pregnant women with presumptive benign ovarian tumors
Article Outline
- Abstract
- 1. Introduction
- 2. Materials and methods
- 3. Results
- 4. Discussion
- 5. Conflict of interest
- References
- Copyright
Abstract
Objective
To evaluate the factors associated with physicians’ choice of laparotomy or laparoscopy in pregnant women with presumptive benign ovarian tumors.
Methods
Retrospective comparative analysis of pregnant women who underwent laparotomy or laparoscopy for ovarian tumors and who delivered at Samsung Medical Center, Seoul, Korea, between July 1995 and April 2008.
Results
Univariate analysis revealed that the following factors had a significant or a borderline significant association with the choice of operation type: maternal age (P
=0.044); surgeon type (professor vs clinical fellow; P=0.094); tumor mass size (P=0.081); gestational age (P=0.035); and time since surgery (P<0.001). Multivariate analysis showed that tumor size (P=0.030), gestational age (P=0.027), and time since surgery (P=0.004) were independent factors associated with physicians’ choice of laparoscopy or laparotomy for the management of presumptive benign ovarian tumors during pregnancy.
Conclusions
In the latter years of the present study, physicians at the study center preferred the laparoscopic approach for managing presumptive benign ovarian tumors during pregnancy. Furthermore, they preferred this approach to laparotomy for pregnancies at a relatively early gestational age and for treating small tumors.
Keywords: Gynecology, Laparoscopy, Laparotomy, Ovarian tumor, Pregnancy
1. Introduction
Laparoscopic surgery is currently the most efficient way to manage benign adnexal tumors in non-pregnant women [1], [2]. The advantages of laparoscopy include reductions in the following: febrile morbidity; urinary tract infections; postoperative complications; postoperative pain; time admitted to hospital; and total cost. However, the risks and benefits of laparoscopic surgery for ovarian tumors during pregnancy have not been fully assessed. Although previous reports attested to the feasibility, safety, and benefits of laparoscopic surgery during pregnancy in patients with benign ovarian tumors [3], [4], [5], there has been no randomized controlled trial in pregnant women to date [6]. Therefore, the selection of laparoscopy or laparotomy has depended primarily on the physician's preference.
The aim of the present study was to evaluate the factors associated with a physician's decision to perform a laparoscopy or a laparotomy in pregnant women with presumptive benign ovarian tumors. In addition, the surgical and obstetric outcomes of each operation type were compared.
2. Materials and methods
Institutional Review Board approval was obtained for reviewing the medical records of women who underwent surgery for adnexal tumors during pregnancy at Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, between July 1995 and April 2008. All patients were pregnant women with symptomatic ovarian mass, or persistent or enlarging asymptomatic ovarian tumor. Patients with incomplete maternal, fetal, or neonatal data were excluded. All procedures were performed under general anesthetic, and the women were grouped according to whether they underwent laparoscopy or laparotomy.
In the laparoscopy group, after anesthesia was administered, the patient was placed in a modified dorsolithotomy position, and a Veress needle was inserted through the umbilicus; the abdomen was then insufflated with CO2 and, after induction of a pneumoperitoneum and insertion of a 5-mm scope, 2 or 3 additional punctures were made for the ancillary instruments under direct vision with scope. A 12-mm cannula was placed in the left lower quadrant, and 5-mm cannulas were placed in the right lower quadrant and suprapubic area. No intracervical instruments were used for mobilization of the uterus. The adnexal pathology was treated using unipolar/bipolar scissors and traction. Adnexal tumors were removed using an endopouch bag after dissection of the ligaments and adhesions.
In the laparotomy group, a low midline or Pfannenstiel incision was made according to gestational age, and subject to physician's preference and experience. There was no strict guideline for selection of cystectomy or oophorectomy in either group, and choice was based on gestational age, mass size, and intraoperative findings. Generally, oophorectomy was preferred for torsion cases, borderline tumors, and huge ovarian masses; cystectomy was preferred in cases of early gestational age.
Pre- and post-operative management was the same for both groups; no tocolytic agents were administered prophylactically in either group. After patients were monitored in the post-anesthesia care unit, they were moved to the delivery section—where uterine contractions were observed in patients who were more than 14weeks pregnant. If regular uterine contractions were present and the patient complained of pain or discomfort, a tocolytic (the intravenous β2-adrenoceptor agonist ritodrine hydrochloride) was administered until the contractions stopped.
Factors were considered that might have influenced procedure selection: emergency status; pain status; bilaterality; maternal age; tumor size; gestational age; surgeon type (professor vs clinical fellow); and time since surgery (i.e. time between surgery and time of writing). Nine professors and 11 clinical fellows acted as primary surgeons, and these 2 groups were used as a marker of surgical experience.
After the factors that had an independent effect on operation type selection had been analyzed, the operative and neonatal outcomes related to operation type were investigated. The 2 groups were matched according to gestational age (1:1) because there was a difference in this factor between the groups.
Median and range were used to describe non-normal data, and mean±SD and confidence interval were used to describe normal distribution. The Wilcoxon rank-sum test or 2-sample t test was used to compare the continuous variables in the 2 groups. The χ2 test or Fisher's exact test was used to compare frequency data between the groups. A binary logistic regression model was used for multivariate analyses. Variables shown to be significant or borderline significant (P<0.10) in the univariate analysis (with the exception of linked variables) were selected for the binary logistic regression model. P<0.05 was considered to be statistically significant. SPSS version 10.0 (SPSS, Chicago, IL, USA) was used for statistical analysis.
3. Results
Fifty-three records with complete data were collected; 29 patients had a laparoscopy and 24 had a laparotomy. The characteristics of the patients are shown in Table 1. There were no twin pregnancies in either group. In the laparoscopy group, maternal age was significantly higher than in the laparotomy group, but in the latter group gestational age at diagnosis was higher and there was a longer time since surgery. There were no differences between the groups in terms of patient gravidity/parity, pain status, surgeon experience, or emergency status. The most common single diagnosis of ovarian tumor was mature cystic teratoma (Table 2). Distribution of adnexal pathology, bilaterality, and tumor size did not differ between the groups.
Table 1. Patient characteristics.a
| Characteristic | Laparotomy (n=24) | Laparoscopy (n=29) | P value |
|---|---|---|---|
| Median maternal age at diagnosis, y | 27.5 (range, 24–36) | 30.0 (range, 23–37) | 0.026 |
| Median GA at diagnosis, wk | 15+1 (range, 7+0 to 33+4) | 13+5 (range, 6+4 to 16+3) | 0.035 |
| Median gravidity | 0 (range, 0–3) | 0 (range, 0–2) | 0.895 |
| Median parity | 0 (range, 0–1) | 0 (range, 0–2) | 0.780 |
| Pain present at diagnosis | 9 (37.5) | 8 (27.6) | 0.597 |
| Torsion confirmed | 7 (29.2) | 8 (27.6) | 0.712 |
| Emergency operation | 5 (20.8) | 7 (24.1) | 0.694 |
| Surgeon type | 0.094 | ||
| Professor | 7 (29.2) | 16 (55.2) | |
| Clinical fellow | 17 (70.8) | 13 (44.8) | |
| Median time since surgery, mo | 116.4 (range, 14.0–155.5) | 15.3 (range, 3.2–136.3) | <0.001 |
aValues are given as number (percentage) unless otherwise indicated. |
Table 2. Pathologic features.a
| Laparotomy (n=24) | Laparoscopy (n=29) | P value | |
|---|---|---|---|
| Pathologic diagnosis | 0.653 | ||
| Benign cystadenoma | 3 (12.5) | 5 (17.2) | |
| Serous type | 0 | 3 | |
| Mucinous type | 3 | 2 | |
| Borderline tumorb | 0 (0.0) | 1 (3.4) | |
| Mature cystic teratoma | 7 (29.2) | 13 (44.8) | |
| Endometrioma | 4 (16.7) | 4 (13.8) | |
| Other benign condition | 10 (41.7) | 6 (20.7) | |
| Corpus luteum cyst | 5 | 2 | |
| Simple cyst | 3 | 0 | |
| Paraovarian cyst | 1 | 0 | |
| Hemorrhagic infarction | 0 | 2 | |
| Follicular cyst | 1 | 2 | |
| Bilaterality | 2 (8.3) | 1 (3.4) | 0.693 |
| Mean tumor size, cm | 9.1±2.6 | 7.8±2.8 | 0.498 |
aValues are given as number (percentage) unless otherwise indicated. |
bBorderline tumor=borderline serous cyst adenoma. |
Of the possible factors affecting choice of operation type (emergency status, pain status, bilaterality, maternal age, tumor size, gestational age, surgeon experience, and time since surgery), maternal age, tumor size, gestational age, surgeon experience, and time since surgery approached statistical significance following univariate analysis. Multivariate analysis showed that tumor size, gestational age, and time since surgery were independent factors associated with the selection of laparoscopy or laparotomy in pregnant women with presumptive benign ovarian tumors (Table 3).
Table 3. Analysis of factors associated with choice of operation type (laparoscopy vs laparotomy).
| Univariate analysis | Multivariate analysis | ||
|---|---|---|---|
| P value | Odds ratio (95% confidence interval) | P value | |
| Emergency status | 0.774 | 1.323 (0.009–1.671) | 0.416 |
| Pain status | 0.442 | 1.186 (0.567–55.260) | 0.240 |
| Bilaterality | 0.551 | 1.414 (0.250–63.950) | 0.327 |
| Surgeon type a | 0.094 | 0.212 (0.016–2.802) | 0.239 |
| Maternal age | 0.044 | 0.898 (0.672–1.200) | 0.467 |
| Mass size | 0.081 | 0.648 (0.438–0.960) | 0.030 |
| Gestational age | 0.035 | 0.904 (0.826–0.988) | 0.027 |
| Time since surgery | <0.001 | 0.998 (0.996–0.999) | 0.004 |
aProfessor or clinical fellow. |
Seventeen cases were selected for each group after matching according to gestational age; the clinical outcomes associated with operation type showed that estimated blood loss (P=0.001) and hospital stay (P<0.001) were reduced in the laparoscopy group (Table 4); maternal age at diagnosis (P=0.016) was higher in this group. Neonatal outcomes, including the number of normal full-term spontaneous vaginal deliveries and the Apgar score, did not differ between the groups and there were no operative complications in either group. In addition, there were no spontaneous abortions, despite there being 7 cases of luteectomy. Two preterm (<37weeks) deliveries occurred: 1 at 35weeks in the laparotomy group and 1 at 34weeks in the laparoscopy group. In the latter group, 1 newborn had a cleft palate (1-minute and 5-minute Apgar scores of 6 and 8, respectively) and there was 1 case of intrauterine growth restriction, with induced delivery at 37+1weeks (1-minute and 5-minute Apgar scores of 7 and 8, respectively).
Table 4. Comparison of clinical outcomes related to operation type after matching according to gestational age.a
| Outcome | Laparotomy (n=17) | Laparoscopy (n=17) | P value |
|---|---|---|---|
| GA at diagnosis, wk | 13+0 (range, 7+0 to 16+3) | 13+5 (range, 7+5 to 16+3) | 0.692 |
| Median maternal age at diagnosis, y | 27 (range, 24–36) | 30 (range, 23–37) | 0.016 |
| No. of patients using tocolytic | 3 (17.6) | 1 (5.9) | 0.294 |
| Operation procedure | 0.728 | ||
| Cystectomy | 7 (41.2) | 6 (35.3) | |
| Oophorectomy | 10 (58.8) | 11 (64.7) | |
| Median estimated blood loss, mL | 200 (range, 100–600) | 100 (range, 10–400) | 0.001 |
| Median hospital stay, d | 6 (range, 5–9) | 3 (range, 2–6) | <0.001 |
| Median operation time b, min | 85 (range, 51–250) | 85 (range, 65–190) | 0.822 |
| NFSD c | 14/16 (87.5) | 11/14 (78.6) | 0.794 |
| Median Apgar score (1min) | 9 (range, 7–9) | 9 (range, 6–9) | 0.872 |
| Median Apgar score (5min) | 9 (range, 8–10) | 9 (range, 8–10) | 0.891 |
| Pregnancy-induced hypertension | 1 (5.9) | 0 (0.0) | 0.786 |
| Preterm delivery | 1 (5.9) | 1 (5.9) | 1.000 |
| Fetal anomaly | 0 (0.0) | 1 (5.9) | 0.786 |
| Intrauterine growth restriction | 0 (0.0) | 1 (5.9) | 0.786 |
| Fetal or neonatal death | 0 (0.0) | 0 (0.0) | 1.000 |
aValues are given as number (percentage) unless otherwise indicated. |
bDefined as time from initial skin incision to time of skin closure. |
cCases of elective cesarean delivery were excluded. |
4. Discussion
In the latter years of the present study, surgeons preferred a laparoscopic approach for the management of presumptive benign ovarian tumors in pregnant women. The most important factors in making a decision were tumor size and gestational age. In addition, the feasibility and the overall favorable outcome of laparoscopic surgery performed during pregnancy were reconfirmed; compared with laparotomy, laparoscopic surgery during pregnancy was associated with low estimated blood loss and a short hospital stay.
The outcomes of laparoscopy during pregnancy were consistent with those reported in earlier studies of patients with ovarian tumors [4], [5], [7], [8] and non-gynecologic conditions such as gallbladder disease and appendicitis [3], [9], [10], [11], [12], [13]. The feasibility and benefits of laparoscopy during pregnancy have been found to be similar to those in non-pregnant patients: less postoperative pain; less postoperative ileus; decreased length of hospital stay; and more rapid return to work [1], [2], [3], [4], [5]. Although laparoscopic surgery during pregnancy for non-gynecologic problems, including gallbladder disease, may sometimes result in poor fetal outcome [14], the outcome can be attributed to the nature of the underlying problem—not the surgical approach used. Barone et al. [10] reported that the laparoscopic approach had outcomes equivalent to those associated with open cholecystectomy, in addition to the well-established benefits of laparoscopy.
Maternal age was higher in the laparoscopy group than in the laparotomy group. This may have been because advanced maternal age has become more common in Korea; the number of pregnant women older than 35years increased from approximately 5% in the 1990s to 13% in 2004 [15]. In addition, laparoscopy was performed more often than laparotomy in the latter years of the study, meaning that the number of older women in the laparoscopy group was greater overall.
There was 1 fetal anomaly and 1 case of intrauterine growth restriction in the laparoscopy group. Animal studies have shown decreased uterine blood flow after increases in abdominal pressure and the use of CO2 gas pneumoperitoneum [16], [17]; however, there is no confirmed relationship between laparoscopy and fetal anomalies/intrauterine growth restriction, and affected newborns have had no additional sequelae to date. The number of cases in the present study was too small to show a difference in the incidence of these conditions between the groups. No early pregnancy loss occurred, even after luteectomy. All 7 cases of luteectomy occurred at more than 7weeks of gestation; it is known that removal of the corpus luteum before 7weeks (5weeks post-ovulation) results in a rapid decrease in maternal serum progesterone levels and spontaneous abortion, but after this time it does not usually cause abortion or labor [18]. Surgical management of symptomatic corpus luteum in pregnant women should be carefully determined based on the individual situation.
There were limitations in the present study. First, it was a retrospective comparative study; the groups were not matched initially and there were differences in patient characteristics in terms of maternal age and gestational age (Table 1). Therefore, these 2 factors could be considered possible determinants of the choice of operation type, although only gestational age was statistically significant following multivariate analysis. Second, maternal age was different between the 2 groups, and because of such a difference in baseline characteristics (Table 4) the outcomes from those data might be meaningless. However, the difference in median age between the groups was only 3years, which was not clinically significant. To overcome these limitations, a large case-control study or a randomized controlled trial would be needed. However, such well-designed studies would be difficult to perform because of the low incidence of ovarian tumors in pregnancy and the ethical problems associated with randomization in this scenario (i.e. performing laparotomy instead of laparoscopy).
In conclusion, the independent factors associated with determining operation type were tumor size, gestational age, and time since surgery. The data showed that, in the latter years of the study, physicians preferred laparoscopy to laparotomy for managing ovarian tumors during pregnancies at a relatively early gestational age and for treating small tumors.
5. Conflict of interest
The authors have no conflicts of interest.
References
- . Laparoscopy versus laparotomy for benign ovarian tumours. Cochrane Database Syst Rev. 2005;(3):CD004751
- Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev. 2009;(2):CD004751
- Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc. 2008;22(9):1917–1927
- . Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol. 2003;108(2):217–222
- . Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril. 1999;71(5):955–960
- . Laparoscopic surgery for presumed benign ovarian tumor during pregnancy. Cochrane Database Syst Rev. 2006;(4):CD005459
- . Laparoscopy for adnexal masses in the second trimester of pregnancy. J Am Assoc Gynecol Laparosc. 2003;10(1):55–59
- . Outcome in laparoscopic management of persistent adnexal mass during the second trimester of pregnancy. Surg Endosc. 2004;18(9):1354–1357
- . Laparoscopic surgery during pregnancy. J Am Assoc Gynecol Laparosc. 1999;6(2):229–233
- . Outcome study of cholecystectomy during pregnancy. Am J Surg. 1999;177(3):232–236
- Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc. 2003;10(2):200–204
- . Laparoscopic surgery in pregnancy: long-term follow-up. J Laparoendosc Adv Surg Tech A. 2003;13(1):11–15
- . Laparoscopic surgery during pregnancy. Anesthesiol Clin North Am. 2001;19(1):57–67
- Laparoscopic surgery during pregnancy. Am J Surg. 1996;171(4):435–437
- . Nationwide Survey of Korean Population. Korea National Statistical Office; 2005;
- . Early postnatal behavior deficits after maternal carbon dioxide pneumoperitoneum during pregnancy. Surg Endosc. 2003;17(11):1823–1825
- Maternal insufflation during the second trimester equivalent produces hypercapnia, acidosis, and prolonged hypoxia in fetal sheep. Anesthesiology. 2004;101(6):1332–1338
- . Maternal Physiology. In: Williams Obstetrics. 22nd edition. New York: McGraw-Hill; 2005;p. 122–150
PII: S0020-7292(09)00491-3
doi:10.1016/j.ijgo.2009.07.040
© 2009 Elsevier Ireland Ltd. All rights reserved.
Volume 108, Issue 1 , Pages 12-15, January 2010
