Manejo de las lesiones anexiales en el embarazo y actualización del abordaje laparoscópico / Management of adnexal masses in pregnancy and an update of the laparoscopic approach

Resumen El manejo del tumor anexial en embarazadas sigue siendo un desafío. El objetivo del siguiente trabajo es realizar una revisión bibliográfica, en la que se abordarán las diferentes alternativas en cuanto a diagnóstico y manejo del tumor anexial en embarazadas, así como también indicaciones de abordaje quirúrgico y recomendaciones para una cirugía segura. Los tumores anexiales en embarazadas son poco frecuentes, y la mayoría son benignos y tipo funcionales. La ecografía ha sido fundamental para lograr diferenciar su carácter benigno o maligno. El manejo puede ser expectante o quirúrgico. El manejo quirúrgico se reserva para ciertas características de las lesiones anexiales. En cuanto a la vía operatoria, la literatura apoya la laparoscopia mostrando que existen múltiples beneficios al compararla con la laparotomía. Para el abordaje quirúrgico existen opciones en cuanto a la técnica, siendo estas anexectomía o quistectomía. Resulta fundamental tener consideraciones especiales en la técnica debido a los cambios fisiológicos de las embarazadas, como por ejemplo la altura uterina y el tamaño del tumor anexial. A modo de conclusión, el manejo de los tumores anexiales en el embarazo sigue siendo controversial y se extrapola principalmente basándose en la literatura de pacientes no gestantes u otros procedimientos quirúrgicos en embarazadas.

Abstract Nowadays the management of the adnexal tumors in pregnant women is still a challenge. The purpose of this article is to perform a bibliographic review and present the differential diagnosis, management, and surgical approaches for the women in this condition. Adnexal tumors in pregnant women are rare, most of them are benign corresponding to functional cysts. In order to differentiate benign from malignant tumors, Ultrasonography has been one of the most important imaging advances. The management can be either expectant or surgical. Surgical management is referred for tumors with certain specific characteristics. In relation to surgical management, the literature supports laparoscopy, showing greater benefits in comparison to laparotomy. There are different options for this kind of approach. Its mandatory to have special considerations in the technique due to the physiological changes in pregnant women, some examples are the uterine and the tumor size. The management of the adnexal tumors in pregnancy is still controversial, its based on studies of non-pregnant patients or other kinds of surgeries in pregnant women.

Practical recommendations for the management of benign adnexal masses / Recomendações práticas para o tratamento de massas anexiais benignas

Abstract Objective To performa comprehensive review to provide practical recommendations regarding the diagnosis and treatment of benign adnexal masses, as well as information for appropriate consent, regarding possible loss of the ovarian reserve. Methods A comprehensive review of the literature was performed to identify the most relevant data about this subject. Results In total, 48 studies addressed the necessary aspects of the review, and we described their epidemiology, diagnoses, treatment options with detailed techniques, and perspectives regarding future fertility. Conclusions Adnexal masses are extremely common. The application of diagnosis algorithms is mandatory to exclude malignancy. A great number of cases can bemanaged with surveillance. Surgery, when necessary, should be performed with adequate techniques. However, even in the hands of experienced surgeons, there is a significant decrease in ovarian reserves, especially in cases of endometriomas. There is an evident necessity of studies that focus on the long-term impact on fertility.

Resumo Objetivo Realizar uma revisão abrangente para fornecer recomendações práticas sobre o diagnóstico e tratamento demassas anexiais benignas, bemcomo informações para um consentimento adequado com relação à possível perda da reserva ovariana. Métodos Uma revisão abrangente da literatura foi realizada para identificar os dados mais relevantes sobre o assunto. Resultados No total, 48 estudos abordaram os aspectos necessários da revisão, e descrevemos sua epidemiologia, diagnósticos, opções de tratamento com técnicas detalhadas, e perspectivas sobre fertilidade futura. Conclusões As massas anexiais são extremamente comuns. A aplicação de algoritmos de diagnóstico é obrigatória para excluiramalignidade. A maioria dos casos pode ser manejada conservadoramente. A cirurgia, quando necessária, deve ser realizada com técnicas adequadas. No entanto, mesmo nas mãos de cirurgiões experientes, há diminuição significativa da reserva ovariana, principalmente nos casos de endometriomas. Há uma evidente necessidade de estudos que enfoquemo impacto das massas anexiais benignas na fertilidade em longo prazo.

Oophoropexy to the round ligament after recurrent adnexal torsion / Ooforopexia ao ligamento redondo em um caso de torção anexial recorrente

Abstract Recurrent adnexal torsion is a rare gynecological emergency. We report a case of recurrent ipsilateral adnexal torsion in a woman with polycystic ovaries, previously submitted to a laparoscopic plication of the utero-ovarian ligament. Due to the recurrence after the plication of the utero-ovarian ligament, the authors performed a laparoscopic oophoropexy to the round ligament, which is an underreported procedure. The patient was asymptomatic for 1 year, after which she had a new recurrence and needed a unilateral laparoscopic adnexectomy. Since then, she regained the quality of life without any gynecological symptoms. Oophoropexy to the round ligament may be considered when other techniques fail or, perhaps, as a first option in selected cases of adnexal torsion, as it may allow the prevention of recurrence without increasing morbidity while preserving the adnexa.

Resumo A torção anexial recorrente é uma emergência ginecológica rara. Os autores descrevem um caso de torsão anexial unilateral recorrente em uma paciente com síndrome de ovário policístico, previamente submetida a plicatura do ligamento utero-ovárico por laparoscopia. Nesta circunstância, os autores decidiram realizar uma ooforopexia laparoscópica ao ligamento redondo, uma técnica pouco descrita na literatura. A paciente manteve-se assintomática durante 1 ano, período após o qual teve nova recorrência, tendo-se decidido realizar uma anexectomia laparoscópica unilateral. Desde então, ela recuperou a qualidade de vida sem qualquer sintoma ginecológico. A ooforopexia ao ligamento redondo é uma técnica que deverá ser considerada quando outras falham e, em casos selecionados de torsão anexial recorrente, poderá ser considerada a primeira abordagem, para prevenir a recorrência e preservar o anexo.

Single-site laparoscopy in gynecology: preliminary study of a series of 50 cases / Laparoscopia por portal único em ginecologia: estudo preliminar de uma série de 50 casos

Objective: to describe the initial experience of a gynecology team, at a tertiary care center, when performing single-port laparoscopic surgery. Methods: this is a retrospective study reviewing the medical records of 50 patients treated at the outpatient gynecology clinic of our institution between June 2012 and July 2013 who underwent single-port laparoscopic surgery. This study was approved by the institution’s Ethics in Research Committee. Results: the mean age of patients is 37.8 years, ranging from 18 to 70 years, and the most frequent surgical indications were adnexal mass (72%) and chronic pelvic pain (24%). The mean operative time was 94.4 minutes with a mean hospital stay of 25.8 hours. There were no perioperative complications. We recorded two conversions to laparotomy due to technical difficulties during the procedure. All cases of conversion had pelvic adhesions. All operative complications were successfully treated and none were considered severe. Conclusion: this is one of the largest case series in the literature regarding surgical treatment by single-port laparoscopy in gynecology and presents evidence on reduction of surgical morbidity and satisfactory cosmetic results. We conclude that single-port laparoscopy is a viable minimally invasive technique, and that it contributes to the construction of a new scenario in modern gynecological surgery. .

Objetivo: descrever a experiência inicial da equipe de ginecologia, em um centro de referência, na realização de cirurgia laparoscópica por portal único. Métodos: trata-se de estudo retrospectivo, com a revisão dos prontuários de 50 pacientes atendidas no ambulatório de ginecologia do Hospital da Baleia – Fundação Benjamin Guimarães, entre junho de 2012 e julho de 2013, e que foram submetidas a tratamento cirúrgico laparoscópico por portal único. Este trabalho foi aprovado pelo Comitê de Ética em Pesquisa da instituição. Resultados: a idade média das pacientes incluídas no estudo é de 37,8 anos, variando entre 18 e 70 anos, e as indicações cirúrgicas mais frequentes foram massa anexial (72%) e dor pélvica crônica (24%). O tempo médio cirúrgico foi de 94,4 minutos, com tempo de internação médio de 25,8 horas. Em nenhum caso ocorreu qualquer tipo de complicação perioperatória. Registraram-se duas conversões para laparotomia por dificuldade técnica durante o procedimento. Todos os casos de conversão apresentavam aderências pélvicas. Todas as complicações operatórias foram tratadas com sucesso e nenhuma delas foi considerada grave. Conclusão: esta é uma das maiores séries de casos da literatura em relação ao tratamento cirúrgico por laparoscopia de portal único em ginecologia e apresenta resultados que sugerem a redução da morbidade cirúrgica e resultados estéticos satisfatórios. Concluímos que a laparoscopia por portal único é uma técnica minimamente invasiva viável e que traz importante contribuição à construção de um novo cenário na cirurgia ginecológica moderna. .

Laparoscopia na abordagem inicial de tumores anexiais / Laparoscopy for diagnosis and treatment of adnexal masses

OBJETIVO: Avaliar o uso da laparoscopia como método diagnóstico e terapêutico na abordagem inicial de tumores anexiais em população de risco para malignidade, bem como fatores clínicos associados à falha do método e conversão para laparotomia, e comparar taxas de complicação com pacientes cuja abordagem inicial se deu por laparotomia. MÉTODOS: Estudo prospectivo com 210 mulheres com exames de imagem prévios constando tumor anexial, das quais 133 foram incluídas. Destas, 45 foram submetidas à laparoscopia e 88, à laparotomia. Catorze das 45 cirurgias iniciadas por laparoscopia foram convertidas a laparotomia no intraoperatório. Foi avaliado se idade, índice de massa corporal (IMC), número de cirurgias abdominais prévias, CA-125, índice de risco de malignidade (IRM), diâmetro do tumor, duração da cirurgia e número de complicações cirúrgicas diferiram entre os grupos laparoscopia, laparoscopia com conversão à laparotomia e laparotomia. Foi também avaliado o motivo reportado pelos cirurgiões como falha da laparoscopia e a razão da conversão para laparotomia. RESULTADOS: A taxa de tumores malignos neste estudo foi de 30%. Houve diferença nos valores de CA-125, IRM e diâmetro do tumor entre os grupos laparoscopia e laparotomia. A duração da cirurgia foi maior no grupo de laparoscopias convertidas à laparotomia, porém as taxas de complicação cirúrgica foram semelhantes entre os grupos e, quando isolados os tumores benignos, as taxas de complicação cirúrgica da laparoscopia se mostraram inferiores à laparotomia. Dentre os fatores em estudo, apenas o tamanho do tumor esteve relacionado à conversão para laparotomia. CONCLUSÃO: Este estudo sugere que a abordagem inicial de pacientes com tumores ...

PURPOSE: To assess clinical factors, histopathologic diagnoses, operative time and differences in complication rates between women undergoing laparoscopy or laparotomy to diagnose and treat an adnexal mass and their association with laparoscopy failure. METHODS: In this prospective study, 210 women were invited to participate and 133 of them were included. Eighty-eight women underwent laparotomy and 45 underwent laparoscopy. Fourteen of the 45 laparoscopies were converted to laparotomy intraoperatively. We assessed whether age, body mass index (BMI), previous abdominal surgeries, CA-125, Index of Risk of Malignancy (IRM), tumor diameter, histological diagnosis, operative time and surgical complication rates differed between the laparoscopy group and the group converted to laparotomy and whether those factors were associated with conversion of laparoscopy to laparotomy. We also assessed surgical logs to evaluate the reasons, as stated by the surgeons, to convert a laparoscopy to laparotomy. RESULTS: In this research, 30% of the women had malignant tumors. CA-125, IRM, tumor diameter and operative times were higher for the laparotomy group than the laparoscopy group. Complication rates were similar for both groups and also for the successful laparoscopy and unsuccessful laparoscopy groups. The surgical complication rate in women with benign tumors was lower for the laparoscopy group than for the laparotomy group. The factors associated with conversion to laparotomy were tumor diameter and malignancy. During laparoscopy, adhesions a large tumor diameter were the principal causes of conversion. CONCLUSION: This study suggests that laparoscopy for the diagnosis and treatment of adnexal masses is safe and does not increase complication rates even in patients who need conversion to laparotomy. However, when doubt about the safety of the procedure and about the presence of malignancy persists, consultation with an expert gynecology-oncologist ...

Laparoscopic ovarian ligament plication in pregnancy / Plicatura laparoscópica del ligamento ovárico en el embarazo

This 32-year old patient presented at seven weeks gestation with severe left-sided lower abdominal pain. This was against the background of a previous history of left salpingectomy from a ruptured ectopic gestation seven years previously. Transvaginal sonographic evaluation revealed a viable seven week intrauterine embryo, a 2 cm left corpus luteum cyst and Doppler studies revealed reduced internal flow. This led the way for a conservative approach via laparoscopy of untwisting the pedicle to restore blood flow. In this case, the ovarian ligament was shorted using 1/0 vicryl and the pregnancy went to term.

Esta paciente de 32 años se presentó en la séptima semana de gestación con un severo dolor abdominal en el lado inferior izquierdo. Esto ocuría teniendo la paciente por antecedente una historia previa de salpingectomía izquierda a partir de la ruptura de un embarazo ectópico siete años antes. La evaluación sonográfica transvaginal reveló un embrión intrauterino viable de siete semanas, un quiste del 2 cm en el cuerpo lúteo izquierdo, y los estudios de Doppler revelaron un flujo interno reducido. Esto abrió el camino para un abordaje conservador vía laparoscopia encaminada a deshacer la torsión del pedículo y restablecer así el flujo sanguíneo. En este caso, el ligamento ovárico fue acortado usando vicryl 1/0, y el embarazo continuó a término.

Quiste ovárico fetal: diagnóstico prenatal y manejo quirúrgico postnatal exitoso / Prenatal diagnosis of fetal ovarian cyst

Los quistes ováricos son el tumor abdominal mas frecuente en las recién nacidas. Presentan complicadones agudas y a largo plazo. La más frecuente es la torsión anexial que presenta dificultades diagnósticas en la etapa neonatal. El diagnóstico prenatal es fundamental para el manejo oportuno de las pacientes. Existen diferentes alternativas terapéuticas donde la cirugía mínimamente invasiva y conservadora juega un importante rol. Presentamos el caso de una recién nacida macrosómica con diagnóstico prenatal de quiste ovárico no complicado que sufrió torsión durante los primeros días de vida y se resolvió exitosamente en forma quirúrgica conservadora gracias a un manejo multidisciplinario.

Ovarian cysts are the most common abdominal tumor in female newborns. They could develop acute or long term complications. The most frequent complication is adnexal torsion, which presents with diagnostic difficulties in the neonatal period. Prenatal diagnosis is essential for the prompt management of patients. There are different treatment options where conservative and minimally invasive surgery plays an important role. We report a female newborn with prenatal diagnosis of macrosomia and uncomplicated ovarian cyst, which suffered adnexal torsion during the first days of life and was successfully resolved with a conservative surgical management by a multidisciplinary staff.

Torsión anexial sin patología ovárica en gestante del primer trimestre / Adnexal torsion without ovarian pathology in a pregnant woman in the first trimester

La torsión anexial durante el embarazo es una entidad muy poco frecuente y casi siempre ocurre en el contexto de una masa anexial. Es importante establecer el diagnóstico mediante ecografía y en caso de duda se recomienda la utilización de laparoscopia diagnóstica para realizar el tratamiento lo más precozmente posible.

Adnexal torsion during pregnancy is a rare entity and usually occurs in the context of an increase in the mass of the annex. It is important to establish the diagnosis by ultrasound and in case of doubt we recommend the use of diagnostic laparoscopy for treatment as early as possible.

Manejo conservador de la torsión anexial: ¿una alternativa o una obligación frente a un posible error de apreciación por parte del cirujano? / Conservative management of adnexal torsion

Antecedentes: La torsión anexial es una complicación frecuente en ginecología que motiva una cirugía de urgencia y muchas veces conlleva la anexectomía como tratamiento basado en la impresión visual cirujano. Objetivo: Evaluar la contabilidad de la impresión visual del cirujano para la toma de decisiones. Método: Se estudiaron las torsiones anexiales operadas entre enero de 2006 y julio de 2009. Se revisaron las placas de los casos sometidos a anexectomía y se determinó la presencia de compromiso vascular irreversible. Se correlacionó la impresión visual del cirujano con la del patólogo usando la biopsia como estándar dorado. Resultados: En el período de estudio se operaron 51 pacientes. La edad promedio fue 35,5 +/- 2 años (rango: 8-80 años). El 72,6 por ciento de los casos fue abordado por laparoscopia y en 60,7 por ciento de los casos se realizó anexectomía. En 38,7 por ciento de los casos sometidos a anexectomía se demostró en la biopsia un infarto hemorrágico masivo. A mayor intervalo de tiempo entre diagnóstico y cirugía, mayor fue la probabilidad de compromiso vascular (regresión logística, p<0,01). La concordancia entre la impresión del cirujano y del patólogo fue leve (kappa 0,2 +/- 0,16 p<0,02). La sensibilidad, especificidad, valor predictivo positivo y negativo de la impresión visual del cirujano para necrosis isquémica fueron 88,9 por ciento, 26,3 por ciento, 36,4 por ciento, 83,3 por ciento respectivamente. Conclusiones: Este estudio demuestra que la apreciación visual del cirujano es un mal predictor de daño vascular irreversible. Ante la sospecha diagnóstica de torsión debe preconizarse el abordaje quirúrgico precoz e intentar preservar el ovario.

Background: Adnexal torsion constitutes one of the major surgical emergencies in gynecology commonly leading to adnexal removal based on visual assessment of vascular damage. Aims: The goal of present study is to establish the accuracy of the surgeon's visual impression in correctly doing the decision-making. Methods: All cases of adnexal torsion undergoing surgery between January 2006 and July 2009 were recruited. A pathological review was conducted in all cases undergoing adnexal removal to assess the presence of irreversible vascular damage. A correlation was done between pathologist and surgeon assessment using pathological report as gold standard. Results: During the period of study a total of 51 patients were operated. The average age was 35.5 +/- 2 years (range: 8-80 years). The 72.6 percent of cases was approached by laparoscopy and in 60.7 percent of cases adnexal removal was done. In 38.7 percent of those cases treated with adnexal removal a massive ischemic necrosis or complete infarction was demonstrated at biopsy. As longer the time interval was between diagnosis and surgery, major the incidence was of vascular damage (log regression, p<0.01). Slight agreement was observed between surgeon and pathologist (kappa 0.2 +/- 0.16, p<0.02). Sensitivity, specificity, positive and negative predictive values for visual assessment of ischemic necrosis done by surgeon were 88.9 percent, 26.3 percent, 36.4 percent, 83.3 percent respectively. Conclusions: This study demonstrates that visual assessment has a low positive predictive value for irreversible vascular damage. In those cases with presumptive diagnosis of adnexal torsion, an early surgical approach should be prompted to preserve the adnexa.

Massas anexiais na gestação / Adnexal masses in pregnancy

O advento da ultrassonografia (US) durante o pré-natal tem contribuído para o aumento da detecção de massas anexiais na gestação. A maior parte dos tumores tem resolução espontânea por volta da 16ª semana de gestação, sendo associada a cistos funcionais. Massas que persistem após esse período podem acarretar riscos de torção, ruptura e obstrução do canal de parto, necessitando, muitas vezes, de uma intervenção cirúrgica de emergência. A ocorrência de tumores malignos é rara. Além da US, que é utilizada como primeira modalidade para o diagnóstico, o estudo do CA-125 e do B-hCG deve ser realizado. Esses marcadores estão normalmente aumentados durante a gestação. No entanto, na presença de massas tumorais, os níveis são bem mais alterados. O manejo dessa patologia na gravidez é desafiante para o médico e acarreta ansiedade para a paciente. A cirurgia, quando indicada, deverá ser realizada entre o segundo e terceiro trimestres da gestação, levando-se em conta os riscos de complicações para a mãe e o feto. Estudos mostram que, havendo indicações precisas de tratamento adjuvante na gravidez, seu uso não deve ser adiado, pois, em longo prazo, o prognóstico para fetos expostos à quimioterapia intra-útero parece ser bom.

The advent of routine prenatal ultrasonography (US) has increased the detection of adnexal masses during pregnancy. The majority of tumors spontaneously resolve around the 16ª week of gestation, usually being associated with functional cysts. Masses that last after this period can complicate on risks of torsion, rupture of obstruction of labor, requiring emergent surgical intervention. The prevalence of malignant tumor is rare. Besides the use of US, which is the primary diagnostic modality, the study of tumor markers, such as CA-125 and B-hCG, must be done. Their levels are already elevated during pregnancy. However, in the presence of certain types of tumors, these levels are much more altered. The management of this pathology during pregnancy is quite challenging to the medical team and involves psychological issues to the patient. When indicated, the surgery must be taken place between the second and third trimester, always considering the risks of complications to the mother and the fetus. Several studies report that if there are strong indications for adjuvant therapy, it should not be delayed, because the longterm fetal outcomes appear to be good for those fetuses exposed to chemotherapy in utero.

Manejo laparoscópico de quistes ováricos complicados o persistentes durante el embarazo / Laparoscopic management of complicated or persistent adnexal cysts during pregnancy

Antecedentes: El incremento en el hallazgo de quistes anexiales durante el embarazo sería el mayor uso de técnicas de reproducción asistida con hiperestimulación ovárica controlada. La complicación más frecuente sigue siendo la torsión anexial. Objetivo: Revisar el manejo de quistes anexiales complicados o persistentes, durante el embarazo, con resolución laparoscópica. Método: Revisión retrospectiva de 9 pacientes consecutivas, ingresadas al Departamento de Obstetricia y Ginecología Clínica Las Condes. Resultados: La edad gestacional de ingreso fue entre 5+5 y 27 semanas. Cinco casos fueron producto de fertilización asistida y cuatro espontáneos. Ocho (85,6 por ciento) embarazadas, ingresaron por dolor abdominal agudo. Otro caso ingresó a cirugía electiva por quiste ovárico persistente. Los quistes tenían entre 6 y 13 cm. En 5 se realizó sólo destorsión ovárica, en 1 ooforectomía y en 1 quistectomía. Se realizó punción, destorsión y fijación a ligamento útero ovárico, bilateral, en la otra paciente. Se registró un caso de fiebre en el postoperatorio. El alta hospitalaria fue a las 48 horas en 6 (67 por ciento), a las 72 en 2 y a las 96 en 1. El estudio biópsico diferido en 3 pacientes demostró: 1 quiste seroso paratubario, 1 quiste luteínico parcialmente hemorrágico y 1 infarto anexial. Todos los embarazos evolucionaron normalmente. Conclusión: Nuestra experiencia confirma que en el embarazo la laparoscopía es una buena opción al requerir una cirugía por quiste anexial complicado o persistente.

Background: Recent reviews show an increase in the finding of adnexal cysts during pregnancy. One reason could be the use of assisted reproductive techniques with controlled ovarian hyperstimulation. Objective: To review the experience in managing via laparoscopy complicated or persistent adnexal cysts during pregnancy. Method: Retrospective review of 9 consecutive patients, admitted at the Department of Obstetrics and Gynecology, Clínica Las Condes. Results: The gestational age was between 5+5 and 27 weeks. Five were the product of assisted fertilization and four spontaneous. Eight (85.6 percent) pregnant women were admitted by emergency room because of acute abdominal pain and another one went through elective surgery for persistent ovarian cyst. Preoperative diagnosis of the 8 patients admitted by emergency: adnexal cyst complicated with torsion in 6 (1 adnexal infarction) and 2 cases of acute abdomen. The cysts were between 6 and 13 cm. Type of surgery: in 5, only distortion; ovarian oophorectomy in 1 and cystectomy in one. Puncture, detorsión and bilateral fixation of uterine ovarian ligament, in another patient. One case required conversion to laparotomy with adnexectomy. Postoperative fever was observed in one patient. Discharge was at 48 hrs in 6 (67 percent) cases, at 72 hrs. in 2 and 96 hrs. in 1. Deferred biopsy performed in 3 patients showed: paratu-barian serous cyst, partially hemorrhagic luteal cyst, adnexal infarction. All pregnancies went on normally. Premature births are not reported. Conclusion: Our experience suggests that laparoscopic approach is a valid option for complicated or persistent adnexal cysts in pregnant women.

Torsión anexial y embarazo: resolución laparoscópica mínimamente invasiva, con entrada bajo visión directa / Adnexal cyst and pregnancy: laparoscopic management

Las masas anexiales durante el embarazo son de baja frecuencia, sin embargo tienen una alta probabilidad de complicarse, produciéndose torsión hasta en un 25 por ciento de ellas. Ante la necesidad de una resolución quirúrgica, debemos tener en cuanta los riesgos de desencadenar una pérdida fetal, como resultado de una cirugía muy invasiva. Gracias a los avances tecnológicos, el mayor conocimiento y manejo de anestesia durante el embarazo, la laparoscopia debería constituir la mejor vía para realizar estas cirugías. De esta forma, se aplican todos los principios de mínima invasión, facilitando un menor daño y rápida recuperación, con poca probabilidad de afectar el embarazo. Presentamos un caso de quiste anexial complicado con torsión, durante el segundo trimestre del embarazo, resuelto por medio de cirugía laparoscópica, con entrada bajo visión directa con cámara, para reducir la posibilidad de daño uterino.

The adnexal masses during pregnancy are of low frequency; nevertheless they have a high probability of complication. The torsion can be observed in a 25 percent of them. When they need surgery, we must be aware of the risks and morbidity imposed to the fetus and the patient. The technological advance and best knowledge of fetal physiology and hemodynamics plus anesthesia during the pregnancy, allow that laparoscopy constitutes the best via to perform this surgery. By the way, all principles of minor invasion are applied, with short hospital stay and lesser morbidity affecting the pregnancy. We present a case of a complicated adnexal cyst, with torsion, during the second trimester of the pregnancy. A laparoscopic surgery was performed, with entrance under direct camera vision, to reduce uterine damage.

[ adnexal torsion in children]

Adnexal torsion is the most frequent gynaecological emergency in children. It requires an early diagnosis and an urgent surgical treatment. To study the clinical, paraclinical and therapeutic aspect of adnexal torsion in paediatric population this is a retrospective review of nine girls with the diagnosis of ovarian torsion observed over a 7 years period [January 1999 to December 2005]. The average age is 9 years [extreme 6 to 13 years]. This pathology was located in 5 cases on the right side and in 3 cases on the left side; a case of bilateral torsion of poly-cystic ovary was encountered in a girl with Down's syndrome. Clinical presentation is made in all the cases by abdominal pains and vomiting. The disorders of the transit and the urinary signs are associated in 3 and 2 cases respectively, the clinical examination objectified a pelvic defense in all the cases and an abdominal mass in 2 cases. Pelvic ultra-sonography was made in 6 observations and give the diagnosis of torsion of the ovary in 4 cases, whereas it was doubtful in the 2 remaining cases when an ovarian mass was observed. In the 3 remaining cases, this examination was not performed since one the diagnosis of acute appendicitis was retained and the patient operated in emergency. All the children of our series were operated; in 1/3 of the cases we found a necrosis of the ovary. 4 cases out of 9 present a torsion on pathologic ovary [cyst, dysplasia], whereas in the 5 remaining cases. We noted a torsion on healthy ovary 4 young girls have undergoes a annexectomy, of which one was bilateral. The evolution was favorable in all the cases. Adnexal torsion is a surgical emergency that need an early diagnosis and management to preserve ovarian function in girls and Doppler sonography every must be done every time there is a pelvic pain without fever in girls

[Laparoscopic management of ovarian cysts in postmenopausal women]

To report our experience with laparoscopic treatment of ovarian cysts in postmenopausal women. During the period January 2000 to December 2006, 18 postmenopausal women were admitted for laparoscopy. The indications for the operation were an ovarian cyst that did not meet the criteria of a simple cyst, or was larger than 4 cm. The median age of the patients was 55 [range 43-82]. The mean time since menopause was 6 years [range: 1-30 years]. All laparoscopies were successfully accomplished. No case of malignancy was found. Histological examination revealed 15 serous cysts, one mucinous cyst, one endometroid cyst and one functional cyst. Neither intraoperative nor post-operative complications occurred. There was no surgery-related mortality. Mobilization of all women was carried out within 12 h of the operation. The mean hospitalization stay was 2 days. Laparoscopic management of carefully selected ovarian cysts is an appropriate alternative for exploratory laparotomy even in elderly patients with or without underlying diseases

Masas anexiales y embarazo: un desafío para el ultrasonografista / Adnexal masses and pregnancy: a challenge for the ultrasonographer

Se presentan 5 casos de embarazadas con masas anexiales complejas diagnosticadas entre las 5 y 34 semanas de gestación. Una de ellas tuvo indicación quirúrgica por abdomen agudo secundario a torsión anexial izquierda y cuatro, por sospecha de malignidad, que se confirmó en un caso. Dos pacientes tenían patología anexial benigna y la otra, una pseudo masa secundaria a un proceso inflamatorio pelviano crónico.

Five pregnant patients, with complex adnexal masses diagnosed between 5 and 34 weeks of gestation, are presented. One of them had surgical indication due to an acute abdominal pain, secondary to the torsion of the adnexal mass; and the other four, because of suspected malignancy, which was confirmed in one. Two patients had benign adnexal masses, and the other a pseudo cyst secondary to a cronic inflamatoty pelvic process.

Tumores anexiales en niñas y adolescentes: experiencia del Hospital Clínico de la Universidad de Católica de Chile, 1991-2003 / Adnexal mass in girls and teenagers: experience of Hospital Clínico de la Universidad de Católica de Chile, 1991-2003

Se analiza retrospectivamente la experiencia de los últimos 13 años en el manejo de la patología anexial quirúrgica en niñas y adolescentes menores de 19 años. Se revisa la forma de presentación clínica y los hallazgos anatopatológicos de 106 pacientes. Del total de lesiones anexiales, un 62 por ciento correspondieron a lesiones neoplásicas benignas y malignas, la mayoría de ellas originadas en el ovario. El riesgo de malignidad para las lesiones neoplásicas fue de un 26,7 por ciento. La neoplasia ovárica benigna más frecuente fue el teratoma maduro (31,1 por ciento). Las neoplasias malignas más frecuentes fueron las originadas en el estroma gonadal específico y en el tejido germinal (en conjunto 37,5 por ciento del total de neoplasias malignas). La forma de presentación clínica más frecuente fue el dolor abdominal habitualmente como manifestación de complicación de una neoplasia benigna. La vía de abordaje más frecuente fue por laparotomía y se privilegió la cirugía conservadora para preservar el potencial reproductivo.

Tumores anexiales y embarazo / Adnexal tumors and pregnancy

Objetivo: Evaluar la frecuencia de tumores anexiales en el embarazo, la histología tumoral y los resultados perinatales. Pacientes y método: Análisis retrospectivo de 33 pacientes con diagnóstico de tumor anexial y embarazo atendidas en el Servicio de Obstetricia del Hospital San Juan de Dios entre febrero de 2001 a julio de 2004. Resultados: La asociación tumor anexial y embarazo fue 1 en 424 embarazos. El tipo histológico más frecuente fue el cistoadenoma seroso (19,2 por ciento no alteró el pronóstico perinatal. Conclusión: Recomendamos la resolución quirúrgica de las masas anexiales complejas durante el embarazo sobre las 12 semanas, período que da un margen de seguridad bastante amplio sin afectar la evolución del embarazo o los resultados perinatales.

Adnexal torsion following gonadotropin-releasing hormone analog therapy: a case report

Torção anexial pode ocorrer em crianças e adolescentes do sexo feminino. Frequentemente está associada com doenças ovarianas que resultam em crescimento da gônada. A torção anexial pode comprometer os ovários isoladamente, as tubas uterinas ou ambos e o sintoma principal é dor pélvica aguda. Descrevemos um caso de dor pélvica aguda em uma menina de 8 anos de idade, com diagnóstico prévio de puberdade precoce e que estava em tratamento com análogo de GnRH. O exame ultra-sonográfico demonstrava útero de tamanho normal com ovários aumentados bilateralmente e múltiplos cistos. Na laparotomia foi encontrado torção completa do anexo direito. O exame histológico demonstrou edema maciço de ovário associado com múltiplos cistos antrais e redução da reserva folicular.

Clinical profile of patients operated for benign adnexal tumors and the histopathological types

To study the clinical presentation of patients with benign adnexal tumors who had surgical management and the histopathological types of the tumors. Retrospective data were collected on 110 patients who underwent surgery for benign adnexal tumor from January 1999 through to April 2002, in Sultan Qaboos University Hospital, Sultanate of Oman. The histopathological types of the tumors were also studied. Abdominal pain was the commonest presenting symptom in 65% of the patients followed by abnormalities of vaginal bleeding. Most of the patients were managed by laparotomy and ovarian cystectomy. The commonest histopathological type was benign mature teratoma in 28% of the patients. Benign mature teratoma was the commonest histopathological type. Most of the patients had laparotomy; ovarian cystectomy and recurrences were few