Laparoscopic Management of Ovarian Remnant

Literature Review Article

Nezhat C, Kearney S, Malik S, Nezhat C, et al. Laparoscopic Management of Ovarian Remnant. Fertil Steril 2005;83:973-8. 

Review
Paul C. Lin, M.D., Seattle Reproductive Medicine

This is an observational study reporting the outcomes of 64 patients with confirmed ovarian remnant treated by laparoscopic surgery. Ovarian remnant syndrome (ORS) is an uncommon but surgically very difficult problem involving ovarian tissue inadvertently left in the pelvic cavity that can cause pelvic pain and cystic masses. Because of its surgical difficulty, exploratory laparotomy is required to completely treat and avoid repeat surgery in a situation where multiple adhesions are common.

Description of the surgical technique is included with following key points: hydrodissection with different pressures was used to create planes of dissection gently; the ureter was always identified by retroperitoneal dissection from the pelvic brim to the bladder with liberal use of ureteral stents to help identify their anatomy; enterolysis was performed when the ovarian remnant was attached to the bowel and repair of bowel was performed with laparoscopic suturing; the ovarian remnant was completely excised with a good margin of healthy tissue and the adminopelvic cavity was examined thoroughly before termination to look for other sites of ovarian tissue.

The authors demonstrate a high level of skill as laparoscopic surgeons with particular expertise with such procedures as laparoscopic bowel resection, ureteroneocystostomy, partial urinary bladder resection and partial vaginectomy. Inevitable and expected complications in such difficult cases include enterotomy, cystotomy, omental umbilical hernia, incisional would abscess and retained ovarian remnant. The authors discuss these complications in detail.

Comments

Elizabeth Pritts, M.D., Assistant Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Wisconsin, Madison, Wisconsin. 

This retrospective review is the largest to date addressing laparoscopic treatment of ovarian remnant syndrome. The highly skilled authors share their complication rates and "success" rates with the readers. There are some issues, however, that seem not to be addressed.

Patients were included in this paper if they had either pelvic pain or an ovarian cyst. While many would agree it is important to remove a persistent ovarian cyst that has the potential for malignancy, the same cannot be said definitively for ovarian remnants that appear to associated with pelvic pain. The paper does not resolve the question as to whether surgery is helpful in eradicating the pain associated with ORS. A single prior report that addressed pelvic pain in women with both endometriosis and ovarian remnant syndrome found that after removal of an ovarian remnant in 26 women who had pain, 20 of the patients had pain relief in the following one to eight years. 

The authors discuss medical management of ovarian remnant syndrome but do not discuss whether medical or surgical treatment is better for those with pain. It is not known which treatment is better since there are no studies addressing this issue.

The authors reported the complications associated with these surgeries. There were four intra-operative complications, 12 minor post-operative complications and three major post-operative complications that yields a complication rate of 5.8% for these skilled surgeons. The complications rate could be expected to be higher for less skilled surgeons. 

Although most general gynecologists would not perform surgeries described in this report, their availability provides physicians and patients an additional treatment option for an ovarian remnant. Future studies by this group comparing medical treatments or sham surgical treatments to laparoscopic excision would be welcome as the results would help guide the clinician to formulate the best treatment plan for women with ovarian remnant syndrome and pelvic pain.

 

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

 

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