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Keywords:

  • Adolescent gynaecology;
  • minimal access surgery

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

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


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

Adolescence is the period of development between the onset of puberty and adulthood. It is marked by the appearance of secondary sex characteristics, ends with the completion of physical growth and emotional maturity and usually spans from 10 to 19 years of age.1 Gynaecological problems in this age group may arise due to congenital anomalies or may be due to common gynaecological conditions merely occurring in a younger age group.

Compared with laparotomy, laparoscopy is associated with less bleeding, adhesions and postoperative pain, faster recovery and a better cosmetic result.2 These benefits are even more valuable in an adolescent population. Faster recovery allows patients to return to their schooling, while less adhesions formation may reduce future fertility issues.

The place of diagnostic laparoscopy

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

The diagnosis of gynaecological pathology in this group is challenging due to the anxiety and embarrassment of the women as well as diagnostic limitations and, in some cases, poor compliance.

In recent years, the accuracy of diagnosis of adolescent gynaecological conditions—and in particular of müllerian duct anomalies—has improved with the introduction of advanced imaging technologies including ultrasound and magnetic resonance imaging (MRI) with the addition of contrast material.3,4 Multidisciplinary teams based in tertiary referral centres usually comprise adolescent gynaecologists, fertility experts, geneticists, endocrinologists, paediatricians, psychologists, specialist nurses and endoscopic surgeons. Such centres with a broad expertise have enabled diagnostic laparoscopy to be largely replaced with less invasive investigations. This allows for a full discussion prior to definitive surgery being carried out. The alternative of two operations, one for diagnosis and the other for treatment, increases the potential risks to the women.

Laparoscopic techniques and instruments

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

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 account when deciding to operate on an adult play a very important role in planning surgery on an adolescent. Laparoscopy is generally contraindicated in haemodynamically unstable patients or in those with known severe abdominal adhesions secondary to previous open surgery. Obtaining a pneumoperitoneum, particularly in young thin individuals, is not without risks. These include extraperitoneal collection of gas and visceral or vascular injury, which occasionally can significantly complicate the intended procedure and compromise the women’s well-being.

Patient position for laparoscopy in the adolescent does not differ from that used in adults. Young women are placed in Lloyd-Davies position and a Foley’s catheter is inserted into the bladder to minimise the risk of bladder injury and aid with pelvic visualisation. Vaginal examination and uterine manipulation are avoided in adolescent girls who have not been sexually active, unless required during the process of the planned procedure. Cases of significant pelvic dissection are given preoperative bowel preparation to enhance vision.

In adolescent and paediatric patients, the technique for obtaining a pneumoperitoneum may differ from the standard techniques applied to adult women. The risks of vascular injury are greater in the very young or very thin patient where the short distance between the anterior abdominal wall and the major retroperitoneal vascular structures can lead to serious inadvertent injuries with the Verres needle. In this group of patients, the Hasson surgical entry technique should be considered, although there has been no good evidence to suggest that the latter entry technique is superior or inferior to the former type of entry.7

Where there is a risk of pelvic adhesions or a large abdominal mass, then Palmer’s point entry (the left subcostal area in the midclavicular line) can be used. The spleen should be palpated for prior to insertion of the Verres needle and one should insert a nasogastric tube to reduce the chance of perforating an inflated stomach.8

The abdomen is insufflated with carbon dioxide to create adequate distension. The overall volume of gas introduced is variable due to patient size, distensibility of the abdominal wall and amount of muscle relaxant drugs used. Carbon dioxide flow ceases when the intra-abdominal pressure reaches a preset value. This is usually 20 mmHg for grown-up adolescents and 12–15 mmHg for young thin adolescents or older children. Younger children may require lower pressure setting at 8–12 mmHg.6

Additional ports must be placed under direct vision so as to avoid injury to viscera or vessels. Ports should be placed either very lateral or medial so as to avoid the inferior epigastric vessels. Identification of abdominal wall vessels is generally easy in this population due to lack of excess abdominal adipose tissue, which facilitates their transillumination.

At the end of the procedure, ports are removed under direct vision and lateral ports ≥10 mm are formally closed to reduce the risk of incisional hernia. Closure of skin incisions is usually accomplished with an absorbable suture material or a special glue.

Gynaecological conditions in the adolescent

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

Procedures can be broadly divided into three groups: procedures to treat congenital anomalies, procedures to treat other gynaecological pathology that happen to occur in this age group and procedures to preserve ovarian function.

Procedures to treat congenital anomalies

Müllerian anomalies and disorders of sex development (DSD, previously known as intersex) are commonly first diagnosed and managed in adolescence. DSD that may require laparoscopic treatment include conditions where the gonads are at risk of becoming malignant and need removal and conditions where the laparoscopic creation of a neovagina might be required. Müllerian anomalies may require surgery at adolescence if they cause menstrual obstruction or in case of uterine and vaginal agenesis to create a neovagina.

Procedures to treat other gynaecological pathology

Certain gynaecological conditions, such as ovarian pathology and endometriosis, are common indications for laparoscopic treatment in adulthood and may also present, although more rarely, in adolescence. Also, as the age of first sexual intercourse decreases, ectopic pregnancy and pelvic inflammatory disease are diagnosed more often in this age group.

Procedures to preserve ovarian function

In cases of rare radiosensitive pelvic tumours where radiation will result in ovarian failure, laparoscopic surgery may be of benefit in fixing the ovaries away from the field of radiation.

Procedures used in the treatment of congenital anomalies

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

Gonadectomy

Gonadectomy is indicated in cases of DSD where a phenotypically female patient has either an XY karyotype or a fragment of a Y chromosome; conditions include complete androgen insensitivity syndrome (CAIS), Swyer syndrome and mosaic Turner’s syndrome. The indication for removal of the gonads is a potential malignancy risk, and the magnitude of this varies from approximately a 5% lifetime risk for structurally normal testes in CAIS to 30% for dysgenetic gonads as in Swyer syndrome.9,10

The timing of the gonadectomy is dependent on the underlying diagnosis, which determines the magnitude of the malignancy risk, the potential for useful hormone production by the gonad and the risk of progressive virilisation in a female patient.

In women with Swyer and Turner’s syndrome, every effort should be made to preserve the uterus; however small this may appear, as there is potential for improved uterine size with estrogen stimulation and the possibility of pregnancy with egg donation. Fallopian tubes, however, often need to be removed at the time of gonadectomy to ensure complete excision of all gonadal tissue. It is therefore important that the possibility of a salpingectomy is discussed with the patient prior to surgery and documented on the consent form. The technique to remove the gonads is otherwise the same as a laparoscopic oophorectomy.11

Difficulties may arise in cases of CAIS where the gonads may be anywhere along the line of testicular descent from high up in the abdominal cavity to low down in the groin or labia. Accurate imaging of the gonads is an essential part of 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 creation of a neovagina

The most common cause of vaginal agenesis is Mayer–Rokitansky–Kuster–Hauser syndrome. However, vaginal agenesis also occurs in DSD such as CAIS. The vagina in either condition is blind ending, and the vaginal length can vary from a shallow dimple to several centimetres. In addition, genital tract anomalies are associated with other complex conditions affecting the urinary and gastrointestinal tracts such as cloacal and anorectal anomalies.

Vaginal dilation should always be recommended as the first line of treatment in vaginal agenesis. The technique has few complications, as there are no anaesthetic and surgical risks. Reported success rates are up to 81%12 but those women who are unsuccessful with dilators will require surgical creation of a neovagina. The ideal time for intervention is at or after adolescence, and vaginal reconstruction procedures performed on infants and prepubertal girls almost always require further surgical revision. Deferring treatment not only allows the women herself to be involved in the decision making but also increases compliance with adjuvant dilation therapy that is required to prevent postoperative stenosis.

The Vecchietti and Davydov techniques for vaginal reconstruction have been widely practised throughout Europe and, over the past decade, have been introduced within the UK.13 These operations were initially devised as open operative procedures, but advances in minimal access techniques allow both procedures to be performed laparoscopically. Recent short-term reports have demonstrated low complication rates with an encouraging level of satisfactory sexual function.14,15

Choosing the right operation is paramount to success.16 Prior abdominal surgery such as bladder reconstruction in women with multiple complex anomalies of the genitourinary tract will mean that laparoscopic techniques such as the Vecchietti and the Davydov procedures are hazardous and should not be attempted. Adjuvant therapy such as vaginal dilation treatment and psychological support can influence outcome and women satisfaction and should be available.

Obstructive müllerian anomalies

Congenital uterine anomalies are common, but the majority are asymptomatic and do not require treatment. However, certain anomalies may lead to menstrual obstruction, resulting in cyclical pain that usually first presents in the early adolescent years. Laparoscopic surgery is the treatment of choice in two specific situations: an obstructed uterine horn and cervical agenesis.

Laparoscopic treatment of an obstructed uterine horn

Delay in diagnosis is a major feature of this condition due to the presence of normal menstruation from the unobstructed side. Often individuals will have endured months of worsening cyclical pain before the diagnosis is confirmed.17 MRI reported by an experienced radiologist can provide useful information on the level of obstruction, the degree of fusion of the uterine horns and associated abnormalities of the cervix and vagina. This will enable careful preoperative planning. An intravenous urogram should also be performed as part of the preoperative assessment to assess the course and number of ureters, as associated renal anomalies occur in approximately 30% of cases. Gonadotrophin-releasing hormone analogues are often used once the diagnosis is confirmed and prior to surgery to suppress menstruation and alleviate pain. They also facilitate surgery by reducing uterine size and vascularity and the extent of any endometriosis due to retrograde menstruation.18 Nowadays, there is little place for open surgery for this condition. A four-port laparoscopy is performed, and after identification of the ipsilateral ureter, if present, the ovarian ligament is divided, followed by the dissection of the uterovesical fold. The connection between the two horns is then identified, and the obstructed horn excised using the harmonic scalpel. The raw aspect of the functioning uterus is oversewn, and the rudimentary uterus is morcelated to allow removal from the abdominal cavity through a 15-mm abdominal port.

Traditional surgical treatment such as metroplasty is impossible in this situation. The obstructed horn is often vestigial with no normal cervix and may be widely separated from the normally functioning horn. Anecdotally, surgical attempts have been made to establish drainage through the normally functioning horn, but these re-obstruct and will also damage the integrity of the other horn. There are no data in the literature on the fertility outcomes of this specific group of anomalies. Available large series of metroplasty in the literature for duplication anomalies do not include women presenting with an obstructive rudimentary horn but only those presenting later in life with recurrent miscarriage and preterm delivery.19 However, it seems logical that removal of the obstructed horn only leaves an undisturbed unicornuate uterus and so this is currently considered the surgical treatment of choice as it alleviates symptoms while conserving fertility. There are, however, little data available on future fertility for this patient group, and it is essential that units operating on this group of young women carefully record and publish their outcome data.

Cervical agenesis

Congenital absence of the cervix is a rare condition with an approximate incidence of 1 in 80 000 births. Presentation is usually with primary amenorrhoea and cyclical lower abdominal pain. Endometriosis or pelvic infection may result from the chronic haematometra. As with other cases of müllerian anomalies, MRI is an important diagnostic tool that will give information on the level of obstruction and the size of the body of the uterus. Treatment options for this condition have evolved over time. In the past, attempts at canalisation of the atretic cervix with simultaneous vaginoplasty had been associated with peritonitis and fatal septic shock.20 Thus, hysterectomy with ovarian conservation was the recommended choice for many years.

Over the last decade, there has been a renewed interest in conservative surgical treatment. Two large series of participants totalling 36 women treated for this rare müllerian anomaly with uterovaginal anastomosis have been reported.21,22 The first reported laparoscopic surgical uterovaginal anastomosis for a women with cervical agenesis was performed in our department in 2005.23 In this technique, following successful pneumoperitoneum and insertion of four ports, the peritoneum at the lower edge of the uterus is incised and the bladder is reflected. The uterine fundus is incised in a sagittal direction and the incision is extended until the cavity is breached. A laparoscopic probe is then inserted in the uterine cavity to identify the level of the obstruction. This will determine the point at which the uterus will be opened to perform the anastomosis. The caudal portion of the obstruction is identified in a similar fashion by using a second probe that is inserted vaginally. Once the levels of anastomosis have been defined, a size 12 Foley silastic catheter is passed from the vagina and guided laparoscopically into the uterus. The upper vagina and lower uterus are then sutured together over the catheter. The catheter is sutured in place in the new tract to maintain patency and removed at hysteroscopy approximately 1 month later.

Subsequently, a series of 12 cases of laparoscopically assisted uterovestibular anastomoses has been reported.24 All procedures were completed successfully, all women experienced regular menstruation postoperatively and six women reported sexual intercourse without difficulties. There are as yet no reported cases of pregnancy following laparoscopic treatment for cervical agenesis.

Endometriosis

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

The prevalence of endometriosis has been reported to be between 17 and 73% in adolescents with chronic pelvic pain25 and between 69.6 and 73% in those unresponsive to nonsteroidal anti-inflammatory drugs and oral contraceptive pills.26,27 There is often a significant delay in diagnosing endometriosis in adolescent girls. The younger the girl at the time of onset of symptoms, the longer the time period is to diagnosis. Delays are usually justified as laparoscopy in young girls presenting with pelvic pain should be performed after thorough assessment and only after unsuccessful medical management. However, when endometriosis is diagnosed in this age group, it tends to be at earlier disease stages,27 although stages III and IV have also been described.28 There are limited data regarding the appropriate management of severe endometriosis in adolescence. However, laparoscopic excisional surgery appears to be relatively safe with good short-term results.27,29 There are no reports on long-term follow up of recurrence of disease or need for repeat surgery.

Ovarian transposition prior to pelvic irradiation

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

Ovarian transposition is a surgical technique used to protect ovaries from the risk of ovarian failure during pelvic irradiation.30 Although initially described as an open technique, it has recently evolved into a laparoscopic procedure. The most commonly seen radiosensitive malignancies in adolescents are pelvic sarcomas and Hodgkin’s lymphomas. The site of the malignancy and the planned irradiation field will determine the location to fix the transposed ovaries.31,32 Where possible, the ovaries are merely fixed medially or laterally without interfering with their blood supply or the integrity of the fallopian tubes with the uterus. A repeat laparoscopy is then performed after completion of the course of radiotherapy to reposition the ovary to its original site.

In cases where the ovaries require complete laparoscopic transposition from the pelvis, the ovarian ligament and attachment of the fallopian tube to the uterus are divided and the infundibulopelvic ligament skeletalised to allow mobilisation of the ovary. Mobilisation must be adequate to allow the ovary to reach the subcostal margin, avoiding tension on or torsion of the pedicle. In this situation, the ovaries are not replaced at a later date.

Adnexal mass

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

The majority of adnexal masses in the paediatric and adolescent population are simple functional cysts and benign ovarian tumours such as dermoids.33 However, it is important to remember that nonepithelial malignant tumours, such as dysgerminomas and choriocarcinomas, do present in this age group.34 Correct diagnosis can be aided with the use of ultrasound, colour Doppler assessment, MRI and tumour markers. However, not infrequently the diagnosis is made during an emergency laparoscopic or open surgical procedure.

Simple ovarian cysts can be managed conservatively unless they cause significant pain. Operative intervention is also warranted if torsion or malignancy is suspected. In the majority of cases, treatment can be performed laparoscopically, bearing in mind that cystectomy is preferred to fenestration due to a lower recurrence rate.

Ovarian torsion

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

Ovarian torsion is a gynaecological emergency. Delay in diagnosis can result in infarction and necrosis of the ovary and fallopian tube and necessitates adnexal removal. Torsion is generally unilateral but can involve the contralateral ovary or adnexum. Although rare, the potential remains for sequential torsion, with devastating effects.35 There are many reported cases of torsion of normal adnexa in prepubescent and adolescent girls, and this has been attributed to excessively mobile mesovaria or fallopian tubes, resulting from congenitally long ovarian ligaments.36

The traditional management of ovarian torsion has been laparotomy and oophorectomy if the ovary was nonviable. This procedure is, however, performed more appropriately laparoscopically. Unfortunately, the management of ovarian torsion is often complicated by misdiagnosis. The most common cause of pelvic pain in children is appendicitis, and ovarian torsion may only be found at an exploratory laparotomy. Even if the diagnosis is correctly suspected, there has been a reluctance to perform laparoscopy in children. However, with the development of new instrumentation appropriate for children, laparoscopic diagnosis and treatment have become well established and should be the standard surgical intervention.

Children who have suffered from ovarian torsion may be at increased risk of repetitive event of either the same ovary (if preserved and not fixed) or the contralateral ovary. In the case of a unilateral torsion where the ovary is nonviable, it is essential to consider the future of the single remaining ovary to secure future fertility. Ovariopexy, performed either at the time of initial surgery or at a later date, is likely to reduce the risk of future torsion, although it may interfere with fallopian tube function.37

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References

Laparoscopic procedures performed in adolescent girls are a relatively new addition to the field of adolescent gynaecology. Gynaecologists operating laparoscopically on children and adolescents should be competent at the procedures they carry out. This is particularly so when operating on children with complex congenital anomalies or advanced endometriosis. In this group, the best surgical results can only be achieved after careful preoperative planning by a multidisciplinary team.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. The place of diagnostic laparoscopy
  5. Laparoscopic techniques and instruments
  6. Gynaecological conditions in the adolescent
  7. Procedures used in the treatment of congenital anomalies
  8. Endometriosis
  9. Ovarian transposition prior to pelvic irradiation
  10. Adnexal mass
  11. Ovarian torsion
  12. Conclusions
  13. Disclosure of interests
  14. Contribution to authorship
  15. Details of ethics approval
  16. Funding
  17. References