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SummaryOperative laparoscopy is a rapidly developing and valuable modality of therapy having a major role in managing most of the gynecologic benign conditions and a minor one in malignant diseases.Laparoscopic removal of ovarian masses is a well established procedure, but controversy exists regarding the selection of tumours that can be removed via laparoscopy. For this reason, pre-operative work- up that offers a reasonable degree of accuracy in evaluating the ovarian masses is necessary.The process of preoperative diagnosis includes careful history taking, thorough clinical examination, ultrasonographic scanning and measurement of serum CA125 level in postmenopausal women.This prospective study was carried out in Zagazig University Hospitals, Department of Obstetrics and Gynaecology from January 2003 to December 2004, and was aiming at comparing the management of benign ovarian cysts via laparoscopy versus laparotomy.It included 40 patients recruited from the outpatient clinic of Obstetric and Gynecology with evident diagnosis of benign ovarian cysts.All cases were subjected to detailed clinical and sonographic evaluation to exclude ominous signs of malignancy.Those patients were divided into two groups:a. Group (A): Laparoscopically managed patients (20 cases) included cases having cysts with smooth distinct borders, size < 10 cm, no septa , no solid parts.b. Group (B): Patients managed by conventional surgery(20 cases), included either patients with purely benign ovarian cysts or with cysts having any suspected sign such as (sepa ? 3 in number and ? 3mm in thickness, presence of solid particles > 25% of cyst size, wall thickness ? 3 mm), or when marked pelvic adhesion were anticipated (previous laparotomies or history suggestive of pelvic inflammatory disease)Patients were appropriately prepared for the chosen surgery and blood samples from postmenopausal patients were obtained for detecting the serum CA125 levels.In group (A) diagnostic laparoscopy was first performed confirming the benign nature of the mass and excluding other factors that may affect the safety of the procedure, then operative part of the approach was conducted including ovarian cystectomy (19 cases) and laparoscopic oophorectomy (1 case).In group (B), after routine pre-surgical preparation, exploration was performed and the definitive procedure was done.Histological evaluation of the cyst wall was done in all cases.The results were statistically analysed by package of computer programs using statistical package of social science program (SPSS) with values <0.05 were considered significant and those < 0.001 were highly significant.? The mean (? SD) age of patients in group (A) was 29. 6 ? 8.6 years compared to 34.1 ? 12.1 years in those of group (B).? The main complaint in all patients was recorded as follows: infertility (40%), menstrual irregularities (22.5%), chronic pelvic pain (20%), while 17.5 % of patients were asymptomatic.? 57.5% of patients were nullipara and the remaining 42.5% were multiparous women.? The most frequent pathology was endometriotic cyst of the ovary (40%), serous cystadenoma (20%), ovarian dermoid, (17.5%), mucinous cystadenoma 10% and persistent functional ovarian cysts (12.5%).? Ultrasonographic specificity was 87.5% in diagnosis of the benignity of ovarian masses while false + ve rate was 12.5%.? The overall mean (? SD) cyst diameter was 6.5 ? 1.6 cm.? Laparoscopic prediction of benign nature of ovarian mass was successful with specificity of 100% and negative predictive value of 100% .? In this study the mean operating time was slightly but not significantly shorter in group (A) patients than in group (B) ones (55.0 ? 14.0 min. vs. 62.0 ? 12.7 min. respectively, P 0. > 0.05 ) with the longest operating time in group (A) was observed in cases of laparoscopic ovarian dermoid cystectomy (73.6 ? 25.5 min.).? Only one intraoperative complication occurred in group (A) patients (bleeding from a bed of an endometrioma after its removal) compared to none in group (B) patients.? No relation was found between the cyst size and the duration of its operating time in patients of group (A).? Post-operative febrile morbidity was significantly lower in group (A) than in group (B) (10% and 25% respectively P < 0.001 ).? Post-operative pain was significantly of less severity in patients of group (A) than those of group (B) as measured with VAS (3.9 ? 0.7 Vs. 5.1 ? 1.1 respectively. P= 0.001).? Patients in group (A) were analgesic free more earlier than those in group (B); ( 4.1 ? 1.7 days versus 9.7 ? 3.1 days respectively with P < 0.001).? Patients of laparoscopy group recovered significantly more quickly and better than did those of laparotomy group. They resumed oral intake after (8.3 ? 1.7 vs. 14.7 ? 4.0 hours, P <0.001), got up independently (9.0 ? 2.5 vs. 16.2 ? 2.7 hours, P <0.001), returned to normal activity (2.7 ? vs. 11.7 ? 2.9 days, P <0.001) respectively.? Also they could performed their domestic work quicker than those of laparotomy ( 10.3 ? 2.0 vs. 15.5 ? 3.2 days, P <0.001 ).? This convalescence was significantly better and earlier in patients of laparoscopy than in those of open surgery.? No major postoperative complications were encountered in both groups. One case of postoperative superficial wound infection in laparoscopy group compared to 3 cases in group (B); two of them were wound infection and the 3rd case was postoperative cystitis. All of them was successfully treated with appropriate anti- biotic.? Postoperative hospital stay was significantly shorter for patients of group (A) than for those of group (B) (29.0 ? 7.9 hours vs. 64.5 ? 17.3 hours respectively, P < 0.001).? No cases in laparoscopy group was converted to laparotomy.? No cyst recurrence was observed in a period of U/S follow up for 3 months.CONCLUSIONS• Proper patient selection is the key to proper management. Most ovarian cysts are benign and their management by operative laparoscopy is a reasonable alternative to open surgery. It gives the advantages of laparoscopic procedures including ; short hospital stay, less patients discomfort, less postoperative complications, easier and faster recovery, better cosmoses with no difference in intra-operative complications if experienced hands and the required instruments are available.• The risk of operating on ovarian cancer can be minimized by proper patient selection using ultrasonographic and clinical selection of patients not at risk of ovarian malignancy followed by laparoscopic evaluation which is 100% accurate in prediction of the benign nature of the ovarian mass.• Although, specificity of U/S in this study was somewhat low (87.5%), this was due to depending on particular parameters of suspicion, hence the increased number of false + ve suspicious cysts. So, using a numerical scoring system is more predictive for the nature of the cyst than depending on a single ultrasonographic morphological sign .• No malignant cases were encountered in this study although 12.5% of the cysts had one or more of the suspicious signs. This clearly demonstrates that sonographically suspicious ovarian cysts should not be considered malignant in all times and again it direct the attention to use a numerical ultrasonographic scoring system rather than depending on a single suspicious parameter.• When the two lines of management for a pathological condition produce identical outcomes, the least morbid modality should be selected.• Use of operative laparoscopy as the 1ry modality for treatment of ovarian cysts which were found to be benign or even had a suspicious sign(s) will decrease the unnecessary laparotomies for management of these ovarian cysts.
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