Laparoscopic-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study

Laparoscopic-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study | 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-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study Menghui Li, Zhiqiang Zhang, Boran Mu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4935932/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Jan, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 4 You are reading this latest preprint version Abstract Objective: To evaluate the safety and feasibility of Laparoscopic-Assisted abdominal small incision for the management of adnexal masses during pregnancy. Design : Retrospective case series. Setting: University-based tertiary-care hospital. Patients: 12 pregnant women with an adnexal mass during the second-trimester. Interventions: Laparoscopic-Assisted Minimally invasive surgery with abdominal small incision. Measurements and Main results: Surgical and obstetric outcomes were evaluated. 1. The median age was 28.5 years (range, 25-40 years), all procedures were done during the second trimester, the mean gestation week was 16 weeks (range, 12-17weeks) at operation. 2. The mean operational time was 130 minutes (range, 45-200 minutes). The median blood loss was 10ml (range, 5-200ml). The mean decrease of hemoglobin was 12g/L (range, 2-35g/L). The mean onset of flatus was 24h (range, 22-56h). The mean hospital stay was 5.5days (range, 2-7days). 3. 13 ovarian cysts and 1 mesosalpinx cyst were sent to histopathological diagnosis and the most common diagnosis is corpus luteum cyst. Cystectomy was performed for all women. 4. All patients had an uneventful recovery. The median gestation at delivery was 39.5weeks (range, 33-41 weeks), and the median birth weight was 3,227.5 g (range, 1465-4,300 g). 5. The median follow-up time was 3.5 years (range, 0.5-7years). All babies were healthy. Conclusion: Based on these initial findings, laparoscopic-Assisted abdominal small incision appears to be a safe and technically feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy. adnexal mass abdominal small incision laparoscopy surgical outcomes obstetric outcome Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Adnexal mass is the most common indication for gynecologic surgery during pregnancy [ 1 ] . Expectant management is the first-choice treatment of adnexal masses, based on an increased rate of spontaneous resolution [ 2 ] . However, surgical management may be indicated in the presence of a persistent or symptomatic adnexal mass larger than 6cm because of major complications such as torsion, rupture, bleeding, or malignancy [ 3 ] . Laparoscopic management of adnexal masses in pregnancy has been demonstrated to be technically feasible [ 3 – 5 ] , and laparoscopy is currently accepted as the most efficient method to manage adnexal masses in pregnancy when surgery is indicated [ 6 ] . Potential concerns include direct trauma to the uterus or fetus, compromise of the uteroplacental perfusion as a result of increased intraabdominal pressure, fetal acidosis caused by carbon dioxide (CO2) absorption, and carbon monoxide poisoning as a result of exposure to smoke generated by laser surgery or bipolar desiccation. An alternative between laparoscopy and laparotomy is the minilaparotomy (ML) which can be an interesting option, thanks to the small incision [ 7 ] . The advantage of a ML is not only shorter operating time with less learning curve compared to laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with lower risk of rupture and in addition the possibility to preserve more ovarian tissue [ 8 ] . On the basis of this method, we developed a novel technique, laparoscopic-assisted minimally invasive surgery with abdominal small incision, such that it can be easily perform surgery. The objectives of the present study were to evaluate the technical feasibility and the surgical and obstetrics outcomes of the novel procedures. Materials and Methods From January 2015 to March 2020, a total of 12 patients diagnosed with adnexal mass during pregnancy. The indications for surgery included mass larger than 6 cm or persistent until 16 weeks of gestation or enlarging masses or suspicion of malignancy on sonography. Patients who had a viable intrauterine fetus and a desire to continue the pregnancy were included. Patients with heterotopic pregnancies or malignancy, and or with induced abortion concomitantly, and or with incomplete medical records were excluded. The hospital records were retrospectively reviewed, after approval by the institutional review board the study. Surgical Procedure All procedures were performed by a surgical team composed of three surgeons (Zhq. Zhang, Mh. Li and BR. Mu) with assistants. Fetal surveillance was performed by monitoring the fetal heartbeat via ultrasonography, before and after the operation. As for the surgical technique, the patient was placed in the supine position slowly and carefully. Abdominal insufflations were done by inserting the Veress needle in the umbilical or supraumbilical area, the location of which is adjusted according to fundal height. The first Trocar which was 5-mm 30-degree was inserted below the umbilicus. Pneumoperitoneum was established with use of CO2 insufflations and was maintained at an intra-abdominal pressure of 10 mmHg. The second Trocar was then placed under direct vision to avoid injury to the uterus. After detection with laparoscopy and make sure of the side of ovarian cyst under laparoscopy, oblique incision with diameter of 2.5cm was made on the right or left side of the lower abdomen according the side of ovarian cyst, an Alexis retractor (small size, Applied Medical, Rancho Santa Margarita, CA) was placed through the 2.5cm oblique skin incision to utilize as a single access working port (Fig. 1 ). The cysts could be easily extracted from the abdominal cavity (Fig. 2 ). Sterile pads were placed around the cyst to avoid, in case of a rupture, a contamination of the abdominal cavity. The ovarian lesions were treated with cystectomy in general manner. Incision was sutured interrupt (Fig. 3 , 4 ). After surgery, the patients were not commonly given acetaminophen as analgesia. A case-by-case administration of prophylactic antibiotics preoperatively or postoperatively was done, and not routinely. Fetal well-being was assessed again routinely before discharge. Patients were allowed to discharge when they were fully mobile, passing urine satisfactorily, and not requiring narcotic analgesia. Follow-up was done for all patients. For those patients who delivered in our institution, pregnancy outcome was obtained from their medical records. For those patients who delivered elsewhere, three attempts were made to collect that information by telephone. Those cases in which information was received by telephone, the patients were asked to deliver the information from the official birth documents to minimize the effect of recall bias. Results A total of 12 patients have been identified, and their median age was 28.5 years (range, 25–40 years) old. The median gestational age was 16 weeks (range, 12-17weeks) at the time of operation. All the procedures were done during the second trimester of pregnancy. None of our patients underwent procedures in the third trimester. The median interval between diagnosis of ovarian cyst to surgery was 11weeks (range, 1-208weeks). Cystectomy was performed for all women. No cases were conceived by In Vitro Fertilization and Embryo Transfer (IVF-ET). All the operations were performed successfully with no complications and minimal blood loss. The median operational time was 130minutes (range, 45–200 minutes). The median blood loss was 10ml (range, 5-200ml), the median decrease of hemoglobin was 12 (2-35g/L), and the median flatus time after operation was 24h (range, 22-56h). All of the patients had an uneventful recovery, and the median hospital stay was 5.5 days (range, 2–7 days). 13 ovarian cysts, 1 mesosalpinx cyst, including 2 cases with bilateral ovarian cysts, were sent to histopathological diagnosis, including 5 corpus luteum, 4 mature teratoma, 2 endometrioma, 1 serous cystadenoma, and 1 mucinous cystadenoma. Pregnancy was continued to term in all patients. 8 patients delivered normal term babies vaginally. 4 patients underwent cesarean section because of obstetric indications, including fetal distress, and labor progress failure, and severe eclampsia. The median gestation at delivery was 39.5weeks (range, 33-41weeks), and the median birthweight was 3227.5g (range, 1465-4300g). 1 preterm labor was reported because of severe eclampsia. All patients and their babies were followed up. The median time was 5 years (range, 2.5-9years). All the babies were healthy. Discussion Our results, show that, laparoscopic-Assisted abdominal small incision is a safe and feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy, with the less risk of potential negative effects of carbon dioxide gas insufflations on mother and fetus. These operations represent another possible alternative between laparoscopy and laparotomy, and are safe, reliable and associated with a decreased risk of maternal and fetal post-operative complications, and with an improvement in post-operative course. The advantage of this approach which we recommend, also considered in literature as a minimal invasive procedure, is not only a shorter operating time with a less learning curve than with laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with a reduced risk of rupture and subsequent the possibility to preserve more ovarian tissue with lower risk for complications, and it represents an interesting option because of a small incision (2.5cm). Secondly, it not only will prevent the hazardous consequences that result from a delay in intervention, but also will allow for surgical treatment of any problem found in the abdomen. Thirdly, the panoramic view of the pelvic organs obtained at laparoscopy may reduce the need for intraoperative uterine manipulation. Fourthly, in special cases if the cyst is bilateral, multi-cystic, very large with a high risk of rupture and childbearing is not completed, laparoscopic-Assisted Minimally invasive surgery with abdominal small incision can be a good option also because each tumor can be easily extracted from the abdominal cavity reducing complications and, in this way, giving the chance to preserve more ovarian tissue. In addition, combined with no use of electro-surgery in the proximity of the uterus, the risk of uterine irritability may be reduced, translating into a decreased incidence of postoperative miscarriage and premature labor, the last but not least, is that an upper abdomen exploration through laparoscopy could be performed, especially when necessary, such as in the case of an unexpected borderline malignant or ovarian tumor diagnosed by frozen section analysis. For treatment of adnexal masses during pregnancy, several surgical approaches have been described, including single-port laparoscopic surgery (SPLS) [ 9 ] , gasless laparoendoscopic single-site surgery [ 10 ] , minilaparotomy [ 8 ] and robotic-assisted laparoscopic surgery (RALS) [ 11 ] , have also been introduced and appears to safe and less invasive alternative to laparotomy or conventional laparoscopy. Laparoscopic-Assisted abdominal small incision is another safe and feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy, with the less risk of potential negative effects of carbon dioxide gas insufflations on mother and fetus. Conclusion The main limitation of this study was that it was not a comparative study of 2 different techniques and the small sample size. The pregnancy and neonatal outcomes in our series patients are promising. Because of the limited cases in our case series, further studies addressing the efficacy and safety of this novel technique with those of other approaches are warranted. In conclusion, the present study suggests that this procedure combines advantages of laparoscopic and abdominal approaches, and generate satisfactory surgical and obstetrics outcomes, and should become a valid alternative to all approaches described so far for patients with adnexal mass during pregnancy. Declarations Conflict of interest We declare that we have no conflict of interest. Availability of data and materials All data generated or analyzed during this study are included in this published article. Funding This work was supported by fund from National key R&D Program of China Number: 2017YFC1001200. IRB Ethical approval The study protocol was approved by the Institution Review Board. Consent to participate declaration: not applicable. Authors' contributions M.H.Li performed the surgery, conceived and designed the study, analyzed the data, contributed materials/analysis tools, and wrote the paper. Zh.Q.Zh performed the surgery, collected analyzed the data, contributed materials/analysis tools, and wrote the paper. B.R.M recruited the patients, performed the surgery, collected the data, and wrote the paper. Acknowledgements The authors wish to thank all of the surgeons who participated in the investigation and Dr Zhan Li for her assistance in the writing of this texts. References Leiserowitz GS. Managing ovarian masses during pregnancy. Obstet Gynecol Surv. 2006. 61(7): 463-70. Cathcart AM, Nezhat FR, Emerson J, Pejovic T, Nezhat CH, Nezhat CR. Adnexal masses during pregnancy: diagnosis, treatment, and prognosis. Am J Obstet Gynecol. 2023. 228(6): 601-612. Whiteside JL, Keup HL. Laparoscopic management of the ovarian mass: a practical approach. Clin Obstet Gynecol. 2009. 52(3): 327-34. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol. 2003. 108(2): 217-22. Boughizane S, Naifer R, Hafsa A, et al. [Laparoscopic management of adnexal tumors after the first trimester of pregnancy]. J Gynecol Obstet Biol Reprod (Paris). 2004. 33(4): 319-24. Cagino K, Li X, Thomas C, Delgado D, Christos P, Acholonu U Jr. Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2021. 28(6): 1171-1182.e2. Trotman G, Foley CE, Taylor J, DeSale S, Gomez-Lobo V. Postoperative Outcomes among Pediatric and Adolescent Patients Undergoing Minilaparotomy vs Laparoscopy in the Management of Adnexal Lesions. J Pediatr Adolesc Gynecol. 2017. 30(6): 632-635. Bolla D, Deseo N, Sturm A, Schoning A, Leimgruber C. Minilaparotomy a good option in specific cases: a case report of bilateral ovarian germ cell tumor. Case Rep Obstet Gynecol. 2012. 2012: 589568. Lee JH, Lee JR, Jee BC, Suh CS, Kim SH. Safety and Feasibility of a Single-port Laparoscopic Adnexal Surgery During Pregnancy.LID - S1553-4650(13)00299-9 [pii]LID - 10.1016/j.jmig.2013.06.002 [doi]. J Minim Invasive Gynecol. 2013. 20(6): 864-870. Takeda A, Imoto S, Nakamura H. Gasless laparoendoscopic single-site surgery for management of adnexal masses during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2014. 180: 28-34. Carter S, Depasquale S, Stallings S. Robotic-Assisted Laparoscopic Ovarian Cystectomy during Pregnancy. AJP Rep. 2011. 1(1): 21-4. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.doc Cite Share Download PDF Status: Published Journal Publication published 06 Jan, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 21 Aug, 2024 Editor assigned by journal 20 Aug, 2024 Submission checks completed at journal 20 Aug, 2024 First submitted to journal 19 Aug, 2024 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-4935932","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":343298038,"identity":"3ed88a3c-4129-4bf4-9078-79ace4395a7e","order_by":0,"name":"Menghui Li","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Menghui","middleName":"","lastName":"Li","suffix":""},{"id":343298043,"identity":"e9219bdf-0cb9-41c3-974e-39d85c6b2687","order_by":1,"name":"Zhiqiang Zhang","email":"","orcid":"","institution":"Beijing Chao-Yang 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05:11:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4935932/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4935932/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-08345-x","type":"published","date":"2026-01-06T15:57:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66656198,"identity":"d63fc4a2-f738-4341-9c01-550502a8e32d","added_by":"auto","created_at":"2024-10-15 08:19:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":109050,"visible":true,"origin":"","legend":"\u003cp\u003eThe site of laparoscopy and the oblique incision with diameter of 2.5cm was made on the left side of the lower abdomen according the side of ovarian cyst，and an Alexis retractor was placed through the 2.5cm oblique skin incision to utilize as a single access working port.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4935932/v1/b75b804c29659512a954888e.jpg"},{"id":66656199,"identity":"84568079-8234-4616-ac32-06d6a5d4edf3","added_by":"auto","created_at":"2024-10-15 08:19:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":89626,"visible":true,"origin":"","legend":"\u003cp\u003eLaparoscopic-Assisted Minimally invasive surgery with abdominal small incision right ovarian cystectomy through the oblique incision.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4935932/v1/e75b5bf2347b1b688c475fd1.jpg"},{"id":66658330,"identity":"596eac47-57bc-4084-a287-e1878e65733e","added_by":"auto","created_at":"2024-10-15 08:27:55","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":59366,"visible":true,"origin":"","legend":"\u003cp\u003eIncision after the surgery.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4935932/v1/9579dadd2a21f59de94cbb25.jpg"},{"id":66656197,"identity":"129d34ef-f905-491d-bc35-1ac6eb2bb529","added_by":"auto","created_at":"2024-10-15 08:19:55","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":90984,"visible":true,"origin":"","legend":"\u003cp\u003eSurvey after sutured.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4935932/v1/8fa5ce28536ddafe973208e3.jpg"},{"id":100069232,"identity":"4af88123-2e42-476c-8521-ccffcf629540","added_by":"auto","created_at":"2026-01-12 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study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAdnexal mass is the most common indication for gynecologic surgery during pregnancy \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Expectant management is the first-choice treatment of adnexal masses, based on an increased rate of spontaneous resolution \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. However, surgical management may be indicated in the presence of a persistent or symptomatic adnexal mass larger than 6cm because of major complications such as torsion, rupture, bleeding, or malignancy \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLaparoscopic management of adnexal masses in pregnancy has been demonstrated to be technically feasible \u003csup\u003e[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, and laparoscopy is currently accepted as the most efficient method to manage adnexal masses in pregnancy when surgery is indicated \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Potential concerns include direct trauma to the uterus or fetus, compromise of the uteroplacental perfusion as a result of increased intraabdominal pressure, fetal acidosis caused by carbon dioxide (CO2) absorption, and carbon monoxide poisoning as a result of exposure to smoke generated by laser surgery or bipolar desiccation.\u003c/p\u003e \u003cp\u003eAn alternative between laparoscopy and laparotomy is the minilaparotomy (ML) which can be an interesting option, thanks to the small incision \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. The advantage of a ML is not only shorter operating time with less learning curve compared to laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with lower risk of rupture and in addition the possibility to preserve more ovarian tissue \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOn the basis of this method, we developed a novel technique, laparoscopic-assisted minimally invasive surgery with abdominal small incision, such that it can be easily perform surgery. The objectives of the present study were to evaluate the technical feasibility and the surgical and obstetrics outcomes of the novel procedures.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eFrom January 2015 to March 2020, a total of 12 patients diagnosed with adnexal mass during pregnancy. The indications for surgery included mass larger than 6 cm or persistent until 16 weeks of gestation or enlarging masses or suspicion of malignancy on sonography. Patients who had a viable intrauterine fetus and a desire to continue the pregnancy were included. Patients with heterotopic pregnancies or malignancy, and or with induced abortion concomitantly, and or with incomplete medical records were excluded. The hospital records were retrospectively reviewed, after approval by the institutional review board the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedure\u003c/h2\u003e \u003cp\u003eAll procedures were performed by a surgical team composed of three surgeons (Zhq. Zhang, Mh. Li and BR. Mu) with assistants. Fetal surveillance was performed by monitoring the fetal heartbeat via ultrasonography, before and after the operation.\u003c/p\u003e \u003cp\u003eAs for the surgical technique, the patient was placed in the supine position slowly and carefully. Abdominal insufflations were done by inserting the Veress needle in the umbilical or supraumbilical area, the location of which is adjusted according to fundal height. The first Trocar which was 5-mm 30-degree was inserted below the umbilicus. Pneumoperitoneum was established with use of CO2 insufflations and was maintained at an intra-abdominal pressure of 10 mmHg. The second Trocar was then placed under direct vision to avoid injury to the uterus. After detection with laparoscopy and make sure of the side of ovarian cyst under laparoscopy, oblique incision with diameter of 2.5cm was made on the right or left side of the lower abdomen according the side of ovarian cyst, an Alexis retractor (small size, Applied Medical, Rancho Santa Margarita, CA) was placed through the 2.5cm oblique skin incision to utilize as a single access working port (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The cysts could be easily extracted from the abdominal cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Sterile pads were placed around the cyst to avoid, in case of a rupture, a contamination of the abdominal cavity. The ovarian lesions were treated with cystectomy in general manner. Incision was sutured interrupt (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e,\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter surgery, the patients were not commonly given acetaminophen as analgesia. A case-by-case administration of prophylactic antibiotics preoperatively or postoperatively was done, and not routinely. Fetal well-being was assessed again routinely before discharge. Patients were allowed to discharge when they were fully mobile, passing urine satisfactorily, and not requiring narcotic analgesia.\u003c/p\u003e \u003cp\u003eFollow-up was done for all patients. For those patients who delivered in our institution, pregnancy outcome was obtained from their medical records. For those patients who delivered elsewhere, three attempts were made to collect that information by telephone. Those cases in which information was received by telephone, the patients were asked to deliver the information from the official birth documents to minimize the effect of recall bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 12 patients have been identified, and their median age was 28.5 years (range, 25\u0026ndash;40 years) old. The median gestational age was 16 weeks (range, 12-17weeks) at the time of operation. All the procedures were done during the second trimester of pregnancy. None of our patients underwent procedures in the third trimester. The median interval between diagnosis of ovarian cyst to surgery was 11weeks (range, 1-208weeks). Cystectomy was performed for all women. No cases were conceived by In Vitro Fertilization and Embryo Transfer (IVF-ET).\u003c/p\u003e\n\u003cp\u003eAll the operations were performed successfully with no complications and minimal blood loss. The median operational time was 130minutes (range, 45\u0026ndash;200 minutes). The median blood loss was 10ml (range, 5-200ml), the median decrease of hemoglobin was 12 (2-35g/L), and the median flatus time after operation was 24h (range, 22-56h). All of the patients had an uneventful recovery, and the median hospital stay was 5.5 days (range, 2\u0026ndash;7 days). 13 ovarian cysts, 1 mesosalpinx cyst, including 2 cases with bilateral ovarian cysts, were sent to histopathological diagnosis, including 5 corpus luteum, 4 mature teratoma, 2 endometrioma, 1 serous cystadenoma, and 1 mucinous cystadenoma.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePregnancy was continued to term in all patients. 8 patients delivered normal term babies vaginally. 4 patients underwent cesarean section because of obstetric indications, including fetal distress, and labor progress failure, and severe eclampsia. The median gestation at delivery was 39.5weeks (range, 33-41weeks), and the median birthweight was 3227.5g (range, 1465-4300g). 1 preterm labor was reported because of severe eclampsia. All patients and their babies were followed up. The median time was 5 years (range, 2.5-9years). All the babies were healthy.\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eOur results, show that, laparoscopic-Assisted abdominal small incision is a safe and feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy, with the less risk of potential negative effects of carbon dioxide gas insufflations on mother and fetus. These operations represent another possible alternative between laparoscopy and laparotomy, and are safe, reliable and associated with a decreased risk of maternal and fetal post-operative complications, and with an improvement in post-operative course.\u003c/p\u003e \u003cp\u003eThe advantage of this approach which we recommend, also considered in literature as a minimal invasive procedure, is not only a shorter operating time with a less learning curve than with laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with a reduced risk of rupture and subsequent the possibility to preserve more ovarian tissue with lower risk for complications, and it represents an interesting option because of a small incision (2.5cm). Secondly, it not only will prevent the hazardous consequences that result from a delay in intervention, but also will allow for surgical treatment of any problem found in the abdomen. Thirdly, the panoramic view of the pelvic organs obtained at laparoscopy may reduce the need for intraoperative uterine manipulation. Fourthly, in special cases if the cyst is bilateral, multi-cystic, very large with a high risk of rupture and childbearing is not completed, laparoscopic-Assisted Minimally invasive surgery with abdominal small incision can be a good option also because each tumor can be easily extracted from the abdominal cavity reducing complications and, in this way, giving the chance to preserve more ovarian tissue. In addition, combined with no use of electro-surgery in the proximity of the uterus, the risk of uterine irritability may be reduced, translating into a decreased incidence of postoperative miscarriage and premature labor, the last but not least, is that an upper abdomen exploration through laparoscopy could be performed, especially when necessary, such as in the case of an unexpected borderline malignant or ovarian tumor diagnosed by frozen section analysis.\u003c/p\u003e \u003cp\u003eFor treatment of adnexal masses during pregnancy, several surgical approaches have been described, including single-port laparoscopic surgery (SPLS) \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, gasless laparoendoscopic single-site surgery\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, minilaparotomy\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e and robotic-assisted laparoscopic surgery (RALS) \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, have also been introduced and appears to safe and less invasive alternative to laparotomy or conventional laparoscopy. Laparoscopic-Assisted abdominal small incision is another safe and feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy, with the less risk of potential negative effects of carbon dioxide gas insufflations on mother and fetus.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe main limitation of this study was that it was not a comparative study of 2 different techniques and the small sample size. The pregnancy and neonatal outcomes in our series patients are promising. Because of the limited cases in our case series, further studies addressing the efficacy and safety of this novel technique with those of other approaches are warranted. In conclusion, the present study suggests that this procedure combines advantages of laparoscopic and abdominal approaches, and generate satisfactory surgical and obstetrics outcomes, and should become a valid alternative to all approaches described so far for patients with adnexal mass during pregnancy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe declare that we have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This work was supported by fund from National key R\u0026amp;D Program of China Number: 2017YFC1001200.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIRB Ethical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institution Review Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate declaration:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.H.Li performed the surgery, conceived and designed the study, analyzed the data, contributed materials/analysis tools, and wrote the paper. Zh.Q.Zh performed the surgery, collected analyzed the data, contributed materials/analysis tools, and wrote the paper. B.R.M recruited the patients, performed the surgery, collected the data, and wrote the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all of the surgeons who participated in the investigation and Dr Zhan Li for her assistance in the writing of this texts.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeiserowitz GS. Managing ovarian masses during pregnancy. Obstet Gynecol Surv. 2006. 61(7): 463-70.\u003c/li\u003e\n\u003cli\u003eCathcart AM, Nezhat FR, Emerson J, Pejovic T, Nezhat CH, Nezhat CR. Adnexal masses during pregnancy: diagnosis, treatment, and prognosis. Am J Obstet Gynecol. 2023. 228(6): 601-612.\u003c/li\u003e\n\u003cli\u003eWhiteside JL, Keup HL. Laparoscopic management of the ovarian mass: a practical approach. Clin Obstet Gynecol. 2009. 52(3): 327-34.\u003c/li\u003e\n\u003cli\u003eMathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol. 2003. 108(2): 217-22.\u003c/li\u003e\n\u003cli\u003eBoughizane S, Naifer R, Hafsa A, et al. [Laparoscopic management of adnexal tumors after the first trimester of pregnancy]. J Gynecol Obstet Biol Reprod (Paris). 2004. 33(4): 319-24.\u003c/li\u003e\n\u003cli\u003eCagino K, Li X, Thomas C, Delgado D, Christos P, Acholonu U Jr. Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2021. 28(6): 1171-1182.e2.\u003c/li\u003e\n\u003cli\u003eTrotman G, Foley CE, Taylor J, DeSale S, Gomez-Lobo V. Postoperative Outcomes among Pediatric and Adolescent Patients Undergoing Minilaparotomy vs Laparoscopy in the Management of Adnexal Lesions. J Pediatr Adolesc Gynecol. 2017. 30(6): 632-635.\u003c/li\u003e\n\u003cli\u003eBolla D, Deseo N, Sturm A, Schoning A, Leimgruber C. Minilaparotomy a good option in specific cases: a case report of bilateral ovarian germ cell tumor. Case Rep Obstet Gynecol. 2012. 2012: 589568.\u003c/li\u003e\n\u003cli\u003eLee JH, Lee JR, Jee BC, Suh CS, Kim SH. Safety and Feasibility of a Single-port Laparoscopic Adnexal Surgery During Pregnancy.LID - S1553-4650(13)00299-9 [pii]LID - 10.1016/j.jmig.2013.06.002 [doi]. J Minim Invasive Gynecol. 2013. 20(6): 864-870.\u003c/li\u003e\n\u003cli\u003eTakeda A, Imoto S, Nakamura H. Gasless laparoendoscopic single-site surgery for management of adnexal masses during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2014. 180: 28-34.\u003c/li\u003e\n\u003cli\u003eCarter S, Depasquale S, Stallings S. Robotic-Assisted Laparoscopic Ovarian Cystectomy during Pregnancy. AJP Rep. 2011. 1(1): 21-4.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adnexal mass, abdominal small incision, laparoscopy, surgical outcomes, obstetric outcome","lastPublishedDoi":"10.21203/rs.3.rs-4935932/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4935932/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate the safety and feasibility of Laparoscopic-Assisted abdominal small incision for the management of adnexal masses during pregnancy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e:\u003cstrong\u003e \u003c/strong\u003eRetrospective case series.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting: \u003c/strong\u003eUniversity-based tertiary-care hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients: \u003c/strong\u003e12 pregnant women with an adnexal mass during the second-trimester.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions:\u003c/strong\u003e Laparoscopic-Assisted Minimally invasive surgery with abdominal small incision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurements and Main results:\u003c/strong\u003e Surgical and obstetric outcomes were evaluated. 1. The median age was 28.5 years (range, 25-40 years), all procedures were done during the second trimester, the mean gestation week was 16 weeks (range, 12-17weeks) at operation. 2. The mean operational time was 130 minutes (range, 45-200 minutes). The median blood loss was 10ml (range, 5-200ml). The mean decrease of hemoglobin was 12g/L (range, 2-35g/L). The mean onset of flatus was 24h (range, 22-56h). The mean hospital stay was 5.5days (range, 2-7days). 3. 13 ovarian cysts and 1 mesosalpinx cyst were sent to histopathological diagnosis and the most common diagnosis is corpus luteum cyst. Cystectomy was performed for all women. 4. All patients had an uneventful recovery. The median gestation at delivery was 39.5weeks (range, 33-41 weeks), and the median birth weight was 3,227.5 g (range, 1465-4,300 g). 5. The median follow-up time was 3.5 years (range, 0.5-7years). All babies were healthy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Based on these initial findings, laparoscopic-Assisted abdominal small incision appears to be a safe and technically feasible alternative to multiport laparoscopic surgery for patients with adnexal mass during pregnancy.\u003c/p\u003e","manuscriptTitle":"Laparoscopic-Assisted abdominal small incision for management of adnexal mass during pregnancy: an academic institution study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 08:19:50","doi":"10.21203/rs.3.rs-4935932/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-21T15:36:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-21T01:58:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-21T01:58:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-08-19T05:09:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"75d8d753-b274-4474-ad43-a6b69bbf5ade","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:02:39+00:00","versionOfRecord":{"articleIdentity":"rs-4935932","link":"https://doi.org/10.1186/s12884-025-08345-x","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2026-01-06 15:57:57","publishedOnDateReadable":"January 6th, 2026"},"versionCreatedAt":"2024-10-15 08:19:50","video":"","vorDoi":"10.1186/s12884-025-08345-x","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08345-x","workflowStages":[]},"version":"v1","identity":"rs-4935932","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4935932","identity":"rs-4935932","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}