{"paper_id":"52fc9959-8a60-43e1-ab33-87bd701f133e","body_text":"Submit Manuscript | http://medcraveonline.com\nBackground\nThe incidence of adnexal masses in pregnancy is estimated at \napproximately 2%.1 Most adnexal masses resolve spontaneously by \nthe second trimester without needing intervention, as long as there is \na low risk for malignancy or complications, such as ovarian torsion. 2 \nHowever, surgical intervention is indicated in cases of acute abdomen, \nhydronephrosis, risk of dystocia, and malignancy.3 \nAdnexal masses are radiologically classified as simple or complex, \nand each category includes both benign and malignant neoplasms. \nAmong adnexal masses in pregnant women, 1% of simple masses, \nand 9% of the complex masses are found to be malignant. 4 Most \nadnexal masses in pregnancy are simple functional cysts less than \n5 cm in diameter and therefore resolve without intervention by the \nsecond trimester.1 \nHowever, if the mass is symptomatic or large (usually greater than \n10cm) surgery is recommended due to the risk of major complications \notherwise aspiration may be considered. 1 Complications of adnexal \nmasses in pregnancy include adnexal torsion, rupture, malignancy, \nabortion, and preterm delivery. 3 Traditionally, adnexal masses in \npregnancy were managed by laparotomy, but recently, studies have \nshown that laparoscopy during any trimester is safe and feasible \nalthough surgery is recommended in the second trimester.5,6 In contrast \nto laparotomy, laparoscopic surgery is associated with faster recovery, \nless pain, and a shorter hospital stay.2 \nSingle incision laparoscopic surgery (SILS) averts the potential \nmorbidity of multiple trocar insertions as well as being associated \nwith less bleeding and pain, as well as improved cosmetic outcomes \nand tissue retrieval. 5,7,8 We describe the case of a pregnant woman \nwith a 20cm adnexal mass who underwent a SILS salpingectomy and \ncystectomy at 16 weeks and 5 days gestation.\nPresentation of the case\nThe patient was a 24 year old, pregnant, Gravida 2, Para 0010, \nwith gestational diabetes and morbid obesity (BMI of 42.18kg/\nm2). She had history of a spontaneous abortion. She presented to \nour clinic at 15 weeks and 3 days gestation for further evaluation \nof a large maternal abdominal cystic mass incidentally detected on \nroutine prenatal ultrasound. She denied gastrointestinal symptoms or \nabdominal pain. Her diabetes was controlled by dietary and lifestyle \nmodifications under medical care with the support of a dietician. \nPelvic ultrasound revealed a large unilocular cyst slightly to the \nright of midline measuring 19.0 x 15.8 x 9.0cm. The cyst was superior \nObstet Gynecol Int J. 2018;9(4):234‒236. 234\n©2018 Rezai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nLaparoendoscopic single-site cystectomy \nin pregnancy for a benign mullerian serous \ncystadenofibroma: a case report with review of \nliterature\nVolume 9 Issue 4 - 2018\nShadi Rezai,1,5 Alexander C Hughes,2 Emily \nWang,2 Ninad M Patil,3 Elise Bardawil,5 \nCassandra E Henderson,4 Xiaoming Guan5\n1Department of Obstetrics and Gynecology, Southern California \nKaiser Permanente, USA\n2St. George’s University, School of Medicine, St. George’s, \nGrenada\n3Department of Pathology & Immunology, Baylor College of \nMedicine, USA\n4Maternal and Fetal Medicine, Department of Obstetrics and \nGynecology, Lincoln Medical and Mental Health Center, USA\n5Division of Minimally Invasive Gynecologic Surgery, \nDepartment of Obstetrics and Gynecology, Baylor College of \nMedicine, USA\nCorrespondence: Xiaoming Guan MD PhD, Section Chief and \nFellowship Director, Division of Minimally Invasive Gynecologic \nSurgery, Department of Obstetrics and Gynecology, Baylor \nCollege of Medicine, 6651 Main Street, 10th Floor, Houston, \nT exas, 77030, USA, T el (832) 826-7464, Fax (832) 825-9349, \nEmail xiaoming@bcm.edu \nReceived: May 12, 2018 | Published: July 06, 2018\nAbstract\nBackground: The incidence of adnexal masses in pregnancy is estimated to be 2%. Surgical \nintervention is required, particularly in the setting of potential malignancy, ovarian torsion, \nor direct mass affect on the pregnancy. Single incision laparoscopic surgery (SILS) averts \nthe potential morbidity of multiple trocar insertions as it is associated with less bleeding, \npain and better cosmetics and tissue retrieval. We describe the use of SILS technique in a \n16 5/7-week pregnancy complicated by a 20cm left adnexal cystic mass that was managed \nwith a single-incision laparoscopic left salpingectomy with cystectomy.\nCase: The patient was a 24 year old, pregnant, Gravida 2 Para 0010 with gestational \ndiabetes and morbid obesity (Body-Mass Index of 42.18). Her only pregnancy ended as \na spontaneous abortion. She initially presented to our clinic at 15 3/7 weeks for further \nevaluation of a large, 19.0 x 15.8 x 9.0cm maternal abdominal cystic mass, which had \nbeen detected on prenatal ultrasound. She was managed by Single-Incision diagnostic \nlaparoscopy and Single-incision laparoscopic left salpingectomy and left paratubal \ncystectomy at 16 5/7 weeks. Pathologic examination of the paratubal cyst revealed the \nmass to be a benign mullerian serous cystadenofibroma. Her recovery was uncomplicated, \nwith discharge on the first postoperative day.\nConclusion: In summary, removal of this patient’s adnexal mass in pregnancy was \nwarranted to avert potential complications. The patient’s paratubal cyst was drained \nwithout leakage and then removed intact through the umbilical incision. Single incision \nlaparoscopic cystectomy for large ovarian and paratubal cysts in pregnancy is not only \nfeasible, but has also been shown to result in better outcomes. There were no complications \nin this patient intraoperatively, postoperatively, or in a subsequent pregnancy. \nKeywords: adnexal mass, cystectomy, paratubal cyst, pregnancy, salpingectomy, SILS \ncystectomy, single-incision laparoscopic surgery\nObstetrics & Gynecology International Journal\nCase Report\n Open Access\n\n\nLaparoendoscopic single-site cystectomy in pregnancy for a benign mullerian serous cystadenofibroma: a \ncase report with review of literature\n235\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Hughes AC, Wang E, et al. Laparoendoscopic single-site cystectomy in pregnancy for a benign mullerian serous cystadenofibroma: a case \nreport with review of literature. Obstet Gynecol Int J. 2018;9(4):234‒236. DOI: 10.15406/ogij.2018.09.00338\nto the uterus and displayed no color flow on Doppler imaging. \nThe right ovary was not visualized, and the ultrasound could not \nconclusively delineate the origin of the cyst, possibilities being ovary, \nmesentery or pancreas. \nThe patient was counseled that the best course of treatment is \nremoval of the cyst in the second trimester due to the cyst’s size \nand lack of flow. At 16 weeks and 5 days of gestation, the patient \nunderwent a single-incision diagnostic laparoscopy and a single-\nincision laparoscopic salpingectomy with left paratubal cystectomy. \nSILS technique\nUnder general endotracheal anesthesia and in dorsal lithotomy \nposition, a 15mm skin incision was made in the umbilicus, and the \nincision was carried down in layers until the abdominal cavity was \nentered. A GelPOINT mini advanced access single-site laparoscopy \ndevice was inserted into the incision. Carbon dioxide was used \nto insufflate the abdominal cavity with careful attention paid to \nintraabdominal pressure. \nUpon visualization of the abdomen a 16 week gravid uterus was \nobserved with a large unilocular left paratubal cyst (Figure 1). The \nleft fallopian tube was extremely distended around due to the cyst, \nand the left ovary was not visualized. The right fallopian tube and \novary appeared grossly normal. A laparoscopic needle aspirator \nwas introduced into the cyst under direct visualization and the cyst \ncontents were aspirated. When approximately half the cyst contents \nhad been aspirated, the articulating Enseal was used to expand the \nsmall puncture site allowing for continued aspiration with the \nlaparoscopic suction-irrigator. Once the cyst was decompressed, the \nfallopian tube was transected near the cornu of the uterus with the \narticulating Enseal. An incision was carried along the mesosalpinx \nuntil the entire fallopian tube was detached. Excellent hemostasis was \nnoted and area was examined. The left ovary appeared viable after the \nprocedure, and no additional cyst was seen. There was approximately \n50ml of blood loss, 1200ml intravenous fluids administered, and \n100ml of urine output. \nFigure 1 Intraoperative image, showing a large, unilocular, clear left paratubal \ncyst. The cyst is superior to the 16 week gravid uterus.\nThe cyst specimen was removed and sent to pathology, which \nrevealed a thick-walled cyst, with occasional branching solid \npapillae along its inner lining. The wall of the cyst showed prominent \nfibromatous stroma and the epithelium was benign, of serous-type. The \npapillae also contained benign serous epithelial inclusions surrounded \nby prominent fibromatous stroma. The pathologic diagnosis was \nconsistent with a benign müllerian serous cystadenofibroma (Figure \n2).\nA postoperative bedside ultrasound confirmed a detectable fetal \nheart beat. The patient had an uncomplicated recovery course and \nwas discharged from the hospital on the day after surgery. At the \n3-week postoperative follow-up, the patient was doing well, with no \ncomplaints. At 38 weeks gestation the patient underwent primary low \ntransverse cesarean delivery due to obstetric indications. Both mother \nand the baby had an uncomplicated hospital stay and postpartum \ncourse. Another pregnancy, 2 years later, was also noted to be \nuncomplicated with no recurrence of the cyst.\nFigure 2 Pathologic examination showed a serous cystadenofibroma, \ncomprised of a cyst with occasional branching solid papillae, lined by benign \nserous epithelium. Serous inclusions (black arrows) are seen in the solid \npapillae. Prominent fibromatous stroma (white arrows) is seen around the \ncyst wall as well as in the solid papillae. (H&E stain).\nDiscussions\nPelvic masses affect both pregnant and non-pregnant women \nalike at similar rates. Management during pregnancy involves \neither surgical intervention or observation, depending on clinical \npresentation. Observation carries the risk of allowing for malignant \ntransformation or torsion. Surgery and anesthesia have their own risks \nto the mother and the fetus. A review of literature indicates that there \nare no universally agreed upon guidelines for the treatment of adnexal \nmasses during pregnancy.\nTraditionally, pelvic masses were removed via laparotomy with \na midline incision8 but with advances in minimally invasive surgical \ntechniques laparoendoscopic surgery has become the standard of care. \nSome surgeons are hesitant to perform endoscopic surgery during \npregnancy due to concerns such as poor surgical visualization, effects \nof CO2 insufflation and iatrogenic trocar injury.8,2,3 Many studies have \nshown endoscopic surgery to be safe and effective during pregnancy. \nLaparoscopic surgery in pregnancy is accepted to have lower rates of \npremature labor and shorter hospital stays compared to laparotomy.8,9,10\nAs mentioned above, the second trimester is the optimal time for \nsurgery during pregnancy. The uterus is still contained within the \npelvis and the second trimester has been shown to have the lowest \nrate of premature labor. 2,6 Surgery is best for adnexal masses during \npregnancy not only for the non-gravid reasons such as torsion, but \nalso because of the malignant potential of some of these masses. 8 \nUnfortunately, conservative management may result in the need for \nemergency surgery which is associated with higher incidence of \nnegative outcomes as compared to planned surgery in the second \ntrimester.11\n\n\nLaparoendoscopic single-site cystectomy in pregnancy for a benign mullerian serous cystadenofibroma: a \ncase report with review of literature\n236\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Hughes AC, Wang E, et al. Laparoendoscopic single-site cystectomy in pregnancy for a benign mullerian serous cystadenofibroma: a case \nreport with review of literature. Obstet Gynecol Int J. 2018;9(4):234‒236. DOI: 10.15406/ogij.2018.09.00338\nSILS in pregnancy is being performed more commonly. As with \na non-pregnant patient, the entire procedure involves a small skin \nincision in the umbilicus through which all instruments are introduced. \nThis method is believed to prevent injury to an enlarged uterus \nfrom insufflation needle or trocar.  By entering the pelvis through \nthe umbilicus, the surgeon is able to visualize adnexal ligaments, \nespecially because the uterus will overstretch these structures during \npregnancy.12\nStudies show that in contrast to a traditional laparoscopic approach, \nSILS has improved cosmetic results from fewer trocar incisions, lesser \npostoperative pain, and reduced need for narcotic use. 2,12,13 SILS has \nalso been reported to have a lower incidence of hernia formation than \nother forms of endoscopic surgery.2\nA majority of smaller (less than 5cm) adnexal masses will resolve \nspontaneously and many by the second trimester. 11 However, when \nsurgery is necessary the least invasive approach should be used. \nSome surgeons have reservations about performing endoscopic \nsurgery during pregnancy, as there is fear of trocar injury to the uterus \nespecially as gestation progresses. With SILS there is only one site of \nentry reducing this risk. Additionally, the peritoneum is entered in an \nopen fashion rather than blind insertion of trocars, further minimizing \nthe risk of injury to intraabdominal structures.\nOne drawback of SILS as compared to multi-port laparoscopy in \npregnancy is limited scope for uterine manipulation. Not only is the \ngravid uterus larger than a non-gravid uterus taking up abdominal \nspace but a uterine manipulator cannot be inserted. In traditional \nlaparoscopic surgery, the uterus can be pulled out away from the field \nof view but with SILS the uterus must be pushed atraumatically from \nbehind through the surgical field of view. This difference can still be \novercome by surgeons with experience and should be a consideration.\nConclusion\nIn summary, the patient’s paratubal cystic mass was drained \nwithout leakage and then removed intact through the umbilical \nincision. Single incision laparoscopic cystectomy for large ovarian \nand paratubal cysts in pregnancy is not only feasible, but also leads \nto better outcomes. 7 There were no complications intraoperatively, \npostoperatively, or in a subsequent pregnancy. \nAdnexal masses are often incidentally detected in pregnancy due \nto routine use of ultrasound. Most masses resolve spontaneously, \nbut some may be malignant or cause adverse outcome. Based on \nultrasound features and the development of symptoms, surgery should \nbe considered. For experienced surgeons, studies have shown that \nSILS appears to be a safer alternative to laparotomy.\nAcknowledgments\nDr. Xiaoming Guan is a speaker for Applied Medical, Rancho \nSanta Margarita, and California. \nConflicts of interest\nAuthors did not report any potential conflicts of interests.\nReferences\n1. Lee JH, Lee JR, Jee BC, et al. Safety and feasibility of a single-port \nlaparoscopic adnexal surgery during pregnancy. J Minim Invasive \nGynecol. 2013;20(6):864–70. \n2. Scheib SA, Jones HH, Boruta DM, et al. Laparoendoscopic single-site \nsurgery for management of adnexal masses in pregnancy: case series. J \nMinim Invasive Gynecol. 2013;20(5):701–7. \n3. Cavaco-Gomes J, Jorge Moreira C, Rocha A, et al. Investigation and \nManagement of Adnexal Masses in Pregnancy,. Scientifica (Cairo).  \n2016;2016:3012802. \n4. Runowicz CD, Brewer M, Adnexal mass in pregnancy. In: Goff B, Falk \nSJ, editors. UpToDate Inc; 2016.\n5. Fader AN, Levinson KL, Gunderson CC, et al. Laparoendoscopic single-\nsite surgery in gynecology: A new frontier in minimally invasive surgery. \nJ Minim Access Surg. 2011;7(1):71–7.\n6. American College of Obstetricians and Gynecologists. Practice Bulletin \nNo. 174: Evaluation and Management of Adnexal Masses. Obstet \nGynecol. 2016;128(5):e210–e226.\n7. Zhang Y , Blazek K, Guan X. Single-Incision Laparoscopic Ovarian \nCystectomy in a 26 Weeks Pregnancy Patient with 17 cm Cyst, Video \nSession 6 – Single-Port Laparoscopy, Video Number 257. J Minim \nInvasive Gynecol. 2017;24(7):S93–S94. \n8. Balthazar U, Steiner AZ, Boggess JF, et al. Management of a persistent \nadnexal mass in pregnancy: what is the ideal surgical approach?. J Minim \nInvasive Gynecol. 2011;18(6):720–5. \n9. Duncan RP, Shah MM. Laparoscopic salpingectomy for isolated \nfallopian tube torsion in the third trimester. Case Rep Obstet Gynecol . \n2012:239352. \n10. Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy \nin pregnancy: a systematic review. Int J Surg. 2008;6(4):339–44. \n11. Schmeler KM, Mayo-Smith WW, Peipert JF, et al. Adnexal masses \nin pregnancy: surgery compared with observation. Obstet Gynecol . \n2005;105(5 Pt 1):1098–103.\n12. Al-Badawi IA, Alshankiti H, Ahmad S. Single Incision Laparoscopic \nSurgery in Pregnancy. CRSLS MIS Case Reports from SLS.org. 2014.\n13. Escobar PF, Fader AN, Paraiso MF, et al. Robotic-assisted \nlaparoendoscopic single-site surgery in gynecology: initial report and \ntechnique. J Minim Invasive Gynecol. 2009;16(5):589–91.","source_license":"CC0","license_restricted":false}