Patient Selection Key to Laparoscopic Management of the Adnexal Mass
▸ Dermoids. Laparoscopic management using careful surgical technique and copious irrigation of the peritoneal cavity if a spill occurs has proved to be safe, and laparoscopic dermoid cyst removal has been performed safely even during pregnancy.
Laparoscopic management of a dermoid cyst (above) requires copious irrigation of the peritoneal cavity.
Laparoscopic management of ovarian torsion can be performed safely and effectively. Photos courtesy Dr. William H. Parker
To Freeze or Not to Freeze?
This month's column is brought to us by William H. Parker, M.D., of the University of California, Los Angeles, who isa past president of the American Association of Gynecologic Laparoscopists.
Dr. Parker has been instrumental in guiding our management of adnexal masses and has published widely on this topic.
He has been successful in balancing a busy practice in Santa Monica, Calif., with an academic and writing career, and has even published several books—including “A Gynecologist's Second Opinion: The Questions and Answers You Need to Take Charge of Your Health” (New York: Plume Books, 2003) and “The Incontinence Solution: Answers for Woman of All Ages” (New York: Simon & Schuster, 2002)—to help a lay audience understand and interpret common gynecologic dilemmas.
Medicine thrives on controversy, which spurs us to learn and reach a consensus about the truth. One area of controversy is the use of frozen sections at laparoscopy in the treatment of ovarian masses. Although I certainly agree that frozen sections enable definitive treatment at the time of the original surgery, I await permanent sections. I believe permanent sections provide the following advantages:
▸ The exact diagnosis can be reached. If necessary, a pathology consultation can be undertaken.
▸ Further preoperative testing can be performed as desired by the gynecologic oncologist.
▸ The gynecologic oncologist has an opportunity to speak directly with the patient and her family and discuss options.
▸ The literature supports the need for early intervention—within 1 month—if an ovarian cancer is disrupted at laparoscopic surgery, but it need not be immediate.
As you will see in this Master Class column, Dr. Parker holds a different opinion. He bases his approach on the fact that frozen sections are 95% accurate when the diagnosis is cancer. He stresses that when physicians use his approach, patients are subjected to only one surgery and recovery.
When the frozen section results are uncertain, Dr. Parker agrees that decisions should be based on the final pathology.
He also brings up an interesting point: Too many physicians operate on suspicious masses when they have no intention of staging the patient if cancer is found. This, we both agree, is bad practice.
