Feasibility and Safety of Laparoscopic Surgery in Large Ovarian Masses
Authors: Kinay Tugba , Kizilkaya Yasemin , Altinbas Sadiman Kiykac , Tapisiz Omer Lutfi , Ustun Yaprak Engin 
Published: April 2023

ABSTRACT
Ovarian masses are relatively common conditions, with approximately 5%–10% of women requiring surgical treatment for an ovarian neoplasm during their lifetimes. A laparoscopic approach is the primary choice in surgical management of benign small ovarian masses; however, concerns remain about the feasibility and safety of laparoscopic surgery for large ovarian masses. Causes of concern include difficult visualization, potential for damage to intra-abdominal organs, and risk of an unintended rupture of occult malignancy leading to intraperitoneal spillage requiring subsequent adjuvant therapy.
This retrospective cohort study aimed to assess the feasibility and safety of laparoscopic treatment for large ovarian masses with benign features. Patients that underwent laparoscopic surgery between 2017 and 2019 at a tertiary care center were included. Only patients with a low risk of malignancy (risk of malignancy index [RMI] <200 or increased serum cancer antigen 125 [CA-125] level with typical characteristics of endometrioma and mature cystic teratoma by ultrasonographic examination) were included. Women were divided into 2 groups based on ovarian mass diameter, with a large mass defined as ≥10 cm and a control group with ovarian masses <10 cm in diameter. Demographic and oncology parameters were compared between groups, as were outcomes including operating time, postoperative day 1 hemoglobin concentration, intraoperative and postoperative complications, conversion to laparotomy, length of hospital stay, and histopathological results. A Student t test was used for normally distributed continuous data, and Mann-Whitney U test was used for data not normally distributed.
A total of 260 women underwent laparoscopic surgery for ovarian masses during the study period, 64 of whom had a large mass with 196 in the control group. The demographic and clinical characteristics were similar between groups, as were the serum CA-125 and RMIs (P < 0.05). Multilocular cystic appearances (45.3% vs 24.5%, P = 0.002) and intra-abdominal ascites (7.8% vs 1.5%, P = 0.024) were more common in the large mass cohort. The salpingo-oophorectomy rate (65.6% vs 44.4%, P = 0.003), conversion to laparotomy rate (7.8% vs 0.0%, P = 0.001), and aspiration of cyst contents rate (29.7% vs 5.1%, P < 0.001) were all significantly higher in patients with large masses than without. No differences were observed between groups in terms of laparoscopy technique, operation time, complication rate, intraoperative cyst rupture rate, preoperative and postoperative hemoglobin levels, or length of hospital stay. Histopathology results varied between groups, with mucinous cystadenoma (25.0% vs 9.2%, P = 0.001) being the most common benign pathology in the large-mass group and follicular cysts (22.4% vs 10.9%, P = 0.044) the most common in the control group. A total of 5 patients in the large-mass group were found to have unexpected malignant or borderline pathologies on frozen section, whereas none were found in the small-mass group (P = 0.001).
The results of this study demonstrate that laparoscopic surgery of large ovarian masses is feasible in large adnexal tumors presumed benign and had comparable operation time and length of hospital stay compared with the control group. Although the rate of conversion to laparotomy was higher among the large-mass group, this was due to intraoperative pathology confirming a malignant mass rather than technical difficulties. Appropriate selection of patients with low suspicion for malignancy is of critical importance.