Ovarian Cancer as Random Finding in Laparoscopy: Optimal Management and Medicolegal Issues

Ovarian Cancer as Random Finding in Laparoscopy: Optimal Management and Medicolegal Issues

Kimon Chatzistamatiou, Leonidas Zepiridis, Grigorios Grimbizis
DOI: 10.4018/978-1-7998-4213-2.ch018
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Laparoscopy can be used for almost all gynecological procedures and is considered as the indicated method for specific procedures. This is especially true for adnexal surgery. Of course, while it is considered a method of choice for the treatment of benign ovarian tumors, the same does not apply to malignant ones, although treatment of ovarian cancer either at an early or even at a more advanced stage is feasible with laparoscopy. Finding malignancy, when not suspected, during laparoscopic treatment of an ovarian cyst is a situation raising several issues, depending on whether the identification of malignancy is intra- or post-operative, which involve inadequate surgical staging, peritoneal spread of cancer cells, intraoperative rupture of a malignant ovarian cystic tumor, and port site metastasis. This chapter analyzes the possible adverse events related to the use of laparoscopy in the treatment of adnexal masses considered as benign but turn out to be malignant, and how they can be mitigated with careful preoperative patient selection and with adequate surgical experience.
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Laparoscopy is a minimally invasive technique consisting a surgical approach that is now daily practice in gynecology for the treatment of both simple and complex diagnostic and therapeutic problems. Laparoscopy, i.e. the visualization of the peritoneal cavity, was developed during the 20th century, when the basic principles of the method were gradually implemented, and it was a change in paradigm for surgery in general (Lane, 2018; Misro, 2015; Nano, 2012; Spaner & Warnock, 1997; Teixeira, 2020). Air insufflation in the peritoneal cavity was first used by Kelling (Kelling, 1902; Schollmeyer, Soyinka, Schollmeyer, & Meinhold-Heerlein, 2007) to treat intraperitoneal hemorrhage in dogs and, during the same year, the first peritoneal cavity examination was performed on a pregnant woman by Ott (Himal, 2002; Von Ott, 1901). Subsequently, following the initial experimental implementation of the above methods, specialized tools and techniques were developed, including the use of carbon dioxide, the development of a specially designed needle for the induction of pneumoperitoneum, by Verres in 1937 (Veress, 1961), and later, the development of automated systems for carbon dioxide insufflation and monitoring of intraperitoneal pressure, for irrigation and aspiration as well as for electrocoagulation with the significant contribution of Kurt Semm (Himal, 2002; Semm, 1983a, 1983b). A medical doctor who had a pivotal role in the development of laparoscopy was Raul Palmer (Litynski, 1997b), who, among others, studied the use of carbon dioxide in laparoscopy, and standardized the insufflation method advocating that the intraabdominal pressure should not exceed 25 mmHg, and that the insufflation speed should not exceed 500 cc per minute (Palmer, 1947). Palmer’s work established safety rules for laparoscopy which are the basis of modern minimally invasive surgery.

During the last decades of the 20th century, laparoscopy has gained significant grounds over the classical surgical approach in the treatment of gynecological diseases (Lim, 2017; Litynski, 1997a). Furthermore, gynecology was among the medical specialties that adopted the new method very quickly, as the benefits, regarding better quality of the post - operative course combined with improved cost of hospitalization for women were greatly appreciated (Lundorff, Thorburn, Hahlin, Kallfelt, & Lindblom, 1991; Magos, Baumann, & Turnbull, 1988; Rademaker, Einarsson, Huirne, Gu, & Cohen, 2019).

Indeed, it was quickly shown that when a procedure was performed with minimally invasive techniques it required shorter duration of post-operative hospitalization and a shorter recovery time after hospital discharge compared to the use of the standard surgical techniques (Lundorff et al., 1991; Magos et al., 1988). Moreover, post-operative pain, post-operative morbidity and the cosmetic result regarding surgical wounds were improved in case of laparoscopy compared to laparotomy (Nguyen et al., 2011; Stocchi, Nelson, Young-Fadok, Larson, & Ilstrup, 2000). These beneficial effects are independent of the kind of the surgical procedure performed on the patient. In addition, concerning the overall health care cost affecting a state’s annual budget and therefore the whole society, laparoscopy also seemed a well-balanced, cost effective process with a substantial economic gain (Levine 1985). Cost effectiveness is very important in the design of a state’s health care policy since the implementation of this basic principle permits a rationalized allocation of the budget available for policies related to the prevention and treatment of diseases, affecting the whole population regardless of sex, age or other demographic parameters (Bartha, 2018; Behera & Dash, 2019; Gupta & Ranjan, 2019; Izadi, Bahadori, Teymourzadeh, Yaghoubi, & Ravangard, 2019; Lomas, Martin, & Claxton, 2019). Altogether, these reasons have led to a widespread worldwide adoption of minimally invasive techniques among surgeons involved in the surgical treatment of gynecological benign as well as malignant diseases.

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