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new technique for temporary ovarian suspensionemporarily displacing the ovaries anterior to the uterus facilitates pelvic side wall access inhe laparoscopic treatment of endometriosisynne Chapman, MB BS; Malini Sharma, MB BS; Panos Papalampros, MD; Pietro Gambadauro, MD; Dimitris Polyzos, MD;

ikolaos Papadopoulos, MD; Adam Magos, MD

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roblem: limited accessreatment of endometriosis that affects

he pelvic side walls can present opera-ive difficulties for the laparoscopic sur-eon because of poor access. It is usuallyecessary to elevate the ovaries and fal-

opian tubes not only to gain access butlso to identify important anatomictructures before surgery. Although arasper can be used to retract the ad-exa, this tactic sacrifices an instru-ent and necessitates the use of addi-

ional ports. Also, the grasper that issed to hold the adnexum may itselfbstruct the operative view and access,nd grasping delicate ovarian tissueould lead to unnecessary bleeding andearing.

ur solutiono overcome these difficulties, we de-ised a simple technique to suspend bothvaries simultaneously and to allow anptimum approach to the ovarian fos-ae. The idea for our technique devel-ped after we tried a method of unilat-

rom the Minimally Invasive Therapy Unitnd Endoscopy Training Center, Royal Freeospital, London, England.

eceived June 28, 2006; accepted Feb. 5,007.

eprints: Lynne Chapman, MB, BS, Universityepartment of Obstetrics and Gynaecology,he Royal Free Hospital, Pond St,ampstead, London, UK NW3 2QG;

ynnechapman2000@yahoo.co.uk.

002-9378/$32.002007 Mosby, Inc. All rights reserved.

oi: 10.1016/j.ajog.2007.02.006

VIDEOClick “Add-On” under the title ofthis article in the Table of Contents.

Download the full-length

darticle at www.AJOG.org.

94.e1 American Journal of Obstetrics & Gynecol

ral ovarian suspension that had beenescribed by Cutner et al.1

With the uterus anteverted, a 75-cm/0 polyglactin suture with a curved nee-le was introduced through the left loweruadrant port and passed first throughhe right ovary and then through the leftvary, taking deep bites of the ovarianissue (Figure 1). The suture was pulledo the outside through the left lateralort, and a Roeder knot was tied andhen pushed in. After the uterus was ret-overted, the ovaries were approximatelyidline over its anterior surface (Figuresand 3). Once tied, the free end of the

uture was cut, and the uterus was ante-erted, which caused both ovaries to beeld in the uterovesical fold away fromhe ovarian fossae. With the ovaries sus-ended, pelvic wall surgery could pro-eed (Figure 4). After the procedure, theoeder knot was released, and the ova-

ies were restored to their anatomic po-ition (Figure 5). Hemostasis was en-ured, and icodextrin solution (4%) waseft in situ to help prevent adhesions.

This technique alters the course of thereters along the pelvic side wall more

han when the ovaries are lifted withrasping forceps. For this reason, thereters must be traced before surgery; if

his proves difficult, the pelvic side walleritoneum should be opened to identifyhem retroperitoneally.

valuating the proceduree studied our method of bilateral ovar-

an suspension (BOS) in 15 women un-

The adnexa frequently hinder access tosurgery for endometriosis. An innovative t

Cite this article as: Chapman L, Sharma M, Pappoulos N, Magos A. A new technique for tempo2007;196:494.e1-494.e3.

erwent laparoscopic surgery for pelvic

ogy MAY 2007

ide wall endometriosis. The partici-ants were between 24 and 47 years oldmean, 37.2 years), and 7 women wereulliparous. All patients had a history ofelvic pain symptoms (eg, dysmenor-

FIGURE 1

he suture is passed through the right ovary.

FIGURE 2

fter the suture is passed through the left ovary,t is pulled out, and an extracorporeal knot isied.

pelvic side wall during laparoscopicc can facilitate dissection.

pros P, Gambadouro P, Polyzos D, Papado-ovarian suspension. Am J Obstet Gynecol

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www.AJOG.org Surgeon’s Corner

hea, dyspareunia); 6 patients were alsoxperiencing infertility. Pelvic ultra-ound imaging showed ovarian cysts thatere consistent with a diagnosis of endo-etriomas in 2 cases. Four of the women

ad a diagnosis of endometriosis thatad been made on a previous

aparoscopy.All the laparoscopic procedures were

erformed with general anesthesia andstandard 3-portal laparoscopy. The

varies were mobilized, and any endo-etriomas were excised. BOS was then

erformed. All laparoscopies were com-leted successfully. With the use of theevised scoring system that was devel-ped by the American Society for Re-roductive Medicine, 8 patients wereiagnosed with minimal/mild endo-etriosis; 4 patients were diagnosedith moderate endometriosis, and 3 pa-

ients were diagnosed with severe dis-ase. Seven patients required ovariolysiso mobilize their ovaries, and the endo-

etriomas were excised.BOS was performed without difficulty

n all cases and added only a few minuteso the total operating time. None of theutures tore out, and the view of theelvic side wall was judged to be excel-

ent in all cases. It was noticed that theourse of the ureters was altered by theaneuver such that the ureters were

ulled anteriorly away from the inter-al iliac vessels (Figure 6). All patientsent on to have endometriotic depos-

ts ablated electrosurgically, and 11 pa-ients underwent excision biopsy of theide wall peritoneum. Histologic find-ngs confirmed endometriosis in all

FIGURE 6

he course of the ureter A, before and B, after

MAY 2007 America

ases. Bleeding from the suture site af-er removal of the ovarian sutures was

inimal; in no case was it necessary topply a hemostatic suture.

useful optionvarian suspension, usually to the ante-

ior abdominal wall, is not a new con-ept. It was first reported in 1970 foromen who were about to receive radio-

herapy for Hodgkin’s disease and wasone through a laparotomy incision.2

varian transposition in young woment the time of Wertheim’s hysterectomyas been commonplace for manyears.3,4 The advent of laparoscopic sur-ery has made it possible to performvarian transposition endoscopically,nd several recent reports have describedaparoscopic ovariopexy or transposi-ion as a means of protecting the ovariesrom subsequent pelvic irradiation for

alignancy.5 For instance, a case reportrom our unit described a young womanhose ovaries were elevated onto theelvic brim before she underwent radio-herapy for medulloblastoma. To ac-omplish this, the ovarian ligament wasivided to create a more mobile pedicleefore it was secured laterally over thesoas muscle.6

Another technique has been advocatedecently as a means of reducing postoper-tive ovarian adhesions. Here the ovari-pexy was performed by the introductionf a straightened ski needle laterallyhrough the anterior abdominal wall andhen through the ovary close to the ovarianigament before it was passed back through

rian suspension.

FIGURE 3

he slip knot is pushed in with a pusher, and thevaries are gently approximated over the ante-ior surface of the uterus at the same time theterus is anteverted.

FIGURE 4

ith the uterus anteverted, the ovaries are sus-ended away from the operative site.

FIGURE 5

he ovaries are restored to their normal restingosition at the end of surgery after the BOSuture is removed.

ova

n Journal of Obstetrics & Gynecology 494.e2

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4

he abdominal wall near the introductionoint. A knot was tied extracorporeallyver a compress to bring the medial sur-ace of the ovary up to the anterior pelvicall.6 The suture was cut after 5-7 days to

elease the ovary.These methods were described as aeans of suspending the ovaries after

urgery. However, temporary ovarianuspension has a role intraoperativelys well. At the same time that Abuzeidt al7 described their procedure forostoperative ovarian suspension,utner et al1 published a very similar

echnique for intraoperative suspen-ion to facilitate surgery for advanced

he editors welcome submissions tohis section. Please see the Information

or Authors at www.AJOG.org. a

94.e3 American Journal of Obstetrics & Gynecol

ndometriosis, with the use of 1 sutureer ovary. Our technique differs fromhat of Cutner et al in that both ovariesre suspended simultaneously, whichs an advantage, because pelvic sideall endometriosis is often bilateral

nd no suture marks are left on thekin. It is possible to suture the ovarieso the abdominal side wall, but this re-uires 2 rather than 1 suture, as withOS.Any laparoscopic surgeon who treats

ndometriosis appreciates that it is oftenwkward to operate on the pelvic sidealls because of the position of the ad-exa. The ability to temporarily elevate

he adnexa without having to rely onontinuous instrumentation offers obvi-us benefits. In our experience, tempo-ary BOS facilitates pelvic side wall sur-ery. We now use this technique in allatients who require treatment to this

rea. f L

ogy MAY 2007

EFERENCES. Cutner AS, Lazanakis MS, Saridogan E.aparoscopic ovarian suspension to facilitateurgery for advanced endometriosis. Fertil Steril004;82;702-4.. Ray GR, Trueblood HW, Enright LP, KaplanS, Nelson TS. Oophoropexy: a means of pre-erving ovarian function following pelvic mega-oltage radiotherapy for Hodgkin’s disease. Ra-iology 1970;96:175-80.. Haie-Meder C, Mlika-Cabanne N, Michel G,t al. Radiotherapy after ovarian transposition:varian function and fertility preservation. Int Jadiat Oncol Biol Phys 1993;25:419-24.. Anderson B, LaPolla J, Turner D, Chapman, Buller R. Ovarian transposition in cervicalancer. Gynecol Oncol 1993;49:206-14.. Tulandi T, Al-Took S. Laparoscopic ovarianuspension before irradiation. Fertil Steril998;70:381-3.. Hart R, Sawyer E, Magos A. Case report ofvarian transposition and review of the litera-ure. Gynaecol Endosc 1999;8:51-4.. Abuzeid MI, Ashraf M, Shamma FN. Tempo-ary ovarian suspension at laparoscopy for pre-ention of adhesions. J Am Assoc Gynecol

aparosc 2002;9:98-102.