Laparoscopic Management of Large Adnexal Masses

Laparoscopic Management of Large Adnexal Masses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Laparoscopic Management of Large Adnexal Masses Behnaz Nouri, Maliheh Arab, Elahe Afshari, Ahmad Reza Baghestani, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-73588/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Aug, 2021 Read the published version in Shiraz E-Medical Journal → Version 1 posted You are reading this latest preprint version Abstract Background: To report the surgical outcomes of laparoscopic resection of large adnexal masses (≥10 cm). Methods: In this cross-sectional study, we enrolled 126 patients with large adnexal masses (≥10 cm), managed by laparoscopic surgery during 2013 to 2020. The rates of intraoperative complications, conversion to open surgery and incidence of cancer were assessed. Results : Mean mass size was 15.08±5.03 in all participants without significant difference based on the tumor type (P=.624). Mean age and operation time were higher in the malignant type compared to that of the benign type (P<.001). Type of surgery and frequency of intra-operative complications were also different among patients with different tumor types (P<.001 and .003, respectively). Conclusion: Our study showed that large adnexal tumors can be operated by laparoscopic approach, while the most important factor for increased surgical complications and duration was malignancy. Internal Medicine Preventive Medicine Laparoscopy Adnexal mass Ovarian neoplasms Tumor size Figures Figure 1 Background Adnexal mass is one of the most common gynecologic diseases among women of all ages, especially during reproductive ages, with an estimated prevalence of 5–10% in different populations ( 1 ). The gold standard management for benign ovarian masses is laparoscopy with surgical outcomes similar to laparotomy and several benefits to laparotomy, such as faster recovery, less and shorter postoperative pain, reduced inpatient admission, and superior cosmetic outcomes ( 2 ). However, laparoscopic management of adnexal masses has some limitations, such as difficulty in inserting trocars and limited surgical field that inhibits the complete exploration of the abdominal cavity, as well as the risk of ovarian rupture and spread of cyst fluid into the abdominal cavity ( 3 ). Some suggest that the iatrogenic or accidental rupture and spillage of the malignant adnexal mass contents upgrades the tumor stage and decrease the overall survival ( 4 ), while some others suggest that it has no adverse prognostic significance ( 5 ). Although the laparoscopic operation would be much easier and faster after puncturing the benign cysts, the risk of spillage of malignant cells hinders the surgeons from puncturing the cyst for the ease of operation, which results in preference of open surgery ( 6 ). Meanwhile, it is not clear whether the risk of rupture differs based on the tumor type, which has to be further investigated. Another important factor for the choice of laparoscopic or laparotomic management of adnexal masses is the size of the mass, and due to the technical difficulty of performing laparoscopy, limited surgical field, and the higher probability of malignant potential in adnexal masses, some suggest the use of laparotomy in large adnexal masses ( 7 , 8 ). However, the cut-off level for the “giant”, “huge”, and “large” tumors are not clearly defined and no contraindications have been defined for the laparoscopic approach based on maximum tumor size ( 5 , 9 ). Despite many restrictions for laparoscopic approach in large adnexal masses, recent literature has suggested that many of these adnexal masses can still be managed using laparoscopy ( 10 ). Some have also suggested that tumor size is not a predictor of perioperative complications ( 11 ). Due to the complications of laparotomy, it is worth to examine the applicability of laparoscopy in large adnexal masses. Considering the controversies regarding the treatment of large ovarian tumors with laparoscopic surgery, the present study aimed to report the surgical outcome of patients with large (≥ 10 cm) adnexal masses undergoing laparoscopic surgery and factors associated with the surgical outcome. Methods This cross-sectional study was conducted at Shohadaye-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran and all women with an adnexal mass of ≥ 10 cm based on preoperative ultrasonography and magnetic resonance imaging (MRI), who underwent laparoscopic surgery from July 2013 to January 2020 were enrolled into the study. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences with the approval number SBMU.RETECH.REC1397.1032. Informed consent was acquired from all participants for participation into the study and conversion to laparotomy, in case of unexpected complications or incidental malignancy finding. A total of 126 participants who had the inclusion criteria were enrolled into the study by census method. All patients underwent preoperative physical examination and imaging. Abdominal and vaginal ultrasound was performed by an expert; the mass size was characterized based on the maximum diameter reported in the imaging studies. One venous blood sample was obtained from all patients and sent to the laboratory for measurement of tumor markers including lactate dehydrogenase (LDH), cancer antigen (CA)19 − 9, CA125, carcinoma embryonic antigen (CEA), Human epididymis protein 4 (HE4), inhibin, and beta-HCG were measured in all patients prior to surgery. Those patients who had ascites or metastasis, obesity, pregnancy, a previous history of abdominal surgery, and a probable malignancy without metastasis (mass features in imaging or elevated tumor markers) were not included into the study. All the surgeries were performed by a single surgeon (B. Nouri), under general anesthesia, with a single surgical protocol. For this purpose, patients were laid in the dorsal lithotomy position and after induction of general anesthesia, a 10-mm trocar was inserted either directly or using an altered open technique at the umbilicus, subxiphoid, or palmar site, according to the tumor size. Other trocars were placed under direct visualization. First, the whole abdomen and pelvis were inspected. Subsequently, peritoneal fluid was sent for cytological assessment. Peritoneal washing was performed in case of no peritoneal fluid. The ovarian masses were removed with caution to remain intact and placed within endo-bag using a 15-cm opening diameter (Endo Catch II TM, Covidien Tyco, Norwalk, CT, USA). If we decided to initiate the drainage of very large masses, we performed cystectomy or oophorectomy with or without salpingectomy, decided based on the patients’ age, medical history, and intraoperative findings. The cyst walls were punctured by either of the following methods. In the first method, we drained the cyst fluid using a 5-mm trocar with sleeve inserted into cyst wall dome in laparoscopic visualization; then, we removed the trocar and placed a suction-irrigation device into the cyst wall through the sleeve. In the second approach, the cyst wall was incised between two graspers and the mass was inserted with the suction-irrigation device. The mass was drained as much as possible and the puncture site was immediately closed by a grasper to avoid leakage. Homeostasis was achieved and the access site for specimen retrieval and the umbilical port site were closed in different anatomical layers. The management plans were made based on the frozen section findings. Surgical staging was performed by laparoscopy and conversion to laparotomy was conducted only for cases with technical difficulties. Intraoperative and postoperative complications, conversion to laparotomy, type of procedure, operation time, and pathologic reports were documented. Operative time was recorded as the time from skin incision to skin closure. Blood loss was measured based on the fluid gathered in the suction bottle. Spillage was characterized as any deliberate or accidental mass wall rupture. If the tumor was drained intentionally into the endo-bag without a peritoneal spill, the tumor was not regarded as a ruptured tumor. Statistical analysis Statistical analysis was performed using Excel program, 2007 version. The Kolmogorov-Smirnov test was used to examine normal distribution of the data. One-way analysis of variance (ANOVA) was applied to determine the differences among the groups; in case of significance, pairwise comparisons were performed using Tukey’s test. Fisher’s exact test was applied to analyze ratio and chi-square test was used for categorical variables. P-values less than .05 were considered significant. Results A total of 126 women completed the study. Patients’ demographic characteristics are shown in Table 1 . The mean age of the patients was 30.21 ± 11.64 years; 80.2% had benign tumor type (N = 101), 7.1% borderline (N = 10), and 11.9% malignant/metastasis (N = 15). There was a significant difference among the three groups in terms of mean age and operation time; age and duration of surgery were higher in the malignant type compared to that of the benign type (P .05; Table 1 ). Mean mass size was 15.08 ± 5.03 in all participants without significant difference based on the tumor type (P = .624; Table 1 ). Table 1 The demographic characteristics of the study participants categorized based on tumor type Variable Total (N = 126) Mean ± SD Benign (N = 101) Mean ± SD Borderline (N = 9) Mean ± SD Malignant or metastasis (N = 15) Mean ± SD P-value among the three groups * P-value Benign-borderline † P-value Benign-Malignant † P-value Malignant-borderline † Age (years) 30.21 ± 11.64 28.31 ± 10.27 33.56 ± 16.78 40.87 ± 11.76 < .001 .359 < .001 .260 BMI (kg/m2) 25.95 ± 6.12 26.03 ± 6.10 25.55 ± 5.15 26.20 ± 6.98 .968 .973 .994 .967 Parity (No.) 2.3 ± 1.2 .78 ± 1.11 .56 ± 1.13 1.13 ± 1.12 .414 .830 .946 .442 Mass size (cm) 15.29 ± 5.09 15.08 ± 5.03 16.33 ± 6.34 16.13 ± 5.08 .624 .763 .739 .995 Duration of surgery (min) 128.88 ± 63.37 116.92 ± 52.08 144.44 ± 92.88 184.67 ± 56.67 < .001 .340 < .001 .210 Bleeding volume (cc) 124.61 ± 287.32 105.02 ± 247.07 84.56 ± 68.38 275.53 ± 519.41 .092 .977 .082 .254 Fluid volume drained from the mass (cc) 1687.27 ± 928.37 1674.51 ± 948.86 2050.00 ± 353.55 1650.00 ± 1060.66 .858 .846 .999 .906 * results of test of ANOVA, † results of Tukey test; all tests were considered significant when < .05 The first trocar was inserted in the umbilicus in 27.8% of patients (N = 35), upper umbilicus in 21.4% (N = 27), subxiphoid in 48% (N = 61), and palmar in 2.8% of patients (N = 3). Seventy-five patients (59.5%) were nulliparous, 17 women (13.5%) had one child, and 34 women (27%) had two or more children. The results of serum parameters are shown in Table 2 . Table 2 The frequency of tumor markers in the study participants Tumor marker Number Percentage Normal 75 59.5 High CA125 26 20.6 High CA125 + High HE4 1 .8 High CA125 + High CA19-9 4 3.2 High HE4 13 10.3 High HE4 + High inhibin + High CA19-9 1 .8 High inhibin 2 1.6 High LDH 1 .8 High LDH + High CA19-9 1 .8 High CA19-9 1 .8 Positive BHCG 1 .8 Abbreviations: cancer antigen 19 − 9; CA19-9, cancer antigen 125; CA125, Human epididymis protein 4; HE4, lactate dehydrogenase; LDH, and beta-human chorionic gonadotropin (HCG) Twelve patients were menopause (9.5%) and there was a significant difference in the frequency of menopause among patients with different tumor types (P = .002; Table 3 ). The type of surgery and frequency of intra-operative complications were also different among patients with different tumor types (P < .001 and .003, respectively; Table 3 ), but the frequency of tumor type and side, site of the first trocar, history of abdominal surgery, and blood infusion were not different in patients with different tumor types (P > .05; Table 3 ). Table 3 The frequency of surgical and tumor characteristics in the study participants categorized based on tumor type Type of malignancy p-value Total (N = 126) Benign (N = 101) Borderline (N = 9) malignant/metastasis (N = 15) Tumor type Cystic 72(57.1) 61(60.4) 4(44.4) 6(40.0) .221 Solid-cystic 52(41.3) 39(38.6) 5(55.6) 8(53.3) Solid 3(2.4) 1(1.0) 0(0.0) 1(6.7) Tumor side Unilateral 97(77.0) 78(82.1) 7(77.8) 11(78.6) .258 Bilateral 21(16.7) 17(17.9) 2(22.2) 2(14.3) Type of surgery Cystectomy 76(63.2) 73(645.2) 2(22.2) 0(0.0) < .001 Cystectomy + staging 1(.8) 0(0.0) 0(0.0) 1(6.7) Salpingo-oophorectomy 31(24.6) 25(23.8) 0(0.0) 6(33.4) TLH + BSO + Omentectomy + Appendectomy 1(.8) 1(.8) 0(0.0) 0(0.0) lh + bilateral oophorectomy + staging 8(6.4) 0(0.0) 4(44.4) 4(26.7) Bilateral oophorectomy + staging 5(4.0) 0(0.0) 2(22.2) 3(20.0) TAH + BSO + cytoreductive surgery 1(.8) 0(0.0) 0(0.0) 1(.8) Mass resection + adhesion release 5(4.0) 3(3.0) 0(0.0) 2(13.3) First trocar site Umbilicus 35(27.8) 28(27.7) 1(11.1) 6(40.0) .527 Upper umbilicus 27(21.4) 19(18.8) 3(33.3) 5(33.3) Sub xiphoid 60(48.0) 50(49.5) 5(55.6) 5(33.3) Palmar 3(2.8) 2(2.0) 1(11.1) 0(0.0) Intra-operative complications None 107(84.9) 90(89.1) 8(88.9) 8(53.3) .816 Accidental cyst rupture 6(4.8) 4(4.0) 0(0.0) 2(14.3) Pelvic abscess 2(1.6) 0(0.0) 0(0.0) 2(14.3) Intestinal perforation 1(.8) 0(0.0) 1(11.1) 0(0.0) Intestinal serous trauma 1(.8) 1(1.0) 0(0.0) 0(0.0) Blood transfusion 5(4.0) 5(5.0) 0(0.0) 0(0.0) Conversion to laparotomy 2(1.6) 0(0.0) 0(0.0) 2(14.2) Rupture of bladder 1(.8) 1(1.0) 0(0.0) 0(0.0) Umbilical infection 1(.8) 0(0.0) 0(0.0) 1(7.1) History of surgery No 75(59.5) 63(62.4) 5(55.6) 7(50.0) .687 Yes 50(40.5) 38(37.6) 4(44.4) 7(50.0) Blood infusion No 117(92.9) 96(95.0) 9(100.0) 11(78.6) .109 Yes 7(5.6) 5(5.0) 0(0.0) 2(14.3) Menopause No 111(88.1) 93(94.9) 7(77.8) 10(66.7) .002 Yes 12(9.5) 5(5.1) 2(22.2) 5(33.3) * results of chi square test, † results of Fisher’s exact test; all tests were considered significant when < .05; all values are reported as number(percentage) Discussion In this study, we reported the surgical outcome of 126 patients with adnexal tumors ≥ 10 cm (mean of 15.08 ± 5.03 cm; maximum of 30 cm), among whom only one required conversion to open surgery. These results suggest the feasibility of laparoscopic management of adnexal masses ≥ 10 cm. In another study on 77 women with ovarian cysts ≥ 10 cm, conversion to open was required in four patients ( 12 ), which is higher than that of ours. This difference could be due to the difference in the experience of the laparoscopic surgeon and the difference in the rate of intra-operative complications between the studies. Among 19 patients, in the study by Vlahos et al. who had adnexal mass with a mean diameter of 8.3 cm, there were no cases of conversion to open ( 13 ). The difference between the results of this study and that of ours could be due to the small sample size of their study, but this study also confirms the results of the present study, considering the low risk of conversion to open surgery in large adnexal masses. One of the important factors against the suggestion of laparoscopic surgery for large adnexal masses is the risk of rupture and its negative effect on patients’ outcomes ( 7 , 8 ). However, in our study, incidental rupture was only observed in 8 patients, two of whom were malignant. These results show that the laparoscopic method has an acceptable rate of cyst rupture. In another study by Shiota et al., comparison of 1483 cases of benign ovarian cysts according to the cyst size showed no difference in the incidence of cyst rupture among patients with cyst size 10 cm ( 14 ), which confirm the results of the present study. In another study by Detorakis et al., studying the surgical outcome of 102 women with adnexal cysts with mean size of 5.7 cm (2.3–10.5 cm) showed cyst rupture in 31.8% of the patients and 7.2% in masses > 8 cm ( 15 ). These authors concluded that laparotomy is the preferred method for large adnexal masses, but generally speaking, iatrogenic or accidental rupture and spillage of the adnexal mass contents are considered an inevitable incidence during surgery and may occur both in laparoscopic and laparotomic approaches ( 4 ). Furthermore, the prognostic value of significant spillage in malignant cases is still controversial and some suggest that laparoscopic treatment of ovarian cancer does not have a higher risk of spillage ( 16 ). Therefore, we believe that the risk of rupture should not ban surgeons from the choice of laparoscopy, considering the other advantages of this method. With the availability of frozen sections at many tertiary centers and adherence to proper surgical techniques, the chance of spreading malignancy has been reduced considerably. Another important surgical complication is the bleeding volume during surgery and requirement of blood transfusion and the results showed that the mean bleeding volume of the studied patients was 124.61 ± 287.32 cc and only five patients required blood transfusion. In another study by Demir et al, the results showed that 97.8% of women with adnexal masses of 8-13cm treated with laparoscopy had blood loss < 200 cc ( 9 ). These results confirm that of the present study on the low bleeding in laparoscopic treatment of large adnexal masses, considered one of the important advantages of laparoscopy vs. laparotomy ( 17 , 18 ). The mean operation time was 128.88 ± 63.37 minutes in our study. In the study by Vlahos et al on 53 women with adnexal masses of all sizes, undergoing laparoscopy, the mean operative time was 45 minutes ( 13 ), which is much less than that of the present study. In the study by Demir et al., 97.92% of surgeries lasted < 136 minutes ( 9 ), which is similar to the results of the present study. But they have only evaluated patients with benign type, while we included patients with any pathologic type. In the study by Machida et al. comparison of the median operation time was significantly higher in cases with adnexal masses > 10 cm vs. <5 cm (73 vs. 59 minutes) ( 11 ). These results suggest that large adnexal masses can prolong the surgical duration, which is justifiable by the technical difficulty of laparoscopy in large masses, considered one of the disadvantages of this approach for these cases. However, the results of our study showed that the risk of surgical complications are not much, when patients are selected after complete physical examination, precise imaging studies, and measurement of tumor markers. Furthermore, all surgeries were carried out by a single surgeon; in the meantime, a multidisciplinary team of experts consisting of pathologists, oncologists, colorectal surgeons, and urologists were involved and ready to be called on when necessary. As suggested, the risk of surgical complications is not predicted by the tumor size ( 11 ). Therefore, it does not seem logical to impose patients to the critical risk of invasive open surgeries, especially in cases with benign pathologies. The maximum tumor size for safe laparoscopic approach is yet to be determined, as 10 cm threshold seems questionable. The incidence rate of incidental finding of ovarian cancer during laparoscopy has been reported to be between 0.65% and 0.9% of premenopausal women and 3% of postmenopausal women ( 19 ). In our study, there were 15 patients with malignancy or metastasis, five of whom (33.3%) were postmenopausal. Other studies have reported other incidence rates for malignant ovarian mass ( 4 , 9 , 12 ), which can vary based on the frequency of malignancy in the study place and based on the inclusion criteria of the study. The results showed that patients with malignancy or metastasis were significantly older and had a longer duration of surgery and intra-operative complications. These results are consistent with the results of the study by Gad et al, which reported higher rate of complications and longer operative time in patients with borderline/malignant adnexal mass, compared to benign group undergoing laparoscopic treatment ( 20 ). Furthermore, they reported higher rate of conversion to open, blood loss, and duration of hospital stay ( 20 ), which was not observed in our study. Other studies have also confirmed the superiority of laparoscopy vs. laparotomy for treatment of ovarian cancers ( 21 , 22 ), as well as comparable accuracy of staging of laparoscopy vs. laparotomy and comparable survival rates ( 23 , 24 ), while the results of the present study suggested higher complication rates in large tumors. Due to the small sample size of this subgroup in our study, further studies should be performed to investigate the applicability of laparoscopy in large adnexal malignant tumors. Our study had some limitations. The first limitation was the cross sectional nature of this study, which limited suggestion of causal relationship between the study variables. Furthermore, we did not follow patients to study the long term results and did not evaluate the survival or recurrence rate in the studied population. The small sample of the study, especially in subgroups, was another limitation of the present study. Conclusion Our study showed that the size of tumor alone might not be a limiting factor for using laparoscopic approach in treatment of adnexal masses, as it resulted in acceptable rates of intra-operative complications. These results suggest the safety and efficacy of laparoscopic approach for large adnexal masses, when performed by an expert laparoscopic surgeon on selected patients. As higher rates of surgical complications and longer operation time were only observed in patients with malignancy or metastasis, due to the small sample size of this subgroup in our study, more studies are required to investigate the feasibility and safety of laparoscopic treatment of this subgroup of large adnexal masses. Abbreviations magnetic resonance imaging MRI lactate dehydrogenase LDH cancer antigen CA carcinoma embryonic antigen CEA Human epididymis protein 4 HE4 Declarations Ethics approval and consent to participate: Written informed was obtained from the participants. Consent for publication: All participants gave consent for anonymous publication of their results. Availability of data and materials: Available upon request. Competing interests: The authors of the present study declare that they have no competing interests. Funding: None. Authors' contributions: Study concept and design: BN and MA, drafting of the manuscript EA and MA and AR and critical revision of the manuscript: BN, and AB Statistical Analysis: AB and KS. All of the authors have given final approval of the version to be published. Acknowledgement: Not Applicable. References Pavlik EJ, Ueland FR, Miller RW, Ubellacker JM, DeSimone CP, Elder J, et al. Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography. Obstetrics Gynecology. 2013;122(2 PART 1):210–7. Liu JH, Zanotti KM. Management of the adnexal mass. Obstetrics Gynecology. 2011;117(6):1413–28. Schorge JO, Eisenhauer EE, Chi DS. Current surgical management of ovarian cancer. 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Surgical management of a suspicious adnexal mass: a systematic review. Gynecol Oncol. 2012;126(1):149–56. Tantitamit T, Lee C-L. Is it the time for laparoscopic management of early-stage ovarian malignancies? Gynecology and minimally invasive therapy. 2018;7(3):93. Cite Share Download PDF Status: Published Journal Publication published 30 Aug, 2021 Read the published version in Shiraz E-Medical Journal → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-73588","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3196226,"identity":"be35423e-709d-4ef2-a615-b0f2fab9b54c","order_by":0,"name":"Behnaz Nouri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBACAwglwSMv//jgAyCLh49YLTKGDWnJIA4PG5FaGGwYDuSoSYBYBLWYM/AefMy7x4KHseEMW+XXHDsZNgbmh49u4NFi2cCXbMzzTIKHnbH32G3ZbclAh7EZG+fgc9gBHjNpngMSPIzNfGm3JbcxA7XwsEkTpYXhGI9ZseS2elK0nOExY/y47TBhLZbNPMaGc4BaDGewJUszbjvOw8ZMwC/m7D2GD94cqLOXl2A++PHntmp7fvbmh4/xaWFgRmbzoIsQBIw/SFE9CkbBKBgFIwYAALXVO4lY/kLKAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-9940-4691","institution":"Shahid Beheshti University of Medical Sciences School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Behnaz","middleName":"","lastName":"Nouri","suffix":""},{"id":3196227,"identity":"fe6984b5-877a-4886-9493-b0d41b6e9410","order_by":1,"name":"Maliheh Arab","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences School of Nursing and Midwifery","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maliheh","middleName":"","lastName":"Arab","suffix":""},{"id":3196228,"identity":"1c273727-9640-4b70-ab0b-67a837e7eb94","order_by":2,"name":"Elahe Afshari","email":"","orcid":"","institution":"Iran University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Elahe","middleName":"","lastName":"Afshari","suffix":""},{"id":3196229,"identity":"41680e6a-0e7a-4feb-bbde-297c79699077","order_by":3,"name":"Ahmad Reza Baghestani","email":"","orcid":"","institution":"Shaheed Beheshti University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"Reza","lastName":"Baghestani","suffix":""},{"id":3196230,"identity":"2172ebb6-ce7e-450e-8f0b-26faaf13904a","order_by":4,"name":"Afshin Rakhsha","email":"","orcid":"","institution":"Shaheed Beheshti University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Afshin","middleName":"","lastName":"Rakhsha","suffix":""},{"id":3196231,"identity":"37db1f43-0718-45a1-80ac-3820db87a57d","order_by":5,"name":"Kourosh Sheibani","email":"","orcid":"","institution":"Eye Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kourosh","middleName":"","lastName":"Sheibani","suffix":""}],"badges":[],"createdAt":"2020-09-07 11:13:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-73588/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-73588/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.5812/semj.113994","type":"published","date":"2021-08-30T19:11:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2882047,"identity":"35e114db-8b6f-4d01-8665-3cc4942b7ab4","added_by":"auto","created_at":"2020-10-09 13:56:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33704,"visible":true,"origin":"","legend":"Comparison of mean age and duration of surgery in the patients with three tumor types ","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-73588/v1/86615d37735e2623bc40b786.png"},{"id":17333802,"identity":"5857685a-a433-430e-9943-fa051711c88e","added_by":"auto","created_at":"2022-01-14 19:11:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":381923,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-73588/v1/dc3808b8-1b24-469f-a9dd-94f5bef9437c.pdf"}],"financialInterests":"","formattedTitle":"Laparoscopic Management of Large Adnexal Masses","fulltext":[{"header":"Background","content":" \u003cp\u003eAdnexal mass is one of the most common gynecologic diseases among women of all ages, especially during reproductive ages, with an estimated prevalence of 5\u0026ndash;10% in different populations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The gold standard management for benign ovarian masses is laparoscopy with surgical outcomes similar to laparotomy and several benefits to laparotomy, such as faster recovery, less and shorter postoperative pain, reduced inpatient admission, and superior cosmetic outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, laparoscopic management of adnexal masses has some limitations, such as difficulty in inserting trocars and limited surgical field that inhibits the complete exploration of the abdominal cavity, as well as the risk of ovarian rupture and spread of cyst fluid into the abdominal cavity (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Some suggest that the iatrogenic or accidental rupture and spillage of the malignant adnexal mass contents upgrades the tumor stage and decrease the overall survival (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), while some others suggest that it has no adverse prognostic significance (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Although the laparoscopic operation would be much easier and faster after puncturing the benign cysts, the risk of spillage of malignant cells hinders the surgeons from puncturing the cyst for the ease of operation, which results in preference of open surgery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Meanwhile, it is not clear whether the risk of rupture differs based on the tumor type, which has to be further investigated.\u003c/p\u003e \u003cp\u003eAnother important factor for the choice of laparoscopic or laparotomic management of adnexal masses is the size of the mass, and due to the technical difficulty of performing laparoscopy, limited surgical field, and the higher probability of malignant potential in adnexal masses, some suggest the use of laparotomy in large adnexal masses (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, the cut-off level for the \u0026ldquo;giant\u0026rdquo;, \u0026ldquo;huge\u0026rdquo;, and \u0026ldquo;large\u0026rdquo; tumors are not clearly defined and no contraindications have been defined for the laparoscopic approach based on maximum tumor size (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Despite many restrictions for laparoscopic approach in large adnexal masses, recent literature has suggested that many of these adnexal masses can still be managed using laparoscopy (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Some have also suggested that tumor size is not a predictor of perioperative complications (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Due to the complications of laparotomy, it is worth to examine the applicability of laparoscopy in large adnexal masses. Considering the controversies regarding the treatment of large ovarian tumors with laparoscopic surgery, the present study aimed to report the surgical outcome of patients with large (\u0026ge;\u0026thinsp;10\u0026nbsp;cm) adnexal masses undergoing laparoscopic surgery and factors associated with the surgical outcome.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eThis cross-sectional study was conducted at Shohadaye-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran and all women with an adnexal mass of \u0026ge;\u0026thinsp;10\u0026nbsp;cm based on preoperative ultrasonography and magnetic resonance imaging (MRI), who underwent laparoscopic surgery from July 2013 to January 2020 were enrolled into the study. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences with the approval number SBMU.RETECH.REC1397.1032. Informed consent was acquired from all participants for participation into the study and conversion to laparotomy, in case of unexpected complications or incidental malignancy finding. A total of 126 participants who had the inclusion criteria were enrolled into the study by census method.\u003c/p\u003e \u003cp\u003eAll patients underwent preoperative physical examination and imaging. Abdominal and vaginal ultrasound was performed by an expert; the mass size was characterized based on the maximum diameter reported in the imaging studies. One venous blood sample was obtained from all patients and sent to the laboratory for measurement of tumor markers including lactate dehydrogenase (LDH), cancer antigen (CA)19\u0026thinsp;\u0026minus;\u0026thinsp;9, CA125, carcinoma embryonic antigen (CEA), Human epididymis protein 4 (HE4), inhibin, and beta-HCG were measured in all patients prior to surgery. Those patients who had ascites or metastasis, obesity, pregnancy, a previous history of abdominal surgery, and a probable malignancy without metastasis (mass features in imaging or elevated tumor markers) were not included into the study.\u003c/p\u003e \u003cp\u003eAll the surgeries were performed by a single surgeon (B. Nouri), under general anesthesia, with a single surgical protocol. For this purpose, patients were laid in the dorsal lithotomy position and after induction of general anesthesia, a 10-mm trocar was inserted either directly or using an altered open technique at the umbilicus, subxiphoid, or palmar site, according to the tumor size. Other trocars were placed under direct visualization. First, the whole abdomen and pelvis were inspected. Subsequently, peritoneal fluid was sent for cytological assessment. Peritoneal washing was performed in case of no peritoneal fluid. The ovarian masses were removed with caution to remain intact and placed within endo-bag using a 15-cm opening diameter (Endo Catch II TM, Covidien Tyco, Norwalk, CT, USA). If we decided to initiate the drainage of very large masses, we performed cystectomy or oophorectomy with or without salpingectomy, decided based on the patients\u0026rsquo; age, medical history, and intraoperative findings. The cyst walls were punctured by either of the following methods. In the first method, we drained the cyst fluid using a 5-mm trocar with sleeve inserted into cyst wall dome in laparoscopic visualization; then, we removed the trocar and placed a suction-irrigation device into the cyst wall through the sleeve. In the second approach, the cyst wall was incised between two graspers and the mass was inserted with the suction-irrigation device. The mass was drained as much as possible and the puncture site was immediately closed by a grasper to avoid leakage. Homeostasis was achieved and the access site for specimen retrieval and the umbilical port site were closed in different anatomical layers.\u003c/p\u003e \u003cp\u003eThe management plans were made based on the frozen section findings. Surgical staging was performed by laparoscopy and conversion to laparotomy was conducted only for cases with technical difficulties. Intraoperative and postoperative complications, conversion to laparotomy, type of procedure, operation time, and pathologic reports were documented. Operative time was recorded as the time from skin incision to skin closure. Blood loss was measured based on the fluid gathered in the suction bottle. Spillage was characterized as any deliberate or accidental mass wall rupture. If the tumor was drained intentionally into the endo-bag without a peritoneal spill, the tumor was not regarded as a ruptured tumor.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using Excel program, 2007 version. The Kolmogorov-Smirnov test was used to examine normal distribution of the data. One-way analysis of variance (ANOVA) was applied to determine the differences among the groups; in case of significance, pairwise comparisons were performed using Tukey\u0026rsquo;s test. Fisher\u0026rsquo;s exact test was applied to analyze ratio and chi-square test was used for categorical variables. P-values less than .05 were considered significant.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eA total of 126 women completed the study. Patients\u0026rsquo; demographic characteristics are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the patients was 30.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11.64 years; 80.2% had benign tumor type (N\u0026thinsp;=\u0026thinsp;101), 7.1% borderline (N\u0026thinsp;=\u0026thinsp;10), and 11.9% malignant/metastasis (N\u0026thinsp;=\u0026thinsp;15). There was a significant difference among the three groups in terms of mean age and operation time; age and duration of surgery were higher in the malignant type compared to that of the benign type (P\u0026thinsp;\u0026lt;\u0026thinsp;.001; Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). But, mean BMI, number of deliveries, bleeding volume, fluid volume drained from the mass were not different based on the tumor type (P\u0026thinsp;\u0026gt;\u0026thinsp;.05; Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mean mass size was 15.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03 in all participants without significant difference based on the tumor type (P\u0026thinsp;=\u0026thinsp;.624; Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eThe demographic characteristics of the study participants categorized based on tumor type\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBenign (N\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBorderline (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMalignant or metastasis (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003cp\u003eamong the three groups\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003cp\u003eBenign-borderline\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003cp\u003eBenign-Malignant\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003cp\u003eMalignant-borderline\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.31\u0026thinsp;\u0026plusmn;\u0026thinsp;10.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e33.56\u0026thinsp;\u0026plusmn;\u0026thinsp;16.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e40.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e25.95\u0026thinsp;\u0026plusmn;\u0026thinsp;6.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e26.03\u0026thinsp;\u0026plusmn;\u0026thinsp;6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e25.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e26.20\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.967\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity (No.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.830\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.946\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.442\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMass size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.29\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16.33\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e16.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.763\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.995\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of surgery (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e128.88\u0026thinsp;\u0026plusmn;\u0026thinsp;63.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e116.92\u0026thinsp;\u0026plusmn;\u0026thinsp;52.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e144.44\u0026thinsp;\u0026plusmn;\u0026thinsp;92.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e184.67\u0026thinsp;\u0026plusmn;\u0026thinsp;56.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding volume (cc)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e124.61\u0026thinsp;\u0026plusmn;\u0026thinsp;287.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e105.02\u0026thinsp;\u0026plusmn;\u0026thinsp;247.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e84.56\u0026thinsp;\u0026plusmn;\u0026thinsp;68.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e275.53\u0026thinsp;\u0026plusmn;\u0026thinsp;519.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluid volume drained from the mass (cc)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1687.27\u0026thinsp;\u0026plusmn;\u0026thinsp;928.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1674.51\u0026thinsp;\u0026plusmn;\u0026thinsp;948.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2050.00\u0026thinsp;\u0026plusmn;\u0026thinsp;353.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1650.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1060.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.906\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003e*\u003c/sup\u003eresults of test of ANOVA, \u003csup\u003e\u0026dagger;\u003c/sup\u003eresults of Tukey test; all tests were considered significant when \u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe first trocar was inserted in the umbilicus in 27.8% of patients (N\u0026thinsp;=\u0026thinsp;35), upper umbilicus in 21.4% (N\u0026thinsp;=\u0026thinsp;27), subxiphoid in 48% (N\u0026thinsp;=\u0026thinsp;61), and palmar in 2.8% of patients (N\u0026thinsp;=\u0026thinsp;3). Seventy-five patients (59.5%) were nulliparous, 17 women (13.5%) had one child, and 34 women (27%) had two or more children. The results of serum parameters are shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency of tumor markers in the study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor marker\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNormal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh CA125\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh CA125\u0026thinsp;+\u0026thinsp;High HE4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh CA125\u0026thinsp;+\u0026thinsp;High CA19-9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh HE4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh HE4\u0026thinsp;+\u0026thinsp;High inhibin\u0026thinsp;+\u0026thinsp;High CA19-9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh inhibin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh LDH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh LDH\u0026thinsp;+\u0026thinsp;High CA19-9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh CA19-9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive BHCG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: cancer antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9; CA19-9, cancer antigen 125; CA125, Human epididymis protein 4; HE4, lactate dehydrogenase; LDH, and beta-human chorionic gonadotropin (HCG)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwelve patients were menopause (9.5%) and there was a significant difference in the frequency of menopause among patients with different tumor types (P\u0026thinsp;=\u0026thinsp;.002; Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The type of surgery and frequency of intra-operative complications were also different among patients with different tumor types (P\u0026thinsp;\u0026lt;\u0026thinsp;.001 and .003, respectively; Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), but the frequency of tumor type and side, site of the first trocar, history of abdominal surgery, and blood infusion were not different in patients with different tumor types (P\u0026thinsp;\u0026gt;\u0026thinsp;.05; Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency of surgical and tumor characteristics in the study participants categorized based on tumor type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eType of malignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBorderline (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003emalignant/metastasis (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTumor type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCystic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61(60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6(40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e.221\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid-cystic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52(41.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39(38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8(53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTumor side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97(77.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78(82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7(77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11(78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76(63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73(645.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCystectomy\u0026thinsp;+\u0026thinsp;staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSalpingo-oophorectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(24.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25(23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6(33.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTLH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;Omentectomy\u0026thinsp;+\u0026thinsp;Appendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elh\u0026thinsp;+\u0026thinsp;bilateral oophorectomy\u0026thinsp;+\u0026thinsp;staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4(26.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral oophorectomy\u0026thinsp;+\u0026thinsp;staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3(20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTAH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;cytoreductive surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMass resection\u0026thinsp;+\u0026thinsp;adhesion release\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFirst trocar site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUmbilicus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35(27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6(40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e.527\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper umbilicus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5(33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub xiphoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60(48.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50(49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5(33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePalmar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eIntra-operative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107(84.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90(89.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8(53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e.816\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccidental cyst rupture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePelvic abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntestinal perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntestinal serous trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConversion to laparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(14.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRupture of bladder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUmbilical infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63(62.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.687\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50(40.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38(37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7(50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood infusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117(92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96(95.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9(100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11(78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMenopause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111(88.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93(94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7(77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10(66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5(33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e*\u003c/sup\u003eresults of chi square test, \u003csup\u003e\u0026dagger;\u003c/sup\u003eresults of Fisher\u0026rsquo;s exact test; all tests were considered significant when \u0026lt;\u0026thinsp;.05; all values are reported as number(percentage)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eIn this study, we reported the surgical outcome of 126 patients with adnexal tumors\u0026thinsp;\u0026ge;\u0026thinsp;10\u0026nbsp;cm (mean of 15.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u0026nbsp;cm; maximum of 30\u0026nbsp;cm), among whom only one required conversion to open surgery. These results suggest the feasibility of laparoscopic management of adnexal masses\u0026thinsp;\u0026ge;\u0026thinsp;10\u0026nbsp;cm. In another study on 77 women with ovarian cysts\u0026thinsp;\u0026ge;\u0026thinsp;10\u0026nbsp;cm, conversion to open was required in four patients (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), which is higher than that of ours. This difference could be due to the difference in the experience of the laparoscopic surgeon and the difference in the rate of intra-operative complications between the studies. Among 19 patients, in the study by Vlahos et al. who had adnexal mass with a mean diameter of 8.3\u0026nbsp;cm, there were no cases of conversion to open (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The difference between the results of this study and that of ours could be due to the small sample size of their study, but this study also confirms the results of the present study, considering the low risk of conversion to open surgery in large adnexal masses.\u003c/p\u003e \u003cp\u003eOne of the important factors against the suggestion of laparoscopic surgery for large adnexal masses is the risk of rupture and its negative effect on patients\u0026rsquo; outcomes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, in our study, incidental rupture was only observed in 8 patients, two of whom were malignant. These results show that the laparoscopic method has an acceptable rate of cyst rupture. In another study by Shiota et al., comparison of 1483 cases of benign ovarian cysts according to the cyst size showed no difference in the incidence of cyst rupture among patients with cyst size\u0026thinsp;\u0026lt;\u0026thinsp;5\u0026nbsp;cm, 5-10cm, and \u0026gt;\u0026thinsp;10\u0026nbsp;cm (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), which confirm the results of the present study. In another study by Detorakis et al., studying the surgical outcome of 102 women with adnexal cysts with mean size of 5.7\u0026nbsp;cm (2.3\u0026ndash;10.5\u0026nbsp;cm) showed cyst rupture in 31.8% of the patients and 7.2% in masses\u0026thinsp;\u0026gt;\u0026thinsp;8\u0026nbsp;cm (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These authors concluded that laparotomy is the preferred method for large adnexal masses, but generally speaking, iatrogenic or accidental rupture and spillage of the adnexal mass contents are considered an inevitable incidence during surgery and may occur both in laparoscopic and laparotomic approaches (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Furthermore, the prognostic value of significant spillage in malignant cases is still controversial and some suggest that laparoscopic treatment of ovarian cancer does not have a higher risk of spillage (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, we believe that the risk of rupture should not ban surgeons from the choice of laparoscopy, considering the other advantages of this method. With the availability of frozen sections at many tertiary centers and adherence to proper surgical techniques, the chance of spreading malignancy has been reduced considerably.\u003c/p\u003e \u003cp\u003eAnother important surgical complication is the bleeding volume during surgery and requirement of blood transfusion and the results showed that the mean bleeding volume of the studied patients was 124.61\u0026thinsp;\u0026plusmn;\u0026thinsp;287.32\u0026nbsp;cc and only five patients required blood transfusion. In another study by Demir et al, the results showed that 97.8% of women with adnexal masses of 8-13cm treated with laparoscopy had blood loss\u0026thinsp;\u0026lt;\u0026thinsp;200\u0026nbsp;cc (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These results confirm that of the present study on the low bleeding in laparoscopic treatment of large adnexal masses, considered one of the important advantages of laparoscopy vs. laparotomy (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The mean operation time was 128.88\u0026thinsp;\u0026plusmn;\u0026thinsp;63.37 minutes in our study. In the study by Vlahos et al on 53 women with adnexal masses of all sizes, undergoing laparoscopy, the mean operative time was 45 minutes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), which is much less than that of the present study. In the study by Demir et al., 97.92% of surgeries lasted\u0026thinsp;\u0026lt;\u0026thinsp;136 minutes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), which is similar to the results of the present study. But they have only evaluated patients with benign type, while we included patients with any pathologic type. In the study by Machida et al. comparison of the median operation time was significantly higher in cases with adnexal masses\u0026thinsp;\u0026gt;\u0026thinsp;10\u0026nbsp;cm vs. \u0026lt;5\u0026nbsp;cm (73 vs. 59 minutes) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These results suggest that large adnexal masses can prolong the surgical duration, which is justifiable by the technical difficulty of laparoscopy in large masses, considered one of the disadvantages of this approach for these cases. However, the results of our study showed that the risk of surgical complications are not much, when patients are selected after complete physical examination, precise imaging studies, and measurement of tumor markers. Furthermore, all surgeries were carried out by a single surgeon; in the meantime, a multidisciplinary team of experts consisting of pathologists, oncologists, colorectal surgeons, and urologists were involved and ready to be called on when necessary. As suggested, the risk of surgical complications is not predicted by the tumor size (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Therefore, it does not seem logical to impose patients to the critical risk of invasive open surgeries, especially in cases with benign pathologies. The maximum tumor size for safe laparoscopic approach is yet to be determined, as 10\u0026nbsp;cm threshold seems questionable.\u003c/p\u003e \u003cp\u003eThe incidence rate of incidental finding of ovarian cancer during laparoscopy has been reported to be between 0.65% and 0.9% of premenopausal women and 3% of postmenopausal women (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our study, there were 15 patients with malignancy or metastasis, five of whom (33.3%) were postmenopausal. Other studies have reported other incidence rates for malignant ovarian mass (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), which can vary based on the frequency of malignancy in the study place and based on the inclusion criteria of the study. The results showed that patients with malignancy or metastasis were significantly older and had a longer duration of surgery and intra-operative complications. These results are consistent with the results of the study by Gad et al, which reported higher rate of complications and longer operative time in patients with borderline/malignant adnexal mass, compared to benign group undergoing laparoscopic treatment (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Furthermore, they reported higher rate of conversion to open, blood loss, and duration of hospital stay (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), which was not observed in our study. Other studies have also confirmed the superiority of laparoscopy vs. laparotomy for treatment of ovarian cancers (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), as well as comparable accuracy of staging of laparoscopy vs. laparotomy and comparable survival rates (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), while the results of the present study suggested higher complication rates in large tumors. Due to the small sample size of this subgroup in our study, further studies should be performed to investigate the applicability of laparoscopy in large adnexal malignant tumors.\u003c/p\u003e \u003cp\u003eOur study had some limitations. The first limitation was the cross sectional nature of this study, which limited suggestion of causal relationship between the study variables. Furthermore, we did not follow patients to study the long term results and did not evaluate the survival or recurrence rate in the studied population. The small sample of the study, especially in subgroups, was another limitation of the present study.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eOur study showed that the size of tumor alone might not be a limiting factor for using laparoscopic approach in treatment of adnexal masses, as it resulted in acceptable rates of intra-operative complications. These results suggest the safety and efficacy of laparoscopic approach for large adnexal masses, when performed by an expert laparoscopic surgeon on selected patients. As higher rates of surgical complications and longer operation time were only observed in patients with malignancy or metastasis, due to the small sample size of this subgroup in our study, more studies are required to investigate the feasibility and safety of laparoscopic treatment of this subgroup of large adnexal masses.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emagnetic resonance imaging\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003elactate dehydrogenase\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLDH\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ecancer antigen\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ecarcinoma embryonic antigen\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCEA\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHuman epididymis protein 4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHE4\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate: \u003c/strong\u003eWritten informed was obtained from the participants.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003eAll participants gave consent for anonymous publication of their results.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAvailability of data and materials: Available upon request.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eCompeting interests: \u003c/strong\u003eThe authors of the present study declare that they have no competing interests.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eNone.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e Study concept and design: BN and MA, drafting of the manuscript EA and MA and AR and critical revision of the manuscript: BN, and AB Statistical Analysis: AB and KS. All of the authors have given final approval of the version to be published.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAcknowledgement: \u003c/strong\u003eNot Applicable.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePavlik EJ, Ueland FR, Miller RW, Ubellacker JM, DeSimone CP, Elder J, et al. Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography. Obstetrics Gynecology. 2013;122(2 PART 1):210\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu JH, Zanotti KM. Management of the adnexal mass. Obstetrics Gynecology. 2011;117(6):1413\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchorge JO, Eisenhauer EE, Chi DS. Current surgical management of ovarian cancer. Hematology/Oncology Clinics. 2012;26(1):93\u0026ndash;109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsushita H, Watanabe K, Yokoi T, Wakatsuki A. Unexpected ovarian malignancy following laparoscopic excision of adnexal masses. Hum Reprod. 2014;29(9):1912\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlobaid A, Memon A, Alobaid S, Aldakhil L. Laparoscopic management of huge ovarian cysts. Obstetrics and Gynecology International. 2013;2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H, Ahn J, Chung H, Kim J, Park N, Song Y, et al. Impact of intraoperative rupture of the ovarian capsule on prognosis in patients with early-stage epithelial ovarian cancer: a meta-analysis. Eur J Surg Oncol. 2013;39(3):279\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNezhat C, Cho J, King LP, Hajhosseini B, Nezhat F. Laparoscopic management of adnexal masses. Obstet Gynecol Clin N Am. 2011;38(4):663\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;ge T, \u0026Ouml;zt\u0026uuml;rk E, Yal\u0026ccedil;ın \u0026Ouml;T. Does size matter? Retrospective analysis of large gynecologic tumors. Journal of the Turkish German Gynecological Association. 2017;18(4):195.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemir RH, Marchand GJ. Adnexal masses suspected to be benign treated with laparoscopy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2012;16(1):71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYerebasmaz N, Dilbaz B, Altinbas S, Sengul O, Dede FS, Altinbas S. Laparoscopy or Laparotomy for Large and Benign Adnexal Masses? JOURNAL OF CLINICAL AND ANALYTICAL MEDICINE. 2016;7(3):380\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachida H, Koyasu Y, Yamada M, Nishio M, Yamamoto K. Does tumor size limit application of laparoscopic surgery to ovarian tumors? Gynecology Minimally Invasive Therapy. 2016;5(4):156\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim S, Lee K-B, Chon S-J, Park C-Y. Is tumor size the limiting factor in a laparoscopic management for large ovarian cysts? Archives of gynecology obstetrics. 2012;286(5):1227\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVlahos N, Iavazzo C, Marcopoulos M, Alamanou A, Kouiroukidou P, Chatzidakis V, et al. Laparoscopic management of large ovarian cysts. Surg Innov. 2012;19(4):370\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiota M, Kotani Y, Umemoto M, Tobiume T, Hoshiai H. Study of the correlation between tumor size and cyst rupture in laparotomy and laparoscopy for benign ovarian tumor: is 10 cm the limit for laparoscopy? 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Diagnostic and Therapeutic Endoscopy. 2015;2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakhija A, Parekh CD, Mankad MH, Desai AD, Dave PS, Patel SM. Rationale of Laparoscopic Surgery in Gynaecological Oncology: Time to Address the Issue! Indian Journal of Gynecologic Oncology. 2018;16(3):47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalcetta FS, Lawrie TA, Medeiros LR, da Rosa MI, Edelweiss MI, Stein AT, et al. Laparoscopy versus laparotomy for FIGO stage I ovarian cancer. Cochrane Database of Systematic Reviews. 2016(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGad MS, El Khouly NI, Soto E, Brodman M, Chuang L, Nezhat FR, et al. Differences in perioperative outcomes after laparoscopic management of benign and malignant adnexal masses. Journal of gynecologic oncology. 2011;22(1):18\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYe P, Zhao N, Shu J, Shen H, Wang Y, Chen L, et al. Laparoscopy versus open surgery for adnexal masses in pregnancy: a meta-analytic review. Archives of gynecology obstetrics. 2019;299(3):625\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEltabbakh G. Laparoscopic surgery for large ovarian cysts-review. Curr Trends Gynecologic Oncol. 2016;1:3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCovens AL, Dodge JE, Lacchetti C, Elit LM, Le T, Devries-Aboud M, et al. Surgical management of a suspicious adnexal mass: a systematic review. Gynecol Oncol. 2012;126(1):149\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTantitamit T, Lee C-L. Is it the time for laparoscopic management of early-stage ovarian malignancies? Gynecology and minimally invasive therapy. 2018;7(3):93.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopy, Adnexal mass, Ovarian neoplasms, Tumor size","lastPublishedDoi":"10.21203/rs.3.rs-73588/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-73588/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo report the surgical outcomes of laparoscopic resection of large adnexal masses (≥10 cm). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this cross-sectional study, we enrolled 126 patients with large adnexal masses (≥10 cm), managed by laparoscopic surgery during 2013 to 2020. The rates of intraoperative complications, conversion to open surgery and incidence of cancer were assessed.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Mean mass size was 15.08±5.03 in all participants without significant difference based on the tumor type (P=.624). Mean age and operation time were higher in the malignant type compared to that of the benign type (P\u0026lt;.001). Type of surgery and frequency of intra-operative complications were also different among patients with different tumor types (P\u0026lt;.001 and .003, respectively).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our study showed that large adnexal tumors can be operated by laparoscopic approach, while the most important factor for increased surgical complications and duration was malignancy.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Laparoscopic Management of Large Adnexal Masses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-09 13:56:07","doi":"10.21203/rs.3.rs-73588/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b9cb0ed-70e7-4266-8783-97d66dfdf8ad","owner":[],"postedDate":"October 9th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":734041,"name":"Internal Medicine"},{"id":734042,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2022-01-14T19:11:05+00:00","versionOfRecord":{"articleIdentity":"rs-73588","link":"https://doi.org/10.5812/semj.113994","journal":{"identity":"shiraz-e-medical-journal","isVorOnly":true,"title":"Shiraz E-Medical Journal"},"publishedOn":"2021-08-30 19:11:05","publishedOnDateReadable":"August 30th, 2021"},"versionCreatedAt":"2020-10-09 13:56:07","video":"","vorDoi":"10.5812/semj.113994","vorDoiUrl":"https://doi.org/10.5812/semj.113994","workflowStages":[]},"version":"v1","identity":"rs-73588","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-73588","identity":"rs-73588","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}