DOI: 10.1111/j.1471-0528.2008.01995.x Review article www.blackwellpublishing.com/bjog

Minimal access surgery in adolescent

GK Pandis, L Michala, SM Creighton, AS Cutner UCL Institute for Women’s Health, Elizabeth Garrett Anderson and Obstetric Hospital, London, UK Correspondence: Dr SM Creighton, UCL Institute for Women’s Health, Elizabeth Garrett Anderson and Obstetric Hospital, Huntley Street, London WC1E 6DH, UK. Email [email protected]

Accepted 22 September 2008.

The benefits of a minimally invasive approach are now well adolescents ought to be aware of the steep learning curve required documented in adult women, and thus surgeons have embraced for achieving proficiency with complex laparoscopic surgery. In the the notion of expanding such expertise in adolescence with group of rare congenital anomalies and advanced , measured enthusiasm and a great sense of responsibility. Faster the best surgical results can only be achieved after careful recovery is likely to have a positive impact on schooling, while less preoperative planning by a multidisciplinary team formation may reduce future fertility issues. Keywords Adolescent gynaecology, minimal access surgery. Gynaecologists performing minimally invasive procedures in

Please cite this paper as: Pandis G, Michala L, Creighton S, Cutner A. Minimal access surgery in adolescent gynaecology. BJOG 2009;116:214–219.

Introduction magnetic resonance imaging (MRI) with the addition of con- trast material.3,4 Multidisciplinary teams based in tertiary Adolescence is the period of development between the onset referral centres usually comprise adolescent gynaecologists, of puberty and adulthood. It is marked by the appearance of fertility experts, geneticists, endocrinologists, paediatricians, secondary sex characteristics, ends with the completion of psychologists, specialist nurses and endoscopic surgeons. physical growth and emotional maturity and usually spans Such centres with a broad expertise have enabled diagnostic from 10 to 19 years of age.1 Gynaecological problems in this laparoscopy to be largely replaced with less invasive investi- age group may arise due to congenital anomalies or may be gations. This allows for a full discussion prior to definitive due to common gynaecological conditions merely occurring surgery being carried out. The alternative of two operations, in a younger age group. one for diagnosis and the other for treatment, increases the Compared with laparotomy, laparoscopy is associated potential risks to the women. with less bleeding, adhesions and postoperative pain, faster recovery and a better cosmetic result.2 These bene- fits are even more valuable in an adolescent population. Laparoscopic techniques and Faster recovery allows patients to return to their school- instruments ing, while less adhesions formation may reduce future fertility issues. Since the 1980s, minimally invasive procedures have been slowly introduced in the adolescent population.5,6 Many of the considerations and risks that are taken into The place of diagnostic laparoscopy account when deciding to operate on an adult play a very important role in planning surgery on an adolescent. Lapa- The diagnosis of gynaecological pathology in this group is roscopy is generally contraindicated in haemodynamically challenging due to the anxiety and embarrassment of the unstable patients or in those with known severe abdominal women as well as diagnostic limitations and, in some cases, adhesions secondary to previous open surgery. Obtaining poor compliance. a pneumoperitoneum, particularly in young thin individuals, In recent years, the accuracy of diagnosis of adolescent is not without risks. These include extraperitoneal collection gynaecological conditions—and in particular of mu¨llerian of gas and visceral or vascular injury, which occasionally can duct anomalies—has improved with the introduction of significantly complicate the intended procedure and compro- advanced imaging technologies including ultrasound and mise the women’s well-being.

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Patient position for laparoscopy in the adolescent does gynaecological pathology that happen to occur in this age notdifferfromthatusedinadults. Young women are placed group and procedures to preserve ovarian function. in Lloyd-Davies position and a Foley’s catheter is inserted into the bladder to minimise the risk of bladder injury and Procedures to treat congenital anomalies aid with pelvic visualisation. Vaginal examination and uter- Mu¨llerian anomalies and disorders of sex development (DSD, ine manipulation are avoided in adolescent girls who have previously known as ) are commonly first diagnosed not been sexually active, unless required during the process and managed in adolescence. DSD that may require laparo- of the planned procedure. Cases of significant pelvic dissec- scopic treatment include conditions where the gonads are at tion are given preoperative bowel preparation to enhance risk of becoming malignant and need removal and conditions vision. where the laparoscopic creation of a neovagina might be In adolescent and paediatric patients, the technique for required. Mu¨llerian anomalies may require surgery at adoles- obtaining a pneumoperitoneum may differ from the standard cence if they cause menstrual obstruction or in case of uterine techniques applied to adult women. The risks of vascular and vaginal agenesis to create a neovagina. injury are greater in the very young or very thin patient where the short distance between the anterior abdominal wall and Procedures to treat other gynaecological the major retroperitoneal vascular structures can lead to seri- pathology ous inadvertent injuries with the Verres needle. In this group Certain gynaecological conditions, such as ovarian pathology of patients, the Hasson surgical entry technique should be and endometriosis, are common indications for laparoscopic considered, although there has been no good evidence to treatment in adulthood and may also present, although more suggest that the latter entry technique is superior or inferior rarely, in adolescence. Also, as the age of first sexual inter- to the former type of entry.7 course decreases, ectopic pregnancy and pelvic inflammatory Where there is a risk of pelvic adhesions or a large abdom- disease are diagnosed more often in this age group. inal mass, then Palmer’s point entry (the left subcostal area in the midclavicular line) can be used. The spleen should be Procedures to preserve ovarian function palpated for prior to insertion of the Verres needle and one In cases of rare radiosensitive pelvic tumours where radiation should insert a nasogastric tube to reduce the chance of per- will result in ovarian failure, laparoscopic surgery may be of forating an inflated stomach.8 benefit in fixing the ovaries away from the field of radiation. The abdomen is insufflated with carbon dioxide to create adequate distension. The overall volume of gas introduced is Procedures used in the treatment of variable due to patient size, distensibility of the abdominal congenital anomalies wall and amount of muscle relaxant drugs used. Carbon diox- ide flow ceases when the intra-abdominal pressure reaches Gonadectomy a preset value. This is usually 20 mmHg for grown-up ado- Gonadectomy is indicated in cases of DSD where a phenotyp- lescents and 12–15 mmHg for young thin adolescents or older ically female patient has either an XY karyotype or a fragment children. Younger children may require lower pressure setting of a Y chromosome; conditions include complete androgen at 8–12 mmHg.6 insensitivity syndrome (CAIS), Swyer syndrome and mosaic Additional ports must be placed under direct vision so as to Turner’s syndrome. The indication for removal of the gonads avoid injury to viscera or vessels. Ports should be placed either is a potential malignancy risk, and the magnitude of this very lateral or medial so as to avoid the inferior epigastric varies from approximately a 5% lifetime risk for structurally vessels. Identification of abdominal wall vessels is generally normal testes in CAIS to 30% for dysgenetic gonads as in easy in this population due to lack of excess abdominal adi- Swyer syndrome.9,10 pose tissue, which facilitates their transillumination. The timing of the gonadectomy is dependent on the under- At the end of the procedure, ports are removed under lying diagnosis, which determines the magnitude of the direct vision and lateral ports ‡10 mm are formally closed malignancy risk, the potential for useful hormone production to reduce the risk of incisional hernia. Closure of skin inci- by the gonad and the risk of progressive virilisation in a female sions is usually accomplished with an absorbable suture mate- patient. rial or a special glue. In women with Swyer and Turner’s syndrome, every effort should be made to preserve the ; however small this Gynaecological conditions in the may appear, as there is potential for improved uterine size adolescent with estrogen stimulation and the possibility of pregnancy with egg donation. Fallopian tubes, however, often need to Procedures can be broadly divided into three groups: proce- be removed at the time of gonadectomy to ensure complete dures to treat congenital anomalies, procedures to treat other excision of all gonadal tissue. It is therefore important that the

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 215 Pandis et al. possibility of a salpingectomy is discussed with the patient Obstructive mu¨llerian anomalies prior to surgery and documented on the consent form. The Congenital uterine anomalies are common, but the majority technique to remove the gonads is otherwise the same as are asymptomatic and do not require treatment. However, a laparoscopic oophorectomy.11 certain anomalies may lead to menstrual obstruction, result- Difficulties may arise in cases of CAIS where the gonads ing in cyclical pain that usually first presents in the early may be anywhere along the line of testicular descent from adolescent years. Laparoscopic surgery is the treatment of high up in the abdominal cavity to low down in the groin choice in two specific situations: an obstructed uterine horn or labia. Accurate imaging of the gonads is an essential part of and cervical agenesis. preoperative planning. If the gonads are in the inguinal canal, then exploration of the groin may be required, which in most units is performed by a urologist. Laparoscopic treatment of an obstructed uterine horn Delay in diagnosis is a major feature of this condition due to Laparoscopic creation of a neovagina the presence of normal menstruation from the unobstructed The most common cause of vaginal agenesis is Mayer– side. Often individuals will have endured months of worsen- Rokitansky–Kuster–Hauser syndrome. However, vaginal ing cyclical pain before the diagnosis is confirmed.17 MRI agenesis also occurs in DSD such as CAIS. The in reported by an experienced radiologist can provide useful either condition is blind ending, and the vaginal length can information on the level of obstruction, the degree of fusion vary from a shallow dimple to several centimetres. In addi- of the uterine horns and associated abnormalities of the tion, genital tract anomalies are associated with other com- and vagina. This will enable careful preoperative planning. An plex conditions affecting the urinary and gastrointestinal intravenous urogram should also be performed as part of the tracts such as cloacal and anorectal anomalies. preoperative assessment to assess the course and number of Vaginal dilation should always be recommended as the ureters, as associated renal anomalies occur in approximately first line of treatment in vaginal agenesis. The technique 30% of cases. Gonadotrophin-releasing hormone analogues has few complications, as there are no anaesthetic and sur- are often used once the diagnosis is confirmed and prior to gical risks. Reported success rates are up to 81%12 but those surgery to suppress menstruation and alleviate pain. They also women who are unsuccessful with dilators will require sur- facilitate surgery by reducing uterine size and vascularity and gical creation of a neovagina. The ideal time for intervention the extent of any endometriosis due to retrograde menstrua- is at or after adolescence, and vaginal reconstruction proce- tion.18 Nowadays, there is little place for open surgery for this dures performed on infants and prepubertal girls almost condition. A four-port laparoscopy is performed, and after always require further surgical revision. Deferring treatment identification of the ipsilateral ureter, if present, the ovarian not only allows the women herself to be involved in the ligament is divided, followed by the dissection of the utero- decision making but also increases compliance with adju- vesical fold. The connection between the two horns is then vant dilation therapy that is required to prevent postopera- identified, and the obstructed horn excised using the har- tive stenosis. monic scalpel. The raw aspect of the functioning uterus is The Vecchietti and Davydov techniques for vaginal recon- oversewn, and the rudimentary uterus is morcelated to allow struction have been widely practised throughout Europe removal from the abdominal cavity through a 15-mm ab- and, over the past decade, have been introduced within the dominal port. UK.13 These operations were initially devised as open oper- Traditional surgical treatment such as metroplasty is ative procedures, but advances in minimal access techniques impossible in this situation. The obstructed horn is often allow both procedures to be performed laparoscopically. vestigial with no normal cervix and may be widely separated Recent short-term reports have demonstrated low compli- from the normally functioning horn. Anecdotally, surgical cation rates with an encouraging level of satisfactory sexual attempts have been made to establish drainage through the function.14,15 normally functioning horn, but these re-obstruct and will also Choosing the right operation is paramount to success.16 damage the integrity of the other horn. There are no data in Prior abdominal surgery such as bladder reconstruction in the literature on the fertility outcomes of this specific group of women with multiple complex anomalies of the genitouri- anomalies. Available large series of metroplasty in the litera- nary tract will mean that laparoscopic techniques such as ture for duplication anomalies do not include women pre- the Vecchietti and the Davydov procedures are hazardous senting with an obstructive rudimentary horn but only those and should not be attempted. Adjuvant therapy such as presenting later in life with recurrent miscarriage and preterm vaginal dilation treatment and psychological support can delivery.19 However, it seems logical that removal of the influence outcome and women satisfaction and should be obstructed horn only leaves an undisturbed unicornuate available. uterus and so this is currently considered the surgical

216 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology Minimal access surgery in adolescent gynaecology treatment of choice as it alleviates symptoms while conserving and between 69.6 and 73% in those unresponsive to nonsteroi- fertility. There are, however, little data available on future dal anti-inflammatory drugs and oral contraceptive pills.26,27 fertility for this patient group, and it is essential that units There is often a significant delay in diagnosing endometriosis operating on this group of young women carefully record and in adolescent girls. The younger the girl at the time of onset of publish their outcome data. symptoms, the longer the time period is to diagnosis. Delays are usually justified as laparoscopy in young girls presenting with Cervical agenesis pelvic pain should be performed after thorough assessment Congenital absence of the cervix is a rare condition with an and only after unsuccessful medical management. However, approximate incidence of 1 in 80 000 births. Presentation is when endometriosis is diagnosed in this age group, it tends usually with primary amenorrhoea and cyclical lower abdomi- to be at earlier disease stages,27 although stages III and IV have nal pain. Endometriosis or pelvic infection may result from the also been described.28 There are limited data regarding the chronic haematometra. As with other cases of mu¨llerian anom- appropriate management of severe endometriosis in adoles- alies, MRI is an important diagnostic tool that will give infor- cence. However, laparoscopic excisional surgery appears to be mation on the level of obstruction and the size of the body of the relatively safe with good short-term results.27,29 There are no uterus. Treatment options for this condition have evolved over reports on long-term follow up of recurrence of disease or need time. In the past, attempts at canalisation of the atretic cervix for repeat surgery. with simultaneous had been associated with peri- 20 tonitis and fatal septic shock. Thus, with ovarian Ovarian transposition prior to pelvic conservation was the recommended choice for many years. irradiation Over the last decade, there has been a renewed interest in conservative surgical treatment. Two large series of participants Ovarian transposition is a surgical technique used to protect totalling 36 women treated for this rare mu¨llerian anomaly ovaries from the risk of ovarian failure during pelvic irradia- with uterovaginal anastomosis have been reported.21,22 The first tion.30 Although initially described as an open technique, it reported laparoscopic surgical uterovaginal anastomosis for has recently evolved into a laparoscopic procedure. The most a women with cervical agenesis was performed in our depart- commonly seen radiosensitive malignancies in adolescents are ment in 2005.23 In this technique, following successful pneu- pelvic sarcomas and Hodgkin’s lymphomas. The site of the moperitoneum and insertion of four ports, the peritoneum at malignancy and the planned irradiation field will determine the lower edge of the uterus is incised and the bladder is the location to fix the transposed ovaries.31,32 Where possible, reflected. The uterine fundus is incised in a sagittal direction the ovaries are merely fixed medially or laterally without and the incision is extended until the cavity is breached. A interfering with their blood supply or the integrity of the laparoscopic probe is then inserted in the uterine cavity to fallopian tubes with the uterus. A repeat laparoscopy is then identify the level of the obstruction. This will determine the performed after completion of the course of radiotherapy to point at which the uterus will be opened to perform the anas- reposition the ovary to its original site. tomosis. The caudal portion of the obstruction is identified in In cases where the ovaries require complete laparoscopic a similar fashion by using a second probe that is inserted vag- transposition from the pelvis, the ovarian ligament and inally. Once the levels of anastomosis have been defined, a size attachment of the fallopian tube to the uterus are divided 12 Foley silastic catheter is passed from the vagina and guided and the infundibulopelvic ligament skeletalised to allow laparoscopically into the uterus. The upper vagina and lower mobilisation of the ovary. Mobilisation must be adequate to uterus are then sutured together over the catheter. The catheter allow the ovary to reach the subcostal margin, avoiding ten- is sutured in place in the new tract to maintain patency and sion on or torsion of the pedicle. In this situation, the ovaries removed at hysteroscopy approximately 1 month later. are not replaced at a later date. Subsequently, a series of 12 cases of laparoscopically assis- 24 ted uterovestibular anastomoses has been reported. All pro- Adnexal mass cedures were completed successfully, all women experienced regular menstruation postoperatively and six women re- The majority of adnexal masses in the paediatric and adoles- ported sexual intercourse without difficulties. There are as cent population are simple functional cysts and benign ovar- yet no reported cases of pregnancy following laparoscopic ian tumours such as dermoids.33 However, it is important to treatment for cervical agenesis. remember that nonepithelial malignant tumours, such as dysgerminomas and choriocarcinomas, do present in this 34 Endometriosis age group. Correct diagnosis can be aided with the use of ultrasound, colour Doppler assessment, MRI and tumour The prevalence of endometriosis has been reported to be markers. However, not infrequently the diagnosis is made between 17 and 73% in adolescents with chronic pelvic pain25 during an emergency laparoscopic or open surgical procedure.

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Simple ovarian cysts can be managed conservatively unless Disclosure of interests they cause significant pain. Operative intervention is also A.S.C. has received financial and academic support from Ethicon and warranted if torsion or malignancy is suspected. In the major- Storz. ity of cases, treatment can be performed laparoscopically, bearing in mind that cystectomy is preferred to fenestration Contribution to authorship due to a lower recurrence rate. All authors contributed to writing and revising the article and approved the final version of the manuscript. Ovarian torsion Details of ethics approval Ovarian torsion is a gynaecological emergency. Delay in diag- Not applicable. nosis can result in infarction and necrosis of the ovary and fallopian tube and necessitates adnexal removal. Torsion is Funding generally unilateral but can involve the contralateral ovary None. j or adnexum. Although rare, the potential remains for sequen- tial torsion, with devastating effects.35 There are many reported cases of torsion of normal adnexa in prepubescent References and adolescent girls, and this has been attributed to exces- 1 World Health Organization. Young people’s health—a challenge for sively mobile mesovaria or fallopian tubes, resulting from society. Report of a Study Group on Young People and Health for All congenitally long ovarian ligaments.36 by the Year 2000, Technical Report Series, No. 731. Geneva, Switzer- The traditional management of ovarian torsion has been land: World Health Organization; 1986. 2 Vermesh M, Silva PD, Rosen GF, Stein AL, Fossum GT, Sauer MV. Man- laparotomy and oophorectomy if the ovary was nonviable. agement of unruptured ectopic gestation by linear salpingostomy: This procedure is, however, performed more appropriately a prospective, randomized clinical trial of laparoscopy versus laparot- laparoscopically. 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