Salpingectomy and Oophorectomy Ben Dhanaraj MBBS, FRANZCOG Tamar Obstetrics and Gynaecology Launceston, Tasmania SALPINGECTOMY • Purpose of fallopian tubes : to facilitate fertilisation • Salpingectomy - the surgical removal of of or both of the fallopian tubes. • For a known pathological process • Prophylactically in a normal tube Types of Salpingectomy • Partial • Complete • Unilateral • Bilateral • Salpingo-oophorectomy – where ovaries are removed as well as the fallopian tubes Indications for Salpingectomy • Ectopic pregnancy – including ruptured ectopic • Hydrosalpinx – fluid filled diseased fallopian tube(s). Removing hydrosalpinges dramatically improves IVF success. • Prevention of ovarian cancer – high and low risk patients • Adnexal neoplasia – of fallopian tubes or ovaries • Infections causing stricture – chlamydia, gonorrhea, syphilis • Concurrent removal with uterus and ovaries in TLHBSO Ectopic Pregnancy • Surgical treatment considered if: • Haemodynamically unstable • Signs and symptoms of impending or ongoing rupture of ectopic mass • Ongoing pelvic and abdominal pain • Evidence of intraperitoneal bleeding (USS finding, shoulder tip pain, cervical excitation) suggestive of rupture • Patients not suitable for MTX criteria or failed MTX treatment with s/s of impending rupture • Concurrent treatment for a hydrosalpinx (high risk of EP anyways) Tubal Ectopic Ectopic Pregnancy • Absolute indications for salpingectomy in EP: • Ruptured tube • Moderately or severely damaged tubes • Large tubal pregnancy (>3.5cm in most centres) • Absolute contraindications for MTX treatment • Considerations : salpingectomy vs salpingostomy • Salpingectomy reduced risk of PTT needing MTX and recurrent EP Salpingectomy vs Salpingostomy Hydrosalpinx • Hydrosalpinx fluid is toxic. Mechanisms: • Flushes embryo out of uterine cavity • Disruption of endometrium at implantation site – decreased endometrial expression of HOXA 10 (important transcription factor for implantation of embryo) • Impaired endometrial receptivity – fluid contains micro organisms, debris, cytokines and prostaglandins • Impairs motility of healthy spermatozoa • Overall improves pregnancy rates in those undergoing ART. Tubal occlusion is an alternative. Hydrosalpinx Opportunistic salpingectomy (OS) • Removal of FT for primary prevention of epithelial ca of FT, ovary or peritoneum in those undergoing pelvic surgery for other indications. • If low risk for epithelial ca above → opportunistic salpingectomy • If high risk for ovarian ca → salpingo-oophorectomy • Common eligible procedures to combine an OS : hysterectomy for benign conditions or at time of sterilization. Rationale for OS in reducing ca risk: • Many apparent ovarian high grade serous ca have a tubal precursor lesion • Epithelial ca of FT, ovaries and peritoneum are considered a single entity • FT is the site of carcinogenesis of high grade serous carcinomas • FT also acts as a conduit for carcinogens or inflammation (eg talc, PID, endometrial tissue) that may implant on ovary of peritoneal surface • Safe procedure with minimal risk OOPHOCRETOMY • Removal of one or both ovaries • Can be done alone or commonly in combination with hysterectomy and fallopian tube removal • If cancer reducing surgery - ovaries are removed together with fallopian tubes (same blood supply) – this is a salpingo-oophorectomy Indications for Oophorectomy • Benign ovarian tumours and ovarian cysts • Endometriosis including endometrioma • Ovarian neoplasm • Tubo-ovarian abscess • Ovarian torsion with a non-viable ovary • Reducing the risk of ovarian cancer or breast cancer in those with an increased genetic / pathological risk Ovarian Pathology Concurrent oophorectomy at HNBC • Limited benefit if patient is not at inherited risk of ovarian cancer • Postmenopausal ovarian conservation <65 yrs still beneficial • If younger age – discussion of risks vs benefit of long term morbidity : • CAD • Osteoporosis • Dementia and cognitive dysfunction • Vasomotor symptoms • Low libido and sexual dysfunction Nurses Health Study • 30000 women enrolled in the Nurses’ Health study, (median follow-up of 24 years), concluded that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, and fatal and nonfatal coronary heart disease.” At no age was oophorectomy associated with increased survival, but equally, it was not associated with a decreased survival in women over the age of 55 at the time of hysterectomy and oophorectomy. BSO for the ’Generalists’ • Postmenopausal >65 yrs with concurrent benign disease requiring surgery • At time of hysterectomy • Ovarian cysts • Laparoscopic pelvic surgery • Those who are ‘inherited risks’ for ovarian or breast ca: • Breast-ovarian cancer syndrome: BRCA 1&2 (also at risk of FT cancer and peritoneal cancer) • Lynch syndrome (HNPCC) : 3-20%lifetime risk of Ov ca and 60% risk of endometrial ca. SPECIAL CONSIDERATIONS • Salpingectomy and ovarian function: • ?does it affect ovarian blood supply thereby reducing ovarian function and earlier menopause? • So far RCTs show no decrease in FSH, AMH or antral follicle count • Current study in Canada in women undergoing bilateral salpingectomy vs tubal ligation for sterilization – age of menopause ? (study in progress) • Cancer risk reducing BSO - the entire FT needs to be removed including any adherent fimbrial end to the ovary if procedure done for those at high risk. SURGICAL ASPECTS OF ADNEXECTOMY • Lap adnexectomy – salpingo-oophorectomy • Common and frequent procedure • Standard technique with few rules to follow • What to be aware of: • Identify the IP ligament • Identify the ureter • The keypoint is the treatment of the IP ligament with the risk of ureteric injury (especially if pathology present) • Remove diseased ovaries intact with endocatch bag. Prevent spillage at all cost! Basic Lap Instruments • Uterine manipulator • Bipolar forceps • Monopolar scissors • (Alternatively : Ligasure or Harmonic scalpel) • Suction irrigation • Atraumatic forceps • Endocatch bag • Optional : Alexis mini retraction device with Gelport Standard Ports: Exposure and Exploration • Retract omentum and small bowel • Explore the pelvic cavity • If ovarian cyst present – peritoneal washings for cytology • Identify key landmarks: • IP ligament • Ureters • Iliac vessels • Uterine cornua Skeletonise IP Ligament • Identify IP ligament and skeletonise in order to avoid ureteric injury Identify Vessels Identify fold in avascular part of BL Open broad ligament Fenestrate BL, laterelise ureter Transect IP Ligament & Check Ureter Cut tube and utero-ovarian ligament Removal using Endocatch Bag Conclusion • Salpingectomy, oophorectomy and salpingo oophorectomy are common procedures • Indications can be for pathological conditions or for preventative measures • Non benign hysterectomies are are the commonest procedures where salpingectomies are performed • Inheritable genetic cancer risks require salping-oophorectomy with complete removal of the FT including the fimbrial end • Anatomical landmarks like the IP ligament and ureter must be identified prior to BSO to prevent ureteric injuries. Thank You Tamar Obstetrics & Gynaecology, Launceton.