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Top definition. Sep 4 Word of the Day. In American democracywhen the majority party has enough votes to pass populist legislation, party leaders deate a scapegoat who will refuse to vote with the party thereby killing the legislation. The opposition is otherwise inexplicable and typically comes from someone who is safe or not up for re-election. This allows for maximum diffusion of responsibility.


Abha Sinha, Ayman A. Although ovarian mature cystic teratomas are the commonest adnexal masses occurring in premenopausal women, there are many challenges faced by gynecologists on deciding upon the best surgical management. There is uncertainty, lack of consensus, and variation in surgical practices. This paper critically analyzes various surgical approaches and techniques used to treat these cysts in an attempt to outline a unified guidance. The two authors conducted the search independently. The laparoscopic approach is generally considered to be the gold standard for the management.

Oophorectomy should be the standard operation except in younger women with a single small cyst. The risk of chemical peritonitis after contents spillage is extremely rare and can certainly be overcome with thorough peritoneal lavage using warmed fluid.

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There is a place for surveillance in some selected cases. Adnexal masses are commonly encountered in gynecologic practice and often present both diagnostic and management dilemmas.

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In asymptomatic women, whether premenopausal or postmenopausal, with pelvic masses including ovarian mature cystic teratoma, transvaginal ultrasound scan TVS is the imaging modality of choice. No alternative imaging modality has demonstrated sufficient superiority to TVS to justify its routine use [ 1 ].

There are controversies amongst gynecologists as regards the best surgical approach to manage ovarian mature cystic teratoma.

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There is paucity of well-deed comparative clinical trials to define the criteria as how to select a particular technique, and consequently there are variations in surgical practices. Various approaches and procedures were employed; however, laparoscopic approach has become the most popular and widely practiced in the past two decades. In this paper, we critically analyze various surgical approaches and techniques used to deal with ovarian mature cystic teratoma. Further, we suggest guidance for management of these lesions based on the best available evidence to help both women and gynecologists make suitable individualized decisions.

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There are several differences in practice as regards surgical management of ovarian mature cystic teratoma. These relate to the following: 1 Surgical approach: laparoscopy versus laparotomy. There is a consensus amongst the investigators that operative laparoscopy is the method of choice for removing ovarian mature cystic teratoma as it offers the advantages of less intraoperative blood loss, reduced postoperative pain, shorter hospital stay, fewer postoperative adhesions, and better cosmetic result.

In the last two decades, two randomized controlled trials RCT including 42 laparoscopic operations versus 42 laparotomy operations [ 49 ] and nine retrospective comparative studies including laparoscopic operations versus laparotomy operations for ovarian mature cystic teratoma highlighted the superiority of the laparoscopic approach over laparotomy [ 10 — 18 ].

A systematic review of six RCT compared the laparoscopic approach with laparotomy in a total of women undergoing removal of ovarian cysts of various natures. Laparoscopy was associated with reduced febrile morbidity, postoperative pain, postoperative complications, overall cost, and earlier discharge from hospital [ 19 ].

Nonetheless, the laparoscopic approach was ificantly associated with longer operating time [ 1417 ] and higher contents spillage rate [ 1416 ]. It was reported that contents spillage occurred in one-third of the laparoscopic cases and it was particularly associated with larger cysts and also in those cases treated with cystectomy [ 14 ].

The guidelines of The Royal College of Obstetricians and Gynecologists RCOG in the UK recommend that when surgery is indicated, a laparoscopic approach be generally considered to be the gold standard for the management of all benign ovarian masses. Laparoscopic management is also cost-effective because of the associated earlier discharge from hospital and return to work.

In the presence of large masses with solid components such as large mature cystic teratoma laparotomy may be appropriate. The maximum cyst size above which laparotomy should be considered is controversial [ 2 ]. In addition, the RCOG recommends that a surgeon with suitable experience and appropriate equipment should undertake laparoscopic management of benign ovarian cysts.

A decision should be made after careful clinical assessment and counselling considering the above factors. Where appropriately trained staff and equipment are unavailable, consideration should be given to referral to another provider [ 2 ]. There is no data in the literature as regards the best procedure. Howard, in a case series 8 laparoscopic versus 12 laparotomydocumented that fertility status influenced the choice of cystectomy or oophorectomy as the surgical procedure for ovarian mature cystic teratoma [ 18 ].

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There was no associated morbidity with spillage [ 17 ]. In a case series of 56 women with ovarian mature cystic teratoma treated laparoscopically with 48 undergoing cystectomyChapron et al. Another noncomparative study, including 99 women with ovarian mature cystic teratoma treated by ovarian cystectomy through laparotomy, observed women for 5 years. Of the 99 women, 18 had bilateral mature cystic teratoma and 10 had multiple teratomas in a single ovary.

Two women developed malignant germ cell neoplasms, and three developed a recurrent mature cystic teratoma in an ovary from which a teratoma was ly removed. Bilateral or multiple mature cystic teratomas were present at the initial operation in four out of these five women. The authors suggested that women with bilateral or multiple ovarian mature cystic teratoma may be at higher risk of recurrence and may have a greater tendency to develop future ovarian germ cell neoplasms [ 22 ]. The RCOG recommends that the possibility of removing an ovary should be discussed with the woman preoperatively.

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This discussion should be in the context of oophorectomy being either an expected or unexpected part of the procedure. Ovarian cystectomy may be the technique of choice in younger women unless the patient chooses oophorectomy. Oophorectomy should be the standard operation in postmenopausal women and in perimenopausal women with multiple cysts in the same ovary or with large ovarian mature cystic teratoma where there is not much ovarian tissue to conserve [ 1822 ].

Chemical peritonitis, in case of spillage of ovarian mature cystic teratoma contents, is rare but difficult to treat. The spillage of contents is ificantly higher in laparoscopic approach when compared with laparotomy. Nevertheless, there is a consensus amongst investigators that spillage does not lead to short or long term complications such as severe chemical peritonitis or persistent pelvic pain if a liberal peritoneal lavage is carried out at the end of the procedure with skimming of the floating debris with suction tube until clear [ 16172125 — 28 ].

In fact, it could be argued that cyst contents spillage is easier and more efficiently treated when it occurs during laparoscopy rather than laparotomy because of the better exposure of the Pouch of Douglas and the feasibility of thorough peritoneal lavage to ensure minimal residues from spillage.

In Albini et al. Similar findings were also stated in two recent retrospective studies including laparoscopic versus laparotomy operations.

Various techniques were used to reduce the spillage rate and the potential consequent chemical peritonitis. Three reports recommended the routine intraoperative use of an endoscopic retrieval bag. The authors either operated in the bag or exteriorized the sac intact in the bag [ 212327 ]. Morelli et al. Kruschinski et al. In 79 cases undergoing cystectomy, there were only three cases of cyst rupture but it was possible to avoid spillage by closing the lesion with a clamp and continuing the enucleation of the teratoma during a lift-laparoscopic operation.

This technique involves using a reusable abdominal wall retraction system that allows the laparoscopic viewing of the abdomen to be combined with operation methods using conventional instruments. Raising the abdominal wall mechanically creates the working space required for the laparoscopic operation and flexible valve-free trocars are used allowing the introduction of both conventional and laparoscopic instruments simultaneously [ 24 ].

This technique is not very popular in Europe and Western Hemisphere Mature aa female is a possible option in resource poor settings. RCOG recommends that spillage of cyst contents should be avoided where possible as preoperative and intraoperative assessment cannot absolutely preclude malignancy. Consideration should be given to the use of a tissue bag to avoid peritoneal spill of cystic contents.

If inadvertent spillage does occur, meticulous peritoneal lavage of the peritoneal cavity should be performed using large amounts of warmed fluid. Use of cold irrigation fluid may not only cause hypothermia, but will also make retrieval of the contents more challenging by solidifying the fat-rich contents. Any solid content should be removed using an appropriate bag [ 2 ].

Some investigators described techniques to maximize ovarian tissues preservation during ovarian cystectomy for mature cystic teratoma. Zupi et al. However, the credibility of this study is questioned due to the fact that it included mainly small cysts with mean diameter of 5. A RCT assessed the mesial-side ovarian incision for laparoscopic cystectomy as an ovarian tissue-preserving technique.

The mesial side is the anterior hilar margin of the ovary where the tubal fimbriae are closely applied to the tubal pole of the ovary.

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Women in both groups had similar characteristics in terms of age, cyst size, and basal hormone levels. The mesial-side incision technique was associated with ificantly higher ovarian reserve in terms of lower FSH values and higher basal antral follicleovarian diameter, and peak systolic velocity.

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Moreover, this technique reduced operative time as there is faster identification of cleavage plane, easier enucleation, and less need for haemostasis [ 31 ]. With the standard laparoscopic cystectomy, Candiani et al. This was because of the loss of ovarian stromal tissue [ 33 ].

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Li et al. Various exteriorization techniques were described in the literature for extraction of ovarian mature cystic teratoma following laparoscopy. Before the modern advances in laparoscopic surgery, colpotomy was used for specimen exteriorization with conflicting. Prophylactic antibiotics were used in colpotomy group since it is difficult to sterilize vaginal epithelium [ 36 ]. The standard technique for exteriorization is through the umbilical port.

It involves placing the cyst after removal in a laparoscopic tissue retrieval bag, which is partially extracted through the umbilical incision. This was followed by suction irrigation and forceps removal of the contents until the collapsed cyst could be removed in the pouch [ 26 ].

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The RCOG recommends that where possible removal of benign ovarian masses should be via the umbilical port. This in less postoperative pain and a quicker retrieval time than when using lateral ports of the same size. Avoidance of extending accessory ports is beneficial in reducing postoperative pain, as well as reducing incidence of incisional hernia and incidence of epigastric vessel injury.

It also le to improved cosmesis [ 2 ]. Ovarian mature cystic teratomas grow over time, increasing the risk of pain and ovarian accidents. Therefore, surgical management is usually appropriate. There is no evidence-based consensus on the size above which surgical management should be considered. The risk of torsion is higher in larger teratomas [ 39 ].

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Caspi et al. Although the TVS appearance of immature teratomas is nonspecific, the tumors are typically heterogeneous with scattered coarse calcifications and large irregular solid components.

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