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Ovarian Cancer (Expert Forum)
Laparotomy vs. Laprascopy
Answered by
Annekathryn Goodman, M.D. - Gynecologic Cancers, Complex Gynecologic, Surgeries, Palliative Care, Acupuncture
Massachusetts General Hospital Cancer Center
Boston - MA
Laparotomy vs. Laprascopy
by Grateful06, Jul 04, 2006 12:00AM
Thank you for your time, your previous answers have helped me so much.
I have had a persistent cyst/tumor that has been in my right ovary for 18 months. While it remained dormant during the time I breastfed (ovaries at rest), it has begun to grow and cause all the usual horrible symptoms. It has grown 1cm in six months or so, and the radiologist reading the MRI said it was complex, and had a nodule "suspicious for malignancy". My gyn/onc is certain it is benign. On the left ovary I have a history of a borderline tumor being removed and ruptured in my abdomen, during c-section.
So that is me . . . my question, I get to choose between spinal and a mini-laparotomy and general anesthesia and lapriscopic surgery. Please give me your opinion. Complication rate is the same for surgery. General anesthesia scares the heck out of me. I had a spinal during c-section, no fun but I was able to maintain control, be awake. I'm leaning toward mini-lap and my husband is almost irate with me that I would choose the most invasive surgery, simply because I fear general anestheia.
Any comments from you would be so very much appreciated. I really have no one with your credentials to bounce this off of, and perhaps this can help someone else on the forum?
I have had a persistent cyst/tumor that has been in my right ovary for 18 months. While it remained dormant during the time I breastfed (ovaries at rest), it has begun to grow and cause all the usual horrible symptoms. It has grown 1cm in six months or so, and the radiologist reading the MRI said it was complex, and had a nodule "suspicious for malignancy". My gyn/onc is certain it is benign. On the left ovary I have a history of a borderline tumor being removed and ruptured in my abdomen, during c-section.
So that is me . . . my question, I get to choose between spinal and a mini-laparotomy and general anesthesia and lapriscopic surgery. Please give me your opinion. Complication rate is the same for surgery. General anesthesia scares the heck out of me. I had a spinal during c-section, no fun but I was able to maintain control, be awake. I'm leaning toward mini-lap and my husband is almost irate with me that I would choose the most invasive surgery, simply because I fear general anestheia.
Any comments from you would be so very much appreciated. I really have no one with your credentials to bounce this off of, and perhaps this can help someone else on the forum?
Doctor's Answer
by Annekathryn Goodman, M.D., Jul 05, 2006 12:00AM
, Jul 05, 2006 12:00AM
Hi There,
The way I think about it is in terms of tools. What is the right tool to get the job done? First you have to ask yourself: what is the goal? What are you trying to accomplish?
I assume the answer is: You want to rule out a malignancy, which will require at least a biopsy of the cyst. You may want to remove the ovarian cyst.
So how to accomplish this? Well you have several tools:
Laparoscopy is a minimally invasive procedure. General anesthesia is necessary. A 5 mm incision is made in the umbilicus (belly button) and a port is placed. (The word port here is used for a hollow tube that is about 12 cm long through which instruments can be inserted into the abdomen.) Then a laparoscope is placed. This is a wonderfully sophisticated piece of equipment with a bright light source through fiber optics and a camera that can be attached through a cord to a TV screen. After doing this, one evaluates the abdomen. At this point the next question is: is there cancer?
If the answer is yes, you can wake the person up and talk about what to do next. The standard of care would be a full hysterectomy, removal of the ovaries and tubes, lymph nodes biopsies This requires a large abdominal incision called a laparotomy. With some people, a preoperative decision is made to go ahead and change over to a laparotomy at the same surgery and not reschedule the bigger surgery for another day.
If the answer is: no cancer, then if it is technically possible, one can remove the cyst with laparoscopic equipment.
The reasons that laparoscopy cannot be performed include:
-The equipment is not available.
-The surgeon is not technically comfortable with this approach.
-There are too many adhesions.
-The cyst is too big.
-There is cancer.
-There is a complication of surgery such as uncontrolled bleeding, an injury to the intestine or to the bladder or ureter in which case a bigger incision is necessary to fix the problem.
Your second surgical tool involves an incision called a laparotomy. The term “mini-laparotomy” just means the incision is smaller. This is usually done under general anesthesia. I must say that unlike the c-section experience, it is really hard on both the patient and the surgeon to do a laparotomy under spinal or epidural anesthesia. I have done them under duress (For my patients with severe lung disease) but it is really not possible to get good anesthesia. Again, you have to remember your goals: you want to rule out cancer. That requires exploring the abdomen. Especially with a history of a borderline tumor that ruptured, it would be ill advised not to carefully explore the abdomen, look at the bowel, palpate the liver, diaghragm, and lymph node chains. A spinal will absolutely not numb you up enough for that. The second issue is muscle relaxation. To do an adequate laparotomy, the abdominal wall muscles need to be paralyzed. If the muscles are adequately paralyzed, you will not breath and that is dangerous. So any time muscle relaxation is needed, general anesthesia is needed. You are actually preventing your surgeon from doing a good and thorough job by not having general anesthesia plus it is not as safe.
Cesarean sections are very different from laparotomies in the non-pregnant state. The goal in a c-section is to make a small incision at the pubic hair line, make an incision in a huge uterus that fills the abdominal cavity and has pushed the bowel out of the way, and grab that baby and get out as fast as possible. There is no exploration of the abdomen and so forth in that setting.
It is hard for me to give more specific advice than this without seeing the x-rays and doing a pelvic exam myself. However perhaps these basic principles will be helpful for you and your surgeon to make an informed decision. People get hung up on the technical aspects. Just remember you want to be clear on what your goal is, then the right tool to use to accomplish this will make more sense.
The way I think about it is in terms of tools. What is the right tool to get the job done? First you have to ask yourself: what is the goal? What are you trying to accomplish?
I assume the answer is: You want to rule out a malignancy, which will require at least a biopsy of the cyst. You may want to remove the ovarian cyst.
So how to accomplish this? Well you have several tools:
Laparoscopy is a minimally invasive procedure. General anesthesia is necessary. A 5 mm incision is made in the umbilicus (belly button) and a port is placed. (The word port here is used for a hollow tube that is about 12 cm long through which instruments can be inserted into the abdomen.) Then a laparoscope is placed. This is a wonderfully sophisticated piece of equipment with a bright light source through fiber optics and a camera that can be attached through a cord to a TV screen. After doing this, one evaluates the abdomen. At this point the next question is: is there cancer?
If the answer is yes, you can wake the person up and talk about what to do next. The standard of care would be a full hysterectomy, removal of the ovaries and tubes, lymph nodes biopsies This requires a large abdominal incision called a laparotomy. With some people, a preoperative decision is made to go ahead and change over to a laparotomy at the same surgery and not reschedule the bigger surgery for another day.
If the answer is: no cancer, then if it is technically possible, one can remove the cyst with laparoscopic equipment.
The reasons that laparoscopy cannot be performed include:
-The equipment is not available.
-The surgeon is not technically comfortable with this approach.
-There are too many adhesions.
-The cyst is too big.
-There is cancer.
-There is a complication of surgery such as uncontrolled bleeding, an injury to the intestine or to the bladder or ureter in which case a bigger incision is necessary to fix the problem.
Your second surgical tool involves an incision called a laparotomy. The term “mini-laparotomy” just means the incision is smaller. This is usually done under general anesthesia. I must say that unlike the c-section experience, it is really hard on both the patient and the surgeon to do a laparotomy under spinal or epidural anesthesia. I have done them under duress (For my patients with severe lung disease) but it is really not possible to get good anesthesia. Again, you have to remember your goals: you want to rule out cancer. That requires exploring the abdomen. Especially with a history of a borderline tumor that ruptured, it would be ill advised not to carefully explore the abdomen, look at the bowel, palpate the liver, diaghragm, and lymph node chains. A spinal will absolutely not numb you up enough for that. The second issue is muscle relaxation. To do an adequate laparotomy, the abdominal wall muscles need to be paralyzed. If the muscles are adequately paralyzed, you will not breath and that is dangerous. So any time muscle relaxation is needed, general anesthesia is needed. You are actually preventing your surgeon from doing a good and thorough job by not having general anesthesia plus it is not as safe.
Cesarean sections are very different from laparotomies in the non-pregnant state. The goal in a c-section is to make a small incision at the pubic hair line, make an incision in a huge uterus that fills the abdominal cavity and has pushed the bowel out of the way, and grab that baby and get out as fast as possible. There is no exploration of the abdomen and so forth in that setting.
It is hard for me to give more specific advice than this without seeing the x-rays and doing a pelvic exam myself. However perhaps these basic principles will be helpful for you and your surgeon to make an informed decision. People get hung up on the technical aspects. Just remember you want to be clear on what your goal is, then the right tool to use to accomplish this will make more sense.
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I will be having surgery next week, to remove the right ovary and tube. Inside the right ovary, there is a complex cyst almost 5cm. My GYN/ONC has given me the choice between the two surgeries: 1) spinal and mini-laparotomy OR 2) general anesthesia and laparoscopy. She believes the complication rate is equal and it is my preference. I have to tell her by Monday, which I choose.
Everyone seems to be telling me to go for the choice 2 (laparoscopy) and I'm just terrified of general anesthesia. What is your opinion on my preferring the mini-laparotomy with spinal. Your opinion would be so valuable to me.
D-day is one week . . .I am 39, have three small kids (1,4,7). Recovery time doesn't matter to me as much as just living through the surgery. General anesthesia is really creepy. Am I simply a whimp?
Which do you prefer to do as a surgeon, and if you get a better "hands on look" with the laparotomy, or does lapriscopic surgery provide a better look?
A side note . . .I am completely impressed by your resume, thank you for taking the time to help all of us, we are all in some state of panic or despair it seems when we come to this forum, either in limbo or just diagnosed, facing surgery, etc. Your taking YOUR time to help us, is so appreciated.
( 1-2 for anesthesia, 2 nurses or scrub techs, 2 surgeons). You are in about one of the safest, most controlled environments in the hospital.
akg
The goal is right ovary/tube removal, and looking around to see if anything suspicious appears, that wasn't seen on MRI or ultra sound. Also a general look at the left ovary, and the simple cyst that appears there now.
I am done with childbearing, however I don't want to go through surgical menopause at 39, so we are going to try to keep my left ovary going for as long as possible. Ironically, the left ovary was the one that was of concern 18 months ago, with a borderline tumor called a "mucinous cystadenoma with focal borderline features". But now that is the one that will remain, with regular follow up. Even with the rupture, the chance of it returning and being cancerous is very low (less than 1% is what I was told). I hope to get to age 45 before having a full hysterectomy.
It sounds to me that laparoscopy is what you would recommend in my circumstance. It sounds like general anesthesia is preferable for either surgery, whether it be laparoscopy or laparotomy.
I'm so bummed, I so very much wanted a spinal! Sigh . . . I need to just get over this fear. Your comment about being well attended to, also helps.
Thank you for all this information and for your time! Do you ever do second opinions by phone, where you are paid for your time? If so, sign me up. I know my surgeon is exceptional, I just believe in second opinions, and having all my pesky questions answered is worth so much.
THANK YOU AGAIN!
I just had laprascopy. I was very apprehensive to general anastesia (almost canceled surger because of my fears relating to gen an. I went through with it realized I would risk rather than dealing with the pain. I was not bad at all, they took real care of me and general ana did not cause any problems except for a mild sore throat after. I will keep you in my prayers that is what got me to go for it. Good luck to you and god bless.
lhamilton
An Update on me, I did go for the general, and lived to tell about it. THANK YOU for the guidance. I also chose laparotomy, and am in pain now! But will recover.
Can I ask a follow up question?
During my surgery, the right ovary/tube and appendix were removed. My lymph nodes were felt, and the omentum biopsied, and a good washing was done.
Final path is not in, but preliminarily the right ovary contained a cyst, with three small cysts. It was like the tumor that was on the left ovary 19 months ago, a MUCUNOUS CYSTADENOMA WITH FOCAL BORDERLINE FEATURES.
The surgeon said it was "weird" it was filled with toothpaste consistency type fluid.
I am used to being "odd" medically, and I'm wondering what borderline really means.
WHAT DOES IT MEAN? If I google it, I get anything from "60% survival rate after 10 years" to "borderline is really just benign and borderline category should be eliminated."
I was told no other treatment is necessary, except follow up for 6 months, and eventually a hysterectomy if this keeps reoccuring. Nothing radical, which I appreciated.
QUESTION: What does borderline really mean?
THANK YOU if you have the time to answer.
Borderline ovarian tumor is a category of malignancy that is usually cured by surgical removal. It is a malignancy because in some people, these tumors can spread, recur, and yes, in some very rare cases, cause death. Luckily , because these tumors are very slow growing, they are discovered at stage I and are cured by surgery.
I agree with your doctor. You are all set. thanks for the follow up. take care