Original Study

Laparoscopic Cystectomy for the Treatment of Benign Ovarian Cystsin Children: An Analysis of 21 Cases_Ibrahim Akkoyun MD*, Saliha G€ulen MDDepartment of Pediatric Surgery, Dr. Faruk S€ukan Maternity and Children's Hospital, Konya, Turkey

a b s t r a c t

Study Objective: To evaluate the outcomes of treatment with minim

al invasive surgery in children with benign ovarian cysts.Design: Retrospective chart review.Settings: Maternity and children hospital.Patients: Between May 2007 and May 2011, 21 children were treated by laparoscopic method for ovarian cysts at our clinic. The age,symptoms, ultrasonographic findings, operation records and follow-up times were retrospectively evaluated.Results: The mean age was 13.2 years. One patient presented with findings of torsion and another presented with findings of rupture; bothwere urgently operated on. The other patients presented with intermittent abdominal pain and were operated on under elective basis. Themean cyst size was 8.4 cm (5-13 cm). One patient with necrotic ovary and salpinx due to torsion underwent salpingo-oophorectomy whilethe others were administered ovary-preserving cystectomy. Only 4 patients required iv paracetamol as an analgesic in the postoperativeperiod. Two patients were discharged on the second postoperative day while the remaining 19 patients were discharged on the firstpostoperative day. During a mean follow-up of 14 months, no recurrence was seen in this period. Cosmetic appearance was good in allpatients.Conclusion: The authors demonstrated that laparoscopic cystectomy was a technically feasible and safe method in the treatment of benignovarian cysts, associated with short hospitalization, minimal analgesic requirement, and a good cosmetic appearance.Key Words: Ovarian cyst, Children, Laparoscopy

Introduction

Ovarian cysts occurring in children aremostly benign andrare. The potential complications of the cyst include rupture,hemorrhage, symptoms associated with hormone secretion,and torsion, particularly in the case of large cysts.1 Thus,cystectomy is recommended in most such cases. Laparo-scopic cystectomy with gonadal preservation is establishedto be feasible and safe in adults. However, only a number ofreports and small series were reported in children. We per-formed this retrospective study to demonstrate whetherlaparoscopic cystectomy could be an alternative to opencystectomy for the treatment of large ovarian cysts in chil-dren and adolescents.

Material and Methods

A total of 61 patients aged 0-17 years with ovarian cystswere followed up and/or treated at the pediatric surgeryclinic between May 2007 and August 2011. Among these, 38patients with cysts smaller than 5 cm without suspicion oftorsion, rupture, ormalignancy recoveredwithout requiringsurgical treatment during follow-up. Seven cysts of 5-7 cmsize were followed by ultrasound examination for at least3 months/menstrual cycles. Two of these regressed. Five

The authors indicate no conflicts of interest.* Address correspondence to: Dr. _Ibrahim Akkoyun, Dr. Faruk Sukan Do�gum

ve Cocuk Hastanesi Selcuklu Konya TR-42090, Konya, Turkey; Phone: þ90 5324742886; Fax: þ90 3 322354205

E-mail address: ibrahimakkoyun@yahoo.com (_I. Akkoyun).

1083-3188/$ - see front matter � 2012 North American Society for Pediatric and Adolehttp://dx.doi.org/10.1016/j.jpag.2012.06.007

non-recovering patients and 16 patients with a cyst largerthan 7 cm, severe abdominal pain, suspicion of rupture ortorsion, a thick cyst wall, or multiloculated cysts (Fig. 1)were operated on via the laparoscopic method (Table 1).Since we preferred open surgery for all cases of ovarianmasses containing a solid component, with a high suspicionof malignancy and elevated ovary-specific tumor markers(CA-125, alpha-feto protein, beta-human chorionic gonad-otropin), such cases were excluded from the study. Simi-larly, cases coincidentally detected to have a cyst during anoperation, such as a laparoscopic appendectomy, andunderwent cyst aspiration were also excluded from thestudy.

Of 21 cysts,14were located on the left and 7were locatedon the right ovary (Table 1). Since 8 patients had a suspicionof solid component in the ovarian cyst or multiloculatedcysts, tumor markers were investigated and detected to benormal. Again, in these 8 patients, pelvic computerizedtomography (CT) was performed to establish the diagnosis.For the other 13 cases, tumor marker investigation or pelvicCT was not required, since the cyst was simple and fluid-filled.

Transurethral catheterswere not inserted before surgery;however, the patients were instructed to empty their blad-ders pre-operatively. All patients were operated on underendotracheal general anesthesia in the 30-degree Trende-lenburg position. Three trocarswere used,1 for the umbilical10-mm camera port, and the other 2 inserted 5mm from thecontralateral part of the ovary where the lesionwas located,1 from the fossa iliaca and the other from higher up at the

scent Gynecology. Published by Elsevier Inc.

Fig. 1. On ultrasound, a hemorrhagic ovarian cyst (91.8 � 56.1 mm in size) presents asa multiloculated thin-walled cyst with fibrin strands.

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lateral edge of the rectusmuscle, andwere used for workingports. Since the surgeonwas also standing contralaterally tothe lesion, both instruments could be easily and ergonomi-cally used. The pelvic organs were explored, and the otherovary was investigated for bilateral involvement. The cap-sule of the ovary containing the cyst was incised bymonopolar cautery. At this stage, after minimal dissectionfollowed by determination of the cleavage plane betweenthe ovary and the cyst, the intra-cyst fluidwas aspirated andemptied to avoid peritoneal spillage caused by potential cystrupture if the cyst was tense. After being grasped by anatraumatic grasper, the cyst wall was totally stripped fromthe ovarian cortex using a dissector or scissor with careful,gentle, sharp and blunt dissections. The cystwall was placedinto the endobag and extracted from the umbilical port.Hemostasis was achieved by bipolar cautery. Suturing of thepotential space occurred if the ovary was not deemednecessary. During the operation, blood loss was minimal. Inthe case of salpingo-oophorectomy due to ovarian torsion

Table 1Patients' characteristics, findings and results

Total number of children with ovarian cyst 61Cyst diameter!5 cm 38 100% regressed5-7 cm 7 28.5% regressedO7 cm 16

LocationLeft ovary 14Right ovary 7

Laparoscopic cystectomy 21Laparoscopic salpingo-oophorectomy

(due to torsion)1

Operative time, mean, minutes 38 (22-74)Postoperative length of hospital stay ! 1 day 19Analgesic requirements 4Operative and postoperative complications 0PathologySimple cyst 6Hemorrhagic cyst 6Corpus luteum cyst 4Follicle cyst 3Serous cystadenoma 2Gangrenous ovary with hemorrhagic cyst 1

Postoperative follow-up time, mean, months 15 (1-25)Recurrence 0

with cyst, it was detorsed, but blood flowdid not return, so itwas then removed. The others were administered ovary-preserving cystectomies.

Results

A total of 21 patients with a mean age of 13.2 � 4.4 years(range 3-17 years) underwent laparoscopic ovarian cys-tectomy. The mean duration of the surgery was 38 � 10.2minutes (range 22-74 min). The mean cyst size was 8.4 �3.3 cm (5-13 cm). None of the patients required return forlaparotomy or additional port placement. All the patientswere ambulated 3 hours after the surgery and began regulardiet after 8 hours. Based on the verbal rating scale, only 4patients required analgesics and were administered para-cetamol. Nineteen patients were discharged on the firstpostoperative day, the remaining 2 on the second post-operative day. Pathologic investigation revealed 6 simplecysts, 6 hemorrhagic cysts, 4 corpus luteum cysts, 3 folliclecysts, and2 serous cystadenoma.During amean follow-upof15 months (1-25), no difference was detected between theovary sizes on the operated side and the contralateral side.No complications or recurrence were seen in our cohort(Table 1). Cosmetic appearance was good in all patients.

Discussion

Ovarian cysts occurring in childhood are rare and mostlybenign. The incidence is higher in adolescence and mostcommonly occurs between 8 and 15 years of age. Thedeficient involution of the follicles in the ovary may lead tocyst formation, and sometimes, if ovulation does not occur,small follicle cysts may continue to grow by hormonalstimulation.1,2 Particularly in large cysts, abdominal painresulting from hemorrhage into the cyst, severe intra-abdominal hemorrhage caused by rupture, and symptomssecondary to torsion and hormonal secretion may occur.3,4

The most important and noninvasive choice is ultrasonog-raphy (US) for establishing the diagnosis. US is adequate forthe diagnosis and follow-up of simple, fluid-filled cystswithout a solid component.5,6 The use of Doppler isparticularly helpful with any cyst that has a solid compo-nent or thickened wall. It may better identify a corpusluteum that one may want to observe longer and treatconservatively (i.e. with analgesics). US was the only choicefor diagnosis and follow-up in most of our patients. We findit unnecessary to investigate the tumor markers in simpleand fluid-filled cysts because such cysts are likely to befunctional cysts and benign. However, for cysts with a thickwall or suspected solid component and multiloculatedcysts, such investigations could be performed.

The follow-up of the ovarian cysts revealed that themajority of the cysts disappeared in children, particularly inadolescence and infancy. Although there are others whorecommend oral contraceptive use during follow-up, we donot use such drugs for hormonal suppression.1 A consensushas not yet been reached on the duration of follow-up for anovarian cyst or the size of the section (in cm) of the cyst to beoperated on. However, the general approach is to recom-mend treatment for cysts with severe symptoms that

_I. Akkoyun, S. G€ulen / J Pediatr Adolesc Gynecol 25 (2012) 364e366366

contain a solid component, exhibit high tumormarkers, anddo not show a reduction in size on 3-month ultrasoundscanning. Nearly 70%of ovarian cysts improve by follow-up.3

We observed regression in all of the 38 ovarian cysts smallerthan 5 cm in size that did notmanifest significant symptoms.The 7 cysts with a size of 5-7 cm were followed up for 3menstrual cycles; however, only 2 improved. Overall, 40(89%) of the 45 cysts that were 1-7 cm in size resolved. Cystslarger than 7 cmwere operated onwithout delay becausewewere anxious about the potential complications; moreover,the availability of a therapeutic choice such as minimallyinvasive surgery facilitated management.

The treatment options for ovarian cysts include cystaspiration, excision, fenestration, or unroofing.1 We believethat cyst aspiration can be performed for cysts that aredetected incidentally during another operation underanother indication. Also, owing to the limited workingspace, very large cysts can be aspirated under ultrasoundscan prior to laparoscopic cystectomy.7 A recurrence rate of5%-8% is reported in the series for fenestration or unroofing.The recurrence rate for our series was 0%.

Open (laparotomy) or laparoscopic ovary-preservingsurgery in children is very important in maintainingfertility in later years. Except for a patient who developednecrosis due to torsion, the ovarian tissue was totallypreserved in all patients. Alternative therapy of a retorsionand an expectant therapy eventually over several days havebeen described in the literature. This is valuable in childrenand adolescents.8,9 In our series, 1 patient with necroticovary and salpinx due to torsion underwent salpingo-oophorectomy, whereas the others were administeredovary-preserving cystectomies.

The feasibility and safety of laparoscopic surgical tech-niques have been described in large series in adults.10,11 Theadvantages of laparoscopic ovarian surgery compared withopen surgery may include better visualization, shorterhospitalization and operative times, faster recovery, lesspostoperative pain, and better cosmetic results, while thedisadvantages include the high cost.12e14 Adnexal proce-dures represent one of the most commonly performedlaparoscopic procedures in routine adult practices. Despitethe reported efficacy and presumed benefits of a laparo-scopic approach in adults, evidence in support of thispractice for ovarian disorders across all pediatric age groupsis very limited.14 There are only a few reports and smallseries on laparoscopic treatment in children. Now, partic-ularly in recent years, minimally invasive surgical tech-niques have been adopted for the treatment of manysurgical diseases in children. The safety and efficacy oflaparoscopic surgery have been well demonstrated in

children, infants, and neonates.15,16 Some authors recentlyadvocated a laparoscopic-assisted transumbilical, extracor-poreal ovarian cystectomy as an auxiliary to the manage-ment of neonatal ovarian cysts.17 Some authors consider thelaparoscopic approach for the treatment of ovarian cysts inchildren and adolescents to be the gold standard.2 The factthat we discharged a majority of our patients on the firstpostoperative day and that most of our patients did notrequire analgesics and had a very good cosmetic appearancesupports the conclusions of these authors.

Conclusion

We determined that the ovary-preserving laparoscopicmethod was a technically feasible and safe method in thetreatment of ovarian cysts in children, and that this methodwas associated with short hospitalization, minimal anal-gesic requirement, and a good cosmetic result. For thesereasons, we recommend laparoscopic cystectomy as thefirst treatment option in childrenwith benign ovarian cysts.

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