Human Reproduction Update 1996, Vol. 2, No. 5 pp.
435446  European Society for Human Reproduction and Embryology
Diagnosis and management of organic ovarian
cysts: indications and procedures for
laparoscopy
Charles Chapron1, Jean-Bernard Dubuisson, Xavier Fritel and Didier Rambaud
Service de Chirurgie Gynecologique, Clinique Universitaire Baudelocque, CHU Cochin Port-Royal, 123, Boulevard
Port-Royal, 75014 Paris, France
TABLE OF CONTENTS
Introduction
Is it possible to be sure of the histological
nature, benign or malignant, of an organic
ovarian cyst without surgical investigation?
Is laparoscopy as reliable as laparotomy for
establishing the suspicion of malignancy
for an ovarian tumour?
What are the limits and risks of laparoscopy
when diagnosing organic ovarian cysts?
Conclusion
References
In the field of gynaecological surgery, the past few
years have been significant due to the development of
operative laparoscopy. Originally recommended for
the diagnosis of female infertility, over the past 15
years laparoscopy has acquired the standing of a
surgical discipline in its own right. Laparoscopic
surgical treatment of ovarian cysts, whether conserva-
tive or radical, has now been completely standardized.
The aim of this work is to specify the indications, pro-
cedures and risks involved with this surgery as applied
to organic ovarian cysts. Only benign ovarian cysts are
suitable for treatment by laparoscopic surgery;
ovarian cancer must always be handled by classic sur-
gery using a mid-line laparotomy. Given that clinical
and other pre-operative investigations can give only
an indication, ovarian lesions require surgical inves-
tigation to diagnose the histological type. Laparoscopy
appears to be as reliable as laparotomy when assessing
whether an ovarian tumour is malignant. The risk of
parietal contamination and peritoneal dissemination
if a malignancy is not recognized means that, if there
are no signs of extra-ovarian extension, adnexectomy
1To whom correspondence should be addressed
is mandatory whenever there is the slightest doubt.
This adnexectomy must obey two important rules: it
435 must be accomplished without rupturing the cyst, and
the cyst must be placed, intact, inside an endoscopic
bag before being extracted. Provided that all stages of
436 the procedure, from pre-operative work-up to the
initial diagnostic phase of the laparoscopy, are carried
out meticulously, laparoscopic surgery is reliable for
440 both the diagnosis and the management of benign
organic ovarian cysts.
441
444 Key words: diagnosis laparoscopy/endoscopic bag/operative
444 laparoscopy/organic ovarian cyst/ovarian cancer
Introduction
The past few years have been marked in gynaecology by the
extended development of operative laparoscopy which has
now become the standard surgical treatment for certain
indications. Several authors (Hulka et al., 1992; Mettler et
al., 1992; Nezhat et al., 1992; Canis et al., 1994a; Chapron et
al., 1994b; Keckstein et al., 1996; Nargund et al., 1996) have
demonstrated that it is technically possible to treat ovarian
cysts both conservatively (intra- or trans-parietal cystec-
tomy) and radically (ovariectomy or adnexectomy). It has
also been demonstrated that operative laparoscopy may pro-
vide a safer and less expensive approach than laparotomy for
the surgical removal of ovarian cysts (Bulletti et al., 1996).
Now that these techniques have been mastered, the major
problem is that of the indications. Surgical treatment of
ovarian cancer must in all cases be carried out via mid-line
laparotomy, and laparoscopic surgery can only be considered
when the cyst to be treated is benign. The aim of this work is
to define the indications and procedures for laparoscopy in
the diagnosis and management of organic ovarian cysts
(OOC). To this end, we will address the following questions
in succession: (i) Is it possible to be sure of the histological
436 C.Chapron et al.

nature, benign or malignant, of an OOC without surgical
investigation?; (ii) Is laparoscopy as reliable as laparotomy
for establishing the suspicion of malignancy for an ovarian
tumour?; and (iii) What are the limits and risks of laparos-
copy when diagnosing OOC?
Is it possible to be sure of the histological
nature, benign or malignant, of an organic
ovarian cyst without surgical investigation?
The reply to this question first requires an assessment of the
reliability of the various complementary investigations
carried out during the work-up for an organic ovarian mass.
We feel that the following means of investigation provide
the most useful information.
Pelvic ultrasonographic investigation
This must be carried out both abdominally and transvaginal-
ly. The specificity and sensitivity differ according to the
technical modalities of the ultrasound investigation (Table I).
The specificity varies between 42 and 95% for abdominal
and between 65 and 98% for transvaginal sonography. The
sensitivity varies between 60 and 93% for abdominal and
between 48 and 100% for transvaginal sonography. The
predictive value of ultrasonographic investigation is
correlated directly with the operators experience and the
degree of exactitude with which the criteria for malignancy
are defined. Among the criteria giving rise to a suspicion of
malignancy, the following can be mentioned: irregularity
and thickness of the cyst wall, the existence of a septum and
its thickness, the existence of a solid intra-cystic element, and
visible intra-cystic vegetations (Figures 111). Certain
authors, including Sassone et al. (1991), have quantified
several of these factors to propose a scoring system enabling
differentiation between benign and malignant ovarian
lesions on the basis of transvaginal sonographic criteria. A
score 9 indicates that malignancy is likely. Whereas this
approach does have the advantage of providing an indica-
tion, it can in no case give an accurate diagnosis (Sassone et
al., 1991). Indeed, even if the risk is low, malignant lesions
have been reported in 0.253.00% of cases in which the
sonographic appearance indicated a unilocular cyst (single,
anechogenic, no vegetations or septa) (Halme, 1994).
Scanner and magnetic resonance imaging
Based on the same morphological criteria as the
sonographic investigation, these methods offer similar
results (Gore et al., 1989; Sanders et al., 1993). Hata et al.
(1992) found the sensitivity and specificity of MRI to be 67
and 97% respectively for the diagnosis of malignancy in
ovarian lesions.

Table I. Value of ultrasound investigation for the diagnosis of malignancy in adnexal masses

Authors Patients Malignant tumours Specificity Sensitivity

n n (%) (%)
Abdominal sonography
Herrmann et al. (1987) 304 50 94 82
Buy et al. (1991) 108 43 92 60
Jacobs et al. (1990) 139 41 83 71
Finkler et al. (1988) 106 37 95 62
Benacerraf et al. (1990) 100 30 87 80
Luxman et al. (1991) 102 29 42 93
Total 859 230 78 74
Transvaginal sonography
Kawai et al. (1994) 109 40 65 90
Kurjak et al. (1992) 83 29 98 48
Hata et al. (1992) 63 27 69 85
Weiner et al. (1992) 53 17 69 94
Granberg et al. (1991) 50 16 82 100
Sassone et al. (1991) 143 13 83 100
Total 501 142 79 83
 Organic ovarian cysts and laparoscopy 437

Figure 1. Clear cyst with smooth borders. Figure 4. Mucinous ovarian cyst.

Figure 2. Clear cyst with smooth borders and thin septa. Figure 5. Clear cyst with thick septa.

Figure 3. Dermoid ovarian cyst. Figure 6. Clear cyst with small papillaritie.
438 C.Chapron et al.
Figure 7. Cyst with large papillaritie and thick septa.
Figure 8. Intra-cystic haemorrhage (pseudo-papillaritie: blood clots).
Figure 9. Complex cyst (mixed echogenicity, septa, large papillaritie).
Figure 10. Borderline tumour: cyst with small papillaritie.
Figure 11. Ovarian carcinoma: cyst with thick, irregular septa and
large papillaritie.
Doppler
Doppler investigations of adnexal masses appear to yield
better results (more sensitive and more specific) than
sonography alone (Table II). However the use of Doppler
investigations during the work-up of ovarian cysts is of
recent origin and is still difficult to interpret. This is
because, for a given tumour, the flows vary according to the
point at which they are recorded (Kurjak et al., 1993;
Valentin et al., 1994), and there are no universally accepted
criteria to indicate a suspicion of malignancy for the
ovarian lesion. Certain authors (Bourne et al., 1989;
Fleischer et al., 1991; Weiner et al., 1992) have suggested
that a pulsatility index <1 points to malignancy. Others
 Organic ovarian cysts and laparoscopy 439

(Hata et al., 1992; Kurjak et al., 1992; Timor-Trisch et al.,
1993) have found the use of the resistance index to have
more advantages. The cut-off value below which the lesion
should be suspected to be malignant has been proposed at
0.72 (Hata et al., 1992), 0.46 (Timor-Trisch et al., 1993)
and 0.41 (Kurjak et al., 1992). Finally, although an absence
of flow is an indication of benignity (Kurjak et al., 1992), in
3% of cases no flow was found in malignant tumours (Kur-
jak et al., 1993; Wu et al., 1994). So, similar to sonographic
investigations, Doppler can be used as an indication but
does not enable a sure and certain diagnosis to be made;
indeed, some authors (Hata et al., 1992; Valentin et al.,
1994) believe it performs no better than transvaginal sono-
graphy.

Table II. Value of Doppler investigations for the diagnosis of malignancy in adnexal masses

Authors Patients Malignant tumours Specificity Sensitivity

n n (%) (%)
Kurjak et al. (1992) 83 29 98 90
Hata et al. (1992) 63 27 53 93
Weiner et al. (1992) 53 17 97 94
Timor-Trisch et al. (1993) 82 12 98 92
Fleischer et al. (1991) 43 11 83 100
Bourne et al. (1989) 18 8 90 87
Total 342 104 89 92

Table III. Stage I ovarian carcinoma: percentage of patients with elevated CA 125 values (>35 IU/ml)

Authors Patients Stage

n I IA/IB IC
(%) (%) (%)
Brioschi et al. (1987) 13 31 18 100
Cruickshank et al. (1987) 6 25 0 50
Fisken et al. (1993) 38 50
Inoue et al. (1992) 45 42
Molina et al. (1992) 12 58
Mann et al. (1988) 13 23 20 25
Pastner (1990) 39 23 6 36
Zurawski et al. (1988) 24 50 31 73
Total 190 40 15 47

Table IV. Value of CA 125 (>35 IU/ml) for pre-operative diagnosis of malignant ovarian tumours

Authors Patients Malignant tumours Specificity Sensitivity

n n (%) (%)
Gadducci et al. (1992) 344 90 67 82
Chen et al. (1988) 211 52 60 88
Finkler et al. (1988) 106 37 74 68
OConnell et al. (1987) 56 30 46 97
Hata et al. (1992) 63 27 92 59
Vasilev et al. (1988) 182 15 77 73
Forest et al. (1990) 39 14 76 79
Total 1001 265 70 80
440 C.Chapron et al.
Tumour marker values
CA 125 is found above all in non-mucinous adenocarcinomas
and in widespread cancer (Bast et al., 1981; Barnhill et al.,
1984). For stage I cancers there is little CA 125 excretion, and
this is all the more true when the capsule has not been
ruptured. CA 125 values are positive (>35 IU/ml) in, on
average, 40% of stage I cancers and 15% of stages 1A and 1B
cancers (Table III). As for mucinous adenocarcinomas,
CA 125 values are found to be elevated in only 65% of cases
(Brioschi et al., 1987; Cruickshank et al., 1987; Chen et al.,
1988; Gadducci et al., 1992; Molina et al., 1992; Fisken et al.,
1993). CA 19.9 (positive if >40 IU/ml) has low sensitivity for
non-mucinous epithelial tumours of the ovary. However, it is
more sensitive than CA 125 for mucinous cystadeno-
carcinomas, being elevated in 85% of cases with a specificity
of 80% (Gadducci et al., 1992; Molina et al., 1992). The
specificity and sensitivity of CA 125 for the pre-operative
diagnosis of malignant ovarian tumours is mediocre (Table
IV). Indeed, CA 125 values are raised in 20% of benign pelvic
tumours and 50% of endometriomas (Chen et al., 1988; Mal-
kasian et al., 1988; Einhorn, 1992; Gadducci et al., 1992;
Vercellini et al., 1995). In the presence of benign ovarian
tumours, the CA 125 values are >35 IU/ml in 33% of cases
and >65 IU/ml in 15% of cases (Table V). However, whereas
for patients before the menopause the advantages of analysing
CA 125 values are limited, the predictive value does increase
after the menopause (Pastner and Mann, 1988) because the
prevalence of benign tumours drops whereas that of cancer
increases.
Some authors have proposed associating these various
paraclinical investigations as an attempt to improve the
accuracy of diagnosis. Jacobs et al. (1990) have suggested
a score combining sonography results, menopausal status
and CA 125 values. The sensitivity and specificity are 78
and 99% respectively. Kurjak et al. (1992) have suggested
an alternative score combining transvaginal sonography
results with those of Doppler investigation. The sensitivity
is 90% and the specificity 95%.
Table V. Benign ovarian tumours: percentage of patients with
elevated CA 125 values
Authors Patients CA 125 (%)
n >35 IU/ml >65 IU/ml
Chen et al. (1988) 89 40 25
Gadducci et al. (1992) 254 33 13
Inoue et al. (1992) 317 34 14
Soper et al. (1992) 22 27 18
Vasilev et al. (1988) 36 19 8
Total 718 33 15
On the basis of these results, it can be stated that, whether
used separately or in combination, these investigations in no
case enable the diagnosis of malignancy for an adnexal mass
to be defined absolutely. Anatomopathological studies alone
can disclose the exact histological nature of an ovarian cyst.
So, although these investigations are of real use for orienta-
tion of the diagnosis, only surgical exploration enables an
accurate and certain diagnosis. The question still remains,
however, as to whether ovarian lesions found in their early
stages can be investigated by laparoscopic surgery or
whether laparotomy should be used.
Is laparoscopy as reliable as laparotomy for
establishing the suspicion of malignancy for
an ovarian tumour?
This calls into question the reliability of macroscopic
assessment via laparoscopy compared with laparotomy for
the diagnosis of malignancy in OOC.
Several teams (Nezhat et al., 1992; Mettler et al., 1993;
Canis et al., 1994a) have demonstrated on the basis of large
studies that, provided it is meticulous, laparoscopy is a reli-
able technique for the diagnosis of malignancy in ovarian
lesions (Table VI). However, in these studies, performed by
departments specializing in operative endoscopy, two out of
34 malignant tumours were unrecognized as such (5.9%).
These results show that, even for highly trained teams, the
risk does exist that an ovarian cancer may go unrecognized
during laparoscopy. Table VII describes 13 cases of malig-
nant tumours of the ovary that were overlooked and were
treated by laparoscopy. This risk of failure to diagnose the
malignant nature of an ovarian cyst during laparoscopy
appears to be correlated with the experience of the laparo-
scopic surgeon, as suggested by the results presented from
multicentre studies where the rate of false negative diagnoses
with laparoscopy is considerably higher (Maiman et al.,
1991; Blanc et al., 1993).
However, the risk of a false negative diagnosis is not
specific to endoscopic investigation, but has also been
reported with laparotomy. Helewa et al. (1986), in a retro-
spective study of 25 patients presenting a stage I malignant
ovarian tumour (16 malignant epithelial tumours and nine
borderline tumours), reported that in 15 cases the diagnosis
of malignancy was not made during the initial laparotomy
but came secondarily only, during histological analysis.
Similarly, Sevelda et al. (1990), in a retrospective study of
204 stage I invasive epithelial cancers, reported that in 20%
of cases surgical treatment was limited to simple adnexec-
tomy because the correct diagnosis had been missed during
laparotomy.
 Organic ovarian cysts and laparoscopy 441

Table VI. Reliability of laparoscopy for the diagnosis of malignancy in ovarian masses

Canis et al. (1994a) Nezhat et al. (1992) Mettler et al. (1993) Total
Number 757 1011 550 2318
Malignant tumours 19 4 11 34
Diagnosed 19 2 11 32
Unrecognized 0 2 0 2
Falsely suspicious masses 27 4 14 45
Sensitivity (%) 100 50 100 94
Specificity (%) 97 99 98 98
Predictive value for malignancy (%) 41 33 44 42

Table VII. Malignant tumours of the ovary overlooked during laparoscopy: review of the literature

Authors Patient age (years) Laparoscopic technique Histology

Benifla et al. (1992) 24 TPC Micro-invasive
Blanc et al. (1993) 30 TPC Grade 1 serous carcinoma
Blanc et al. (1993) 33 TPC Borderline serous
Canis et al. (1994b) 38 Cystectomy Serous carcinoma
Cristalli et al. (1992) ? Cystectomy Borderline
Cristalli et al. (1992) ? Cystectomy Borderline
Crouet and Heron (1991) 49 TPC Borderline serous
Gleeson et al. (1993) 31 Adnexectomy Borderline serous
Nezhat et al. (1992) 45 Cystectomy Borderline endometrioid
Nezhat et al. (1992) 43 Biopsy Mucinous carcinoma
Querleu (1993) 42 Adnexectomy Borderline serous
Querleu (1993) 42 Cystectomy Borderline serous
Trimbos and Hacker (1993) 53 Puncture Serous carcinoma

TPC = transparietal cystectomy.

These results imply that, for ovarian cancers seen at an What are the limits and risks of laparoscopy
early stage when they are limited to the ovary, the risk of when diagnosing organic ovarian cysts?
failure to diagnose the malignant nature of the lesion is very
In addition to the risks inherent to any laparoscopic pro-
real, and exists regardless of whether laparotomy or lap-
cedure (Corfman et al., 1993; Chapron and Querleu, 1994),
aroscopy is employed. No study has been published com-
there are certain risks specific to the laparoscopic diagnosis
paring the reliability of laparoscopy and laparotomy for the
of OOC. If the malignant nature of a lesion limited to the
diagnosis of stage I ovarian cancers. Only a prospective
ovary is missed during the diagnostic phase of laparoscopy,
and randomized study, which would be very difficult to
there is a risk of peritoneal dissemination. This has two
implement in practice, could determine with any accuracy
components: firstly the risk of peritoneal dissemination
which of these techniques performs better than the other.
itself, as a result of the opening of a cyst whose malignancy
The difficulty of making an early diagnosis is one of the
had not been suspected; and secondly, the risk of parietal
characteristics of ovarian cancer, as shown by Bell and
dissemination, by which is meant a parietal implant occurring
Scully (1994). They recently reported 14 cases of ovarian
during laparoscopic treatment and extraction of an ovarian
cancer discovered by histology in ovaries which were nor-
cyst that had not been recognized as being malignant.
mal macroscopically, and for which the diagnosis had not
been suspected in any of the cases during laparotomy.
The risk of peritoneal dissemination
The risk of overlooking an early malignant ovarian
tumour exists whatever the means of surgical investigation For borderline tumours it is generally agreed that rupture of
used. Therefore, in the presence of any clinical or paraclinical the tumour does not worsen the prognosis (Tasker and
suspicion of a malignant lesion limited to the ovary, it is Langley, 1985; Bostwick et al., 1986; Chambers, 1989;
perfectly permissible to carry out laparoscopy. Neverthe- Leake et al., 1992; Manchul et al., 1992). Concerning
less, laparoscopy for diagnosing OOC raises certain prob- invasive epithelial cancers of the ovary, the results are
lems which will be discussed below. rather different. Whereas a number of teams have underlined
442 C.Chapron et al.

the negative role played by peroperative rupture (Erdmann
and Spaulding, 1921; Meigs, 1940; Diddle, 1949; Purula
and Nieminen, 1968; Webb et al., 1973; Williams et al.,
1973), other authors have reported that, nevertheless, it
does not affect survival rates (Cariker and Dockerty, 1954;
Turner et al., 1959; Malloy et al., 1965; Parker et al., 1970;
Sevelda et al., 1989; Dembo et al., 1990; Finn et al., 1992;
Sainz de la Cuesta et al., 1994). However, if only those
studies are taken into consideration that include multifac-
torial analysis according to Coxs (1972) model, then all
the teams except one (Sainz de la Cuesta et al., 1994) agree
that peroperative rupture or extension of the lesion to the
ovarian cortex only has no effect on the prognosis if, and
only if, complete surgical treatment is carried out during
the same anaesthesia. However, if there is any delay
between rupture and surgical exeresis, then there is a def-
inite risk of dissemination and the prognosis is altered
(Maiman et al., 1991; Trimbos and Hacker, 1993). The fact
that peroperative rupture does not seem to affect the prog-
nosis if complete surgical treatment follows during the
same operation should not hide the necessity that every-
thing must be done to avoid this rupture. Adnexectomy and
the use of an endoscopic bag, which will be discussed later,
are excellent means of limiting the risk of peritoneal dis-
semination subsequent to peroperative rupture.
This risk of peritoneal dissemination is not specific to
laparoscopic management, but has been observed after
treatment via laparotomy during restaging operations.
Hopkins and Morley (1989) reported, in a series of 15
laparotomies for subsequent restaging of borderline
tumours, that tumours were present in 46% of cases (seven
patients). In two cases this was a recurrence on the ovary
after cystectomy, with one patient suffering from involve-
ment of the contralateral ovary (stage IB). Two patients
suffered pelvic peritoneal implants (stage II), and the last
three cases experienced peritoneal dissemination (stage
III) (microscopic for two patients and macroscopic for
one). Similarly, Soper et al. (1992), in a series of 30 cases of
laparotomy for restaging carried out in patients who had
not been given optimum surgical treatment during the
initial laparotomy, reported that the stage was worsened for
30% of patients.
So the risk of dissemination is very real if the malignancy
is not recognized or the assessment is not sufficiently rigor-
ous during the diagnostic phase of the initial operation.
This risk exists regardless of whether the initial operation is
carried out via laparoscopy or laparotomy. The real prob-
lem therefore is not the technique used to investigate a
lesion thought suspicious but limited to the ovary (i.e. lap-
aroscopy or laparotomy), but rather the ability of the sur-
geon to suspect neoplastic pathology when tackling this
adnexal lesion, so that the most suitable therapeutic strat-
egy is used from the outset.
The risk of parietal dissemination
Unlike the previous situation, the risk of parietal dissem-
ination seems to be specific to the endoscopic approach. A
review of the literature has made it possible to collate 12
cases of parietal dissemination secondary to laparoscopic
surgical treatment of ovarian lesions which were not recog-
nized as malignant (Table VIII). This problem, however, is
not specific to malignant tumours of the ovary (Childers et
al., 1994), and has been reported after laparoscopic treat-
ment of malignant bowel lesions (Alexander et al., 1993)
or vesicular lesions (Drouard et al., 1991).

Table VIII. Parietal or peritoneal metastases after laparoscopy: review of the literature

Authors Laparoscopy Laparotomy Stage Histology

Time Parietal implant
Hsiu et al. (1986) Biopsies exocystic vegetations 3 weeks 1.5 cm IIIA Borderline serous
Hsiu et al. (1986) Biopsies exocystic vegetations 3 weeks 4 cm IIIA Borderline serous
Gleeson et al. (1993) Adnexectomy and contralateral biopsy 2 weeks 2 cm IIC Borderline serous
Gleeson et al. (1993) Biopsy peritoneal carcinosis 2 weeks Yes III Barely differentiated carcinoma
Gleeson et al. (1993) Biopsy peritoneal carcinosis 2 weeks Yes III Barely differentiated carcinoma
Blanc et al. (1993) Cystectomy 10 months 3 cm IIIC Mucous carcinoma
Blanc et al. (1993) Puncture cystectomy 2 weeks 5.5 cm IIIC Serous carcinoma
Canis et al. (1994b) Cystectomy 3 weeks Microscopic IIIC Serous carcinoma
Crouet and Heron (1991) Cystectomy 3 weeks Yes IC Borderline serous
Querleu (1993) Puncture? Cystectomy 2 weeks Microscopic IIIC Borderline serous
Tissot et al. (1994) Bilateral ovariectomy 16 weeks Yes Metastasis, pancreatic carcinoma

Figure 12. Management of organic ovarian cysts.
With the knowledge gained by these observations, we
can propose the following therapeutic method for manage-
ment of OOC (Figure 12). From the practical point of view
we are confronted with three totally different situations.
The first is those patients who, following clinical work-
up and other investigations (Doppler sonography, tumoural
markers, etc.), present a strong suspicion of ovarian cancer
with signs of dissemination and for whom there is no doubt
about the diagnosis of malignancy (Figure 12; first situ-
ation). These patients must have a mid-line laparotomy
with no preliminary laparoscopy. Several years ago, Lacey
et al. (1978) and Spinelli et al. (1976) estimated that there
was a 5% risk of parietal metastasis when laparoscopy was
carried out on a patient presenting with peritoneal carcino-
sis. More recently, Gleeson et al. (1993) reported two cases
of parietal implant which occurred 15 days after laparos-
copy in patients who presented with ascites on clinical
examination, confirmed by sonography. The suspicion of
peritoneal carcinosis is a formal counterindication for diag-
Organic ovarian cysts and laparoscopy 443
nostic laparoscopy and requires mid-line laparotomy from
the outset.
The second is those patients who show no sign of malig-
nancy following pre-operative work-up (Figure 12; second
situation). These patients can be investigated by laparos-
copy, but in order for this to be reliable, it must be carried
out according to very precise rules. The surgery must sys-
tematically start with sampling of the peritoneal liquid for
cytological examination. After prior peritoneal cytology,
the first phase in the operation is purely diagnostic, to de-
termine signs indicating a possibility of malignancy (Du-
buisson et al., 1992). If any suspicious extra-ovarian signs
are discovered (extra-ovarian vegetations, suspicious per-
itoneal lesions), mid-line laparotomy is mandatory im-
mediately during the same anaesthesia. If any signs are
discovered which are suspicious but limited to the ovary
(vegetations restricted to the surface of the cystic ovary,
abnormal vascularization on the surface of the cyst, etc.),
then adnexectomy must follow without opening the cyst.
444 C.Chapron et al.
The adnexa must be placed intact inside an endoscopic bag,
which thus enables extraction without any risk of either
peritoneal or parietal contamination (Chapron et al.,
1994a). The results of the frozen pathological examination
will indicate the necessity to carry out mid-line laparotomy
during the same anaesthesia. When there are no signs indi-
cating possible malignancy, then laparoscopic surgical
treatment is possible. If this is planned to be radical, the
next step is laparoscopic adnexectomy. If conservative
treatment is being considered, then the cyst can be punc-
tured and opened. Any suspicious signs within the cyst
(intra-cystic vegetations, pale brown liquid, etc.) require
immediate adnexectomy. The excised tissues are extracted
in the same manner as before inside an endoscopic bag, and
sent for frozen examination. Only if the endo-cystic exam-
ination reveals everything is normal can laparoscopic cys-
tectomy then be performed. With this strategy it was
possible, in a consecutive series of 108 patients with a
dermoid cyst, to perform laparoscopic surgical treatment in
90% of cases (97 patients). The laparoscopic surgical pro-
cedures included ovariectomy (15 cases; 15.5%), transperi-
toneal cystectomy (four cases; 4.1%) and intraperitoneal
cystectomy (78 cases; 80.4%) (Chapron and Dubuisson,
1996).
The third situation arises after the pre-operative work-up
when a patient presents with a clinical or paraclinical suspi-
cion of an ovarian tumour limited to the ovary [stage I
according to the International Federation of Gynecology
and Obstetrics (1987) classification; Figure 12; third situ-
ation]. In practical terms, the patient presents with an
ovarian cyst that is suspicious because of either its sono-
graphic appearance or tumoral markers (CA 125) but
where there is no change in the general condition or any
ascites. In this situation, provided the ovary measures
<8 cm, diagnostic laparoscopy is considered to be legit-
imate. If there are no signs of extra-ovarian dissemination,
which of course would require immediate mid-line laparo-
tomy, laparoscopic adnexectomy can be carried out. The
operation must proceed strictly according to the following
rules: adnexectomy without opening the cyst and extrac-
tion intact in an endoscopic bag (Chapron et al., 1994a).
The results of frozen study will indicate whether mid-line
laparotomy during the same anaesthesia is necessary.
Conclusion
Clinical and other pre-operative investigations serve merely to
indicate the possibility of a malignant diagnosis. For OOC that
are obviously malignant and/or when there are signs of extra-
ovarian dissemination, the treatment must be mid-line
laparotomy from the outset. Laparoscopy can be carried out in
all other cases. The first phase of the laparoscopic procedure is
devoted to diagnosis and the search for any signs indicating a
possible malignancy, which will of course require immediate
laparotomy under the same anaesthesia. Whenever there is
any doubt as to the existence of a malignant lesion limited to
the ovary, diagnostic ovariectomy via laparoscopy is feasible.
This attitude is only valid provided the adnexectomy is carried
out without opening the cyst, the excised tissues are extracted
using an endoscopic bag, and frozen examination is possible.
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Received on January 2, 1996; accepted on July 16, 1996