peritoneal inclusion cyst ( pic ) is defined as an aggregate mass of variable sized , fluid - filled mesothelial - lined cysts of the pelvis , upper abdomen and retroperitoneum 1 .
benign ( multi ) cystic peritoneal mesothliomas ,   inflammatory cysts of the peritoneum ,  and  postoperative peritoneal cysts ,  1 .
the pathogenesis is not well understood , yet they are thought to arise secondary to intra - abdominal inflammation and subsequent cyst formation with serous fluid derived from the ovarian stroma 3 .
the most likely mechanism is that the small amount of follicular fluid extracted in the normal ovary in the ovulatory phase is mostly absorbed 4 , but the injured peritoneum due to pelvic inflammatory disease or postoperative adhesion reduces the absorption capacity and the peritoneal fluid gradually accumulates 5 .
it is thought that pic is formed by the accumulation of unabsorbed follicular fluid secreted by the normal ovary in the adhered peritoneum , and the latter is caused by pelvic inflammation and injury 6 .
the fact that the main peak incidence of pic is the premenopausal women gives support that active ovarian tissue contributes the formation of pic .
the treatment options are observation , hormonal management , imaging - guided aspiration , image - guided sclerotherapy and surgical excision 1 , 7 - 10 . although complete surgical resection is recommended by some authors 11,12 , recurrence after surgical treatment has been reported in about half of the patients 1 . however , most studies have been case reports and small series , and there is a lack of long - term follow - up data
the advantages of laparoscopic surgery include decreased postoperative pain , a short recovery period and improved cosmesis .
however , the disadvantages include a longer operating time and the technical difficulty of laparoscopic procedures .
the objective of this study is to compare the laparoscopy with laparotomy for the treatment of pic with respect to various demographic , perioperative and postoperative parameters .
we conducted a retrospective study involving patients who were operated on at the saint vincent hospital , catholic medical college , during the period january 2003 - december 2009 .
the preoperative diagnosis was made by transvaginal ultrasonography , computer tomography ( ct ) or magnetic resonance imaging ( mri ) .
the size of the cyst was defined as the mean diameter of the longitudinal and transverse dimensions and the height of the cyst .
the outcome was assessed according to the operative time , the estimated blood loss , the serum ca-125 level , the number of septations of the cyst , the difference of hemoglobin between pre - operation and the one day post - operation , the length of hospital stay , the perioperative and postoperative complications , and recurrence of pic .
the operating time was defined as the time from entry into the operating room to the time of the delivering the patient to the postoperative anesthesia care unit . for each patient , subsequent follow - up evaluations were performed by clinical assessment and an ultrasound examination in the outpatient clinic .
the histories of previous abdominal and pelvic surgery were total hysterectomy , abdominal myomectomy , cesarean section , an operation on the ovary and fallopian tube , appendectomy and surgery of the small and large bowel .
we categorized the follow - up results of the operation to complete remission , clinically successful and recurrence .
if a patient 's symptoms improved and the mean diameter of the longitudinal and transverse dimensions of a cyst decreased by more than 50% , then the operation was considered as clinically successful . however , if the mean diameter of a cyst increased by over 50% the operation was considered as recurrence 13 .
all the data was described as means  standard deviation ( sd ) or numbers ( percentages ) .
recurrence was calculated from the date of diagnosis to the date of recurrence or the last follow - up .
differences in recurrence between two groups and other characteristics in terms of univariate analysis were assessed with the log - rank test .
after disinfection and sterile coverage , we started with a small horizontal incision for placing the veres needle .
after insufflation of co2 to a limited pressure of 12mhg , a 10 mm re - usable trocar was placed and the camera was inserted . however , when peritoneal adhesion was suspected by lifting the abdomen around the umbilicus , we tried the open method for entry of a 10 mm trocar 14 .
the whole abdominal cavity , including the peritoneum , liver , gall bladder , stomach , spleen , appendix and bowels , was inspected for pathologies .
further two 5 mm trocars were placed laterally right and left . after placing the patient in a head - down position ,
the bowels were moved out of the pelvic and the inner genital organs were inspected .
the peritoneum was incised over the cyst with scissors or monopolar cutting with low voltage . with the use of meticulous dissection close to the abdominal and pelvic structures , the delineated cyst wall was mobilized and resection was done .
the cyst was placed into an endobag ( sejong corporation , incheon , korea ) , and the sac and cyst were extracted through the 10-mm port .
somerville , nj , usa ) was applied to the site of the former adhesion to prevent further adhesion . after deflating the intra - abdominal carbon dioxide gas ,
laparotomy was done either through a horizontal incision above the symphysis or by vertical incision depending on the size of the cyst and the previous operative scar .
opening and inspection of the abdominal cavity , and pushing the bowels out of the pelvis were done .
the peritoneum was incised over the cyst with mayo scissors or metzenbaum . with the use of meticulous dissection close to abdominal structures ,
the barrier agent interceed ( ethicon inc . , somerville , nj , usa ) was applied to the site of the former adhesion to prevent further adhesion . after bleeding control ,
the operation was done under general anesthesia with the patients in the trendelenburg position . after disinfection and sterile coverage , we started with a small horizontal incision for placing the veres needle .
after insufflation of co2 to a limited pressure of 12mhg , a 10 mm re - usable trocar was placed and the camera was inserted . however , when peritoneal adhesion was suspected by lifting the abdomen around the umbilicus , we tried the open method for entry of a 10 mm trocar 14 .
the whole abdominal cavity , including the peritoneum , liver , gall bladder , stomach , spleen , appendix and bowels , was inspected for pathologies .
further two 5 mm trocars were placed laterally right and left . after placing the patient in a head - down position ,
the bowels were moved out of the pelvic and the inner genital organs were inspected .
the peritoneum was incised over the cyst with scissors or monopolar cutting with low voltage . with the use of meticulous dissection close to the abdominal and pelvic structures ,
the cyst was placed into an endobag ( sejong corporation , incheon , korea ) , and the sac and cyst were extracted through the 10-mm port .
somerville , nj , usa ) was applied to the site of the former adhesion to prevent further adhesion . after deflating the intra - abdominal carbon dioxide gas ,
laparotomy was done either through a horizontal incision above the symphysis or by vertical incision depending on the size of the cyst and the previous operative scar .
opening and inspection of the abdominal cavity , and pushing the bowels out of the pelvis were done .
the peritoneum was incised over the cyst with mayo scissors or metzenbaum . with the use of meticulous dissection close to abdominal structures ,
somerville , nj , usa ) was applied to the site of the former adhesion to prevent further adhesion . after bleeding control ,
a laparoscopy was performed in 35 patients and a laparotomy was performed in 48 patients . of the 35 patients , 4 underwent laparoscopic adhesiolysis of the pic and 31 underwent laparoscopic complete resection of the pic .
of the 48 patients in the laparotomic group , 11 underwent only adhesiolysis of the pic , and 37 underwent complete resection of the pic .
one case in the laparoscopy was converted to laparotomy due to severe pelvic adhesion and excessive bleeding .
no significant difference was found in the mean age , parity , the mean number of previous abdominal operations , the type of operation , and the mean cyst diameter , the duration since the last operation and the serum ca 125 level between the two groups . in both group ,
there were a significantly shorter mean length of hospital stay , less estimated blood loss and a lesser difference between the preoperative and the one day postoperative hemoglobin level in the laparoscopic group compared to that of the laparotomic group ( p=0.037 , p=0.047 and p=0.040 , respectively ) .
the mean operative time was lower in the laparoscopic group than that of the laparotomic group , but there was no statistical significance ( p=0.053 ) .
the intraoperative , short - term and long - term complications are listed in table 3 .
the total complication rate was lower in the laparoscopic group than that in the laparotomic group ( p=0.037 ) . in the laparoscopic group , two patients had postoperative ileus .
they received conservative care without further procedures . in the laparotomic group , 4 cases of wound problems including 2 case of wound seroma , 1 case of wound disruption , and 1 case of ventral hernia , 2 cases of postoperative ileus and 2 cases of perioperative transfusion .
of the 4 patients with wound problem , 2 underwent wound revision and hernia repair .
conservative care and intravenous antibiotics therapy were done for the 2 cases of postoperative ileus .
both the intrapoerative bladder injury and small bowel injury were detected intraoperatively and primary repair was then done .
five cases recurred in the laparoscopic group and 10 cases recurred in the laparotomic group ( table 4 ) .
of the 5 cases in laparoscopic group , 2 cases underwent ultrasonography - guided aspiration and 3 cases underwent repeat laparoscopic cyst resection without further recurrence .
of the 10 recurred cases in laparotomic group , 2 cases underwent ultrasonography - guided aspiration and 1 case underwent laparoscopic cyst resection without further recurrence .
two cases had underlying pelvic endometriosis ( stage iv ) and 1 case had underlying pelvic inflammatory disease .
, we performed a univariate analysis to determine the impact of age , the mean number of previous abdominal operations , the type of operation , the number of septations in the cyst and concurrent disease on recurrence .
there was no statistical difference of the recurrence rate between two groups on the cox proportional hazards model ( p=0.209 ; fig.1 ) .
pic is a rare tumor of an unknown origin , and it is most frequently encountered in women of reproductive age .
some investigators have mentioned that pic may form as a result of a localized peritoneal fluid collection due to the presence of peritoneal adhesions , and these peritoneal adhesions have a relation to previous pelvic surgery , endometriosis or pelvic inflammatory disease .
however , others have said that a pic has a neoplastic etiology according to its recurrence , as well as according to the gross tumor - like appearance of these lesions 11 .
the current literature is mostly based on case reports and small series and a uniform treatment approach and long - term follow - up data are lack .
observation with serial imaging is a feasible management option for asymptomatic patients with an incidentally discovered pic 15 .
image - guided aspiration provides fluid for cytologic evaluation and it can lead to resolution of symptoms with minimal intervention and few complications .
however , conservative management of a cystic lesion has not been effective and a tissue sample is required for making the histologic diagnosis and a biopsy is recommended if there is any suspicion of malignancy 16 .
birch et al . reported that approximately 50% of cysts recur after aspiration , and aspiration may provide temporary relief of symptoms but not a histologic diagnosis 10 .
sclerotherapy using of an intracystic catheter to instill either ethalol or povidone - iodine is a less invasive method and it has been used for the treatment of cysts in the abdominal organs and for treating postoperative lymphoceles 9,17 .
reported that 30 cases of aspiration and sclerotherapy under ultrasonography and/or fluoroscopy guidance with absolute ethanol or 10% povidone - iodine showed a 90% of success rate and there was complete resolution 18 .
however , studies with the long - term data , follow - up and complication rate of sclerotherapy are lack
. complications of sclerotherapy may occur such as viscus perforation , infection , bleeding , or the spillage of cystic fluid and/or sclerosant into the peritoneal cavity .
long - term data regarding the procedural complications or effects of sclerotherapy are also not available 9,13 .
although not a pic , takayasu et al . reported a case of a hepatic benign cyst that developed into adenocarcinoma after sclerotherapy with ethanol 19 .
the recommended treatment is complete resection and the importance of surgery for making the diagnosis and treatment is supported by most authors 10,12 .
the advantage of surgical management is that a definitive diagnosis is possible by obtaining a histologic specimen .
reported that successful laparoscopic removal of a well - differentiated papillary mesothlioma of the peritoneum in a 46-year - old woman 20 .
nezhat et al . reported successful treatments of 3 cases of peritoneal mesothlioma associated with pelvic endometriosis 21 .
pic is associated with severe adhesion to the adjacent visceral organ and peritoneal wall . for resection of pic , abdominal and pelvic adhesiolysis
adhesiolysis by laparoscopy and laparotomy can be very time - consuming and technically difficult and it is best performed by an expert surgeon . however , laparoscopy has some advantages compared to laparotomy in our experience .
first , despite lengthy laparoscopy , most patients are discharged earlier than when undergoing a laparotomy , they experience minimal complications and they return to full activity within one and two weeks of surgery 22 .
second , in laparoscopy , the port wound and the wound at the target of dissection are far away from each other , so the chances of adhesion to the peritoneum are less because for adhesion , both layers , which tend to adhere to each other , should be in contact 23 .
third , in laparoscopy there is less chance of drying of tissue because the inside environment is cut off from the outside .
fourth , the excellent visualization and magnification of laparoscopy allowed better access and exposure for further adhesiolysis 22 .
our study showed that laparoscopy was superior to laparotomy for the mean estimated blood loss , the mean difference of hemoglobin , the mean length of hospital stay , and the complication rate .
however , there is no significant statistical difference for the recurrence rate of pic between two groups .
first , the surgical procedure was performed by several gynecologists with different levels of experience , and the participation of multiple operators may have affected the results .
we preferred laparoscopy for the direct inspection of pathology and to make the differential diagnosis of malignancy .
a comparative study between laparoscopy and sclerotherapy as a minimal invasive technique may be necessary . however , our study is the first study that has compared laparoscopy with laparotomy for the treatment of pic , and we showed that the laparoscopy is superior to the laparotomy .
laparoscopy by well - skilled surgeons may decrease the mean operative time , the rate of conversion to laparotomy and the surgical complication . in conclusion ,
laparoscopic surgery is a safe , effective and reliable method for the treatments of pic .
laparoscopic surgery may reduce the perioperative and postoperative complications and hasten the recovery and return to routine activity .
however , for the evaluation of recurrence rate , it is necessary to perform a long - term , larger - scale study .
 objectives : peritoneal inclusion cyst ( pic ) is defined as a fluid - filled mesothelial - lined cysts of the pelvis and it is most frequently encountered in women of reproductive age . 
 the treatment options are observation , hormonal management , imaging - guided aspiration , image - guided sclerotherapy and surgical excision . 
 the objective of this study is to compare between the laparoscopic and laparotomic surgery for the treatment of pic.methods : thirty - five patients with laparoscopy and forty - eight patients with laparotomy were included in the study . 
 we compared the perioperative and postoperative data , the complications and the recurrence between the two groups.results : there was a significantly reduced mean length of the hospital stay , estimated blood loss and complication rate in the laparoscopic group as compared to that of the laparotomic group ( p=0.037 , p=0.047 and p=0.037 respectively ) . 
 there was also no statistical difference of recurrence rate between thelaparoscopic and laparotomic groups on the cox proportional hazards model ( p=0.209).conclusion : our study showed that laparoscopy was superior to the laparotomy for the mean estimated blood loss , the mean length of the hospital stay and the complication rate except for the recurrence rate . 