Adnexa Procedure

By
Dr Nabilah Rashid Redza

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Ovarian Cystectomy
Introduction

During reproductive years, the majority of ovarian masses are benign with
the risk of malignancy being less than 1%

The incidence of ovarian cancer increases with advancing age. In post

menopausal women, incidens anywhere between 5-17%.

Ovarian cysts may be symptomatic, discovered incidentally or detected

through screening.
Symptoms

Symptoms have a very low Positive predictive values were less

predictive value for malignancy. than 1% for each symptom, except
In a recent study, symptoms abdominal distension, which had a
were associated with ovarian value of 2.5%.
cancer, including;

Abdominal distension.
Urinary frequency.
Abdominal pain.
Postmenopausal bleeding.
Loss of appetite..
Abdominal bloating.
History

Family history can be used to define women who are increased risk of
ovarian ca

Women (high risk with ovarian ca) has 1st degree relative

2 or more with ovarian ca (1st degree)

1 relative with ovarian ca + 1 relative with breast ca (dx under 50 yo)
1 relative with ovarian ca + 2 relatives with breast ca (dx under 60 yo)
3 or more relatives with colon ca with / without stomach,endometrial,
small bowel ca (dx under 50)
1 relative with both breast and ovarian ca
Imaging
USG
Transvaginal ultrasonography
(TVS) is the most valuable tool
in the initial evaluation of an
adnexal mass.
Additional information can be
obtained with transabdominal
(TAS) ultrasound, especially
when a mass is large or beyond
the field of a TVS probe.
- Sensitivity 89%, specificity 73%
Functional ovarian cyst
Simple ovarian cysts are;
 round or oval shape
 Uniform thin walled
 Posterior acoustic enhancement
 Anechoic fluid
 absence of septation or nodules
Complex ovarian cyst;
 Complete septation (8% ca)
 Solid nodules (36-39% ca)
 Papillary projection
Tumor marker
Tumor marker

CA 125 - normal <35 kU/L

- elevated in 80% of women with ovarian cancer although 50% of early
stage disease will have a normal level
- 81% sensitivity, 75% specitivity
- 78% has pooled sensitivity & specificity 78% to differentiate benign from
malignant adnexal mass

HE4 - human epididymis protein 4

- glycoprotein found in epididymal epithelium
- Occurs in ovarian ca as well as in lung, pancreas, breast, bladder,
endometrial ca
- Sensitivity 92.3%, specificity 75% in post menopausal
Tumor marker
Additional tumor marker

These may be useful if there is a possibility that the pelvic mass

represents a metastasis from a separate primary cancer.

Indication;

CEA Suspected colorectal primary

CA 19-9 Suspected colorectal and pancreatic primary
CA 153 Suspected breast primary
Risk of malignancy (RMI)

The ‘risk of malignancy index’ (RMI) should be used to select those women
at greater risk of malignancy. Using an RMI cut-off of 200, a sensitivity of
78% and specificity of 87% can be achieved.

International Ovarian Tumour Analysis (IOTA) classification can also be

used by those with recognised training.

Women at high risk of malignancy (usually RMI >200 @ clinical suspicion)

need to be discussed with a gynaecological oncologist
The RMI is a clinical prediction rule based on ultrasound, CA-125, and
menopausal status defined as follows

RMI = U x M x CA-125

U = The ultrasound score is calculated by awarding 1 point for each of the

following characteristics:
multilocular cyst evidence of solid areas
evidence of metastases presence of ascites
bilateral lesions

U = 0, if none of the above listed features is found

U = 1, for ultrasound score of 1
U = 3, for ultrasound score ≥ 2
CA-125 = Serum CA-125 in kU/L
Menopausal status (M = 1 if premenopausal , M = 3 if postmenopausal)
International Ovarian Tumor Analysis

Simple USG rules – B rules & M rules

- Sensitivity 95%, specificity 91%
In 2 year follow up study,

Asymptomatic postmenopausal women with cyst smaller than 5

- dissapear 5%
- static 28%
- enlarged 11%
- decreased 3%
- fluctuate in size 6%
Procedure

Introduction

Removal of ovarian cyst while preserving the ovary who desire fertility

Goals

Gentle handling of ovarian tissue to limits postoperative adhesion formation &

reconstruction of normal ovarian anatomy

Indication
Diagnostic confirmation, exclusion of ovarian CA
Removal of symptomatic cyst
Cyst size > 7cm
Not a suitable candidate for ovarian cystectomy?

Post-menopause
- specially if the cyst appears complex on the ultrasound

Malignancy is suspected
- avoid the rupture and spill of the cancerous cells into the pelvis

Very large ovarian cyst or mass

Ovary is torsed (twisted)

Laparatomy Cystectomy

 incision into the ovarian capsule Incision was made over the ovarian
must be made very carefully to capsule near the base of the cyst
prevent rupture of the cyst.
 hemostasis must be achieved to
avoid ovarian hematoma – best
performed with a running mattress
suture

Dissect the alveolar

tissue between the
cyst and the ovarian
capsule
Mattress suture is placed starting from the upper pole
Salphingectomy
Procedure

Indication
- ectopic pregnancy (most cases)
- inflammatory disease with a unilateral hydrosalpinx.

Points of Caution.
- the cornual portion of the Fallopian tube and mesosalpinx are extremely vascular ar
eas. Hemostasis must be insured.
- cornual portion of the tub Each of the pedicles The mesosalpinx is
e is clamped with a Kelly c The procedure has
tied with interrupted reperitonealized with a
lamp, and the remainder been completed.
3-0 synthetic running 3-0 synthetic
is grasped with a Babcock absorbable suture. absorbable suture
clamp – elevated
- fenestrations in the
mesosalpinx are
performed with a straight
Halsted clamp - pedicles
Salphingoophorectomy
Procedure

The purpose of the operation is to remove the tube and ovary.

Points of Caution

-the indundibulopelvic ligament must be dissected clear to the ureter if the

ligament is to be clamped in the area of the pelvic brim.
- the infundibulopelvic ligament should be doubly tied because the venous
network within this ligament tends to retract, producing hematomas that
dissect up to the renal vessels.
-round ligament on th -infundibulopelvic ligament
e affected side is tied is undermined with finger
and transected. dissection identify the ureter
- posterior leaf of the - infundibulopelvic ligament
broad ligament is then is triple-clamped and incised
opened.. between the first and
second clamps
- proximal side of the
infundibulopelvic
ligament is tied with a
0 synthetic absorbable
suture, then sutured
again.
-mesosalpinx of the Fallopian
tube is penetrated
- tubes, suspensory ligament,
and mesosalpinx are transected
, and the tube and ovary are
removed
- distal portion of the round ligament is reapproximated to the
cornu of the uterus with a 0 synthetic absorbable mattress suture
- proximal stump of the round ligament is buried within the broad
ligament
- defect in the broad ligament and the peritoneal lining of the
mesosalpinx are reestablished with a running 3-0 synthetic absorb
able suture starting at the cornu of the uterus and extending to the
stump of the infundibulopelvic ligament.
Tubal Ligation
Tubal ligation

Introduction

Tubal ligation : sterilization technique, woman’s fallopian tubes either clamped/blocked/severed/

sealed can be performed peripartum/postpartum

Numerous Fallopian tube sterilization techniques are available to provide obstruction to the Fallo
pian tubes to prevent sperm and oocyte from fertilizing and being carried into the uterus

failure rate 1/200 and most probably occur through;

recanalization of the tube, development of a tuboperitoneal fistula

Indication

Desire for permanent sterilization also complete family

Procedure
Pomeroy
 introduced in 1930
 taking a section of Fallopian tube,
tying the base of the tube, excising
a knuckle of tube
 traditional and effective method of
female sterilization
Kroner
 introduced in 1935
 removes the fimbriae from the Fallopian
tube (the stump of the ampullar portion
of the Fallopian tube is tied, and the
fimbriae are removed)
.
Ucheda

 fallopian tube is grasped with a Babcock

clamp and elevated
 serosal covering injected with saline
solution
 longitudinal incision is made in the serosa
over the area injected with the saline solu
tion.
 fallopian tube is dissected out and a  serosa is closed with several fine
piece is removed between ties of 3/0 3/0 synthetic absorbable sutures
silk suture
 distal segment of the proximal portion
of the fallopian tube is buried
 proximal segment of the distal portion
is exteriorized through the serosal
opening.
Modified Irving
 purpose of the procedure is to prevent
pregnancy by obstructing the Fallopian tubes
by burying their proximal portions back into
the myometrium
 Fallopian tube is grasped with an Allis or a
Babcock clamp.
 absorbable sutures are used to tie, and the
segment of Fallopian tube is transected and
removed
 tie on the distal segment of the proximal portion
of Fallopian tube is threaded onto 2 French eye
needles
 mosquito hemostat is used to open a defect in
the posterior wall of the uterus in the cornual
region
 French eye needles are passed through  both proximal portions of the Fallopian tube
this defect, then suture is tied, pulling the buried within the myometrium
proximal portion of the Fallopian tube into  distal portions of the Fallopian tube are ligat
the defect ed and left in place
Hulka Clip Fallope Ring

 introduced in 1972
 introduced by In-Bae Yoon 1974
 placing of a locking Silastic metallic
 Silastic band is placed around a knuckle of
clip across the Fallopian tube
Fallopian tube. The knuckle is not excised
as in the Pomeroy technique. The Silastic
band stays in place and creates obstruction.
Wheeless Other

 Introduce 1970
 laparoscopic electrocoagulation
technique
 section of evulsed tube will not have
bleeding from the proximal or distal end
of the remaining tube nor the bed of the
mesosalpinx
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