q2000 Blackwell Science Ltd Gynaecological Endoscopy 2000 9, 51±54 51

Use of the SAND balloon catheter for the laparoscopicsurgery of benign ovarian cysts

Takashi Yamada, Yukiko Okamoto and Hajime Kasamatsu

Department of Obstetrics and Gynecology, Hirakata City Hospital, Osaka, Japan

ABSTRACT

Objective We studied the advantages and disadvantages of using the newlydeveloped SAND balloon catheter for the laparoscopic treatment of benignovarian cysts and hydrosalpinx.Methods The SAND balloon catheter, which has two balloons at the tip, canhold and extend the ovarian cyst, which allows suction of the cystic fluid,and irrigation of the cystic cavity. Laparoscopic surgery using this catheterwas carried out in 36 cases of ovarian or uterine cysts, or hydrosalpinx (32patients).Results The cystic fluid in all 36 cases was successfully aspirated withoutgross identification of spillage. Adhesiolysis of the cyst was easily done bypulling the ovarian cyst with the SAND balloon catheter. None of the 36cysts ruptured during aspiration and irrigation. The balloon did not slideduring the procedure in any of the 36 cases. In 16 of the 32 patients whounderwent the laparoscopic procedure, a conservative cystectomy pro-cedure, in which only the cyst was excised, was performed. In the remaining16 patients, ooÈphorectomy was performed.Conclusions The SAND balloon catheter was extremely useful for aspiratingthe cystic fluid, and for the irrigation and excision of the cyst, during thelaparoscopic surgery of benign ovarian cysts.

Keywords

adhesiolysis, extracorporeal proce-dure, hydrosalpinx, laparoscopicsurgery, ovarian cyst, SAND ballooncatheter.

Correspondence

T. Yamada, Department of Pathology,Osaka Medical College, 2-7 Daigaku-machi,Takatsuki, Osaka 569-8686, Japan.

Accepted for publication 17 February 1999

INTRODUCTION

During laparoscopic surgery of ovarian cysts, it isoften necessary to grip and aspirate the cyst. In thisstudy, we studied the advantages and disadvantagesof using the new Hakko SAND balloon catheter,which was developed for use in the laparoscopic treat-ment of ovarian cysts. This catheter has two balloonsat the tip, which hold and extend the ovarian cyst,thereby allowing the suction and irrigation of cystic¯uid.

SUBJECTS AND METHODS

The laparoscopic procedures using the SAND ballooncatheter (Hakko Shoji, Tokyo, Japan; `SAND' derivedfrom `sandwich') were carried out in patients with

ovarian cysts which were believed to be benign. Eachpatient gave her informed consent.

Before the laparoscopic procedure, we conductedthe following tests in an attempt to rule out malignancy:1 vaginal and/or abdominal ultrasonography;2 diagnostic magnetic resonance imaging (MRI) of

the cyst, and3 measurement of the level of serum tumour markers.

During the laparoscopic procedure, ascitic cytologyincluding peritoneal washing and cystic ¯uid cytologywere carefully monitored to con®rm that no malig-nancy was present. Part of the cystic wall was examinedas a frozen section during the laparoscopic procedure;the remainder of the cystic wall was ®xed with formalinand observed under a microscope after the operation.All of the cysts were con®rmed to be benign throughthese examinations.

52 T. YAMADA e t al .

Surgery was done by means of a direct extracorporealoperative procedure or an intracorporeal procedure.Treatment for mature cystic teratoma was invariablydone using a direct extracorporeal approach. Conser-vative cystectomy procedures, where only the cyst wasexcised, were carried out according to the patient's ageand request.

Using the SAND balloon catheter allows the surgeon:(i) to hold and extend the ovarian cyst; (ii) to applysuction to the cystic ¯uid and irrigate the cyst, and (iii)to excise the cyst. The catheter of the SAND balloondevice has an outer diameter of 2.75 mm; in the centreof the catheter is a needle which punctures the cyst.Two balloons at the tip of the catheter, grip and ®xthe cyst in a stationary position. The needle, which hasa diameter of 2.3 mm, can be removed after the cyst ispunctured; this prevents tissue damage. When the twoballoons at the tip of the catheter are injected with10 ml of physiological saline, each balloon swells to adiameter of approximately 25 mm (see Figs 1 and 2).The SAND balloon catheter can be used with trocarsof greater than 5-mm ; in this study, it was used througha 12-mm trocar in the mid-position between the umbi-licus and pubic symphysis.

RESULTS

Amongst the 89 laparoscopic surgical procedureswhich were done in the Department of Obstetricsand Gynecology at Hirakata City Hospital between1996 and 1997, a laparoscopic approach using theSAND balloon catheter was used in 36 cases of ovariancyst, hydrosalpinx, or uterine cyst, in 32 patients. Theages of the latter ranged from 14 to 66 years (mean6 SD, 31 6 12).

Of the 32 patients, 27 patients had ovarian cysts,and three of these had cysts bilaterally; one patienthad a uterine cyst; four patients had hydrosalpinx,one of these having both an ovarian cyst and hydro-salpinx. The diameter of the cysts ranged from 40 to130 mm (63 6 23). All of the cysts were benign. Thehistological characteristics of the ovarian cysts were:serous adenoma (four patients), mucinous adenoma(three patients), mature cystic teratoma (eightpatients), endometriosis (chocolate cyst; 12 patients),haemorrhagic corpus luteum (three patients), andfollicular cyst (one patient). The mean operatingtime (6 SD) was 114 6 31 min. The results of intra-operative emergency cytology and frozen section

Gynaecological Endoscopy 2000 9, 51±54 q2000 Blackwell Science Ltd

Figure 1 Structure of the SAND balloon catheter.

SAND BALLOON CATHETER FOR OVARIAN CYSTS 53

investigations came back within 30 min, during theoperation.

The cystic ¯uid was successfully aspirated in all ofthe 36 cases in this study, without gross identi®cationof spillage. When an adhesion was identi®ed, adhesio-lysis was easily done by pulling the cyst with the SANDballoon catheter. During suction-irrigation, neitherrupture of the cyst nor sliding of the balloons occurredin any of the 36 cases. Two chocolate cysts, however, didrupture during adhesiolysis.

In 16 of the 32 patients, a conservative cystectomyprocedure, in which only the cyst was excised, wasperformed. In the remaining 16 cases, ooÈphorectomy,which involved the excision of one or both ovaries, wasdone.

DISCUSSION

Benign ovarian tumours can be treated using laparo-scopic surgery.1 Many benign ovarian tumours arecysts, which are commonly aspirated during the lapa-roscopic procedure to reduce their size prior to exci-sion. However, the cyst may rupture during aspiration,thereby causing the spillage of cystic ¯uid into theperitoneum. Such spillage of cystic ¯uid into the peri-toneal cavity should be prevented to the greatest extentpossible. Though it has been reported that intraopera-tive or iatrogenic rupture showed virtually no relationto dissemination,2 spillage from a malignant tumourmay lead to an advance in the staging of ovariantumours. Additionally, spillage from chocolate cysts ormature cystic teratomas, may cause chemical peritonitis,

which may lead to postoperative fever in the patient andperitoneal adhesion.

With the SAND balloon catheter it is possible toaspirate the cystic ¯uid with virtually no spillage. Thecystic ¯uid can be aspirated even with chocolate cystsand mature cystic teratomas. The cystic ¯uid in thecavity of the cyst is removed by the repeated injectionof warm physiological saline and suctioning.

Additionally, it is easier to perform extracorporealextraction of the cyst using the SAND balloon catheter,®rstly because the cyst can be pulled after it is punctu-red, and secondly because the diameter of the balloonscan be adjusted to a length of between 5 and 22 mm,by discharging 2±10 ml of saline. This reduces the sizeof the balloon to allow extracorporeal removal of thecyst, using an endocatch, from a small incision madein the abdominal wall or through a trocar. In particularit is very useful with large ovarian cysts where debulkingobviously makes surgery easier.

Direct extracorporeal operative procedures3 arealso an option in the conservative surgery of cysts, aslong as the degree of adhesion of the cyst to the tissueis not signi®cant. In operative procedures, the cyst canbe extracted at its smallest possible size, without causingdamage to the surrounding tissues. In the case ofmature cystic teratomas, only lipids can be aspiratedwith the SAND balloon catheter. If the size of the cystcan not be reduced suf®ciently, an extracorporealextraction, followed by extracorporeal extraction ofthe remaining hair etc., can be done to remove thecyst. Using the SAND balloon catheter for intracorpo-real cystectomies also signi®cantly reduces the risk of

q2000 Blackwell Science Ltd Gynaecological Endoscopy 2000 9, 51±54

Figure 2 Technique for using the SAND balloon catheter. Suction of the cystic ¯uid and holding the cyst.

54 T. YAMADA e t al .

spillage of cystic ¯uid. However, if spillage of cystic¯uid does occur during the procedure, the areashould be irrigated and the ¯uid should be thoroughlysuctioned.4

The SAND balloon catheter can also be applied tocysts of the uterus and fallopian tube, as well as thoseof the ovary. In this study, laparoscopic surgery usingthe SAND balloon catheter was successfully performedfor a uterine cyst and hydrosalpinx.

Screening for malignancy is very important, priorto conducting a laparoscopic operation on an ovariantumour.5 It is vital that a thorough preoperative exam-ination is carried out to detect signs of malignancy;additionally, intraoperative cytological and histologi-cal surveillance of the cyst should be done to thegreatest extent possible. If an ovarian tumour is foundto be malignant during the laparoscopic procedure, thelatter must immediately be converted to a laparotomy;6

the peritoneum must be suf®ciently irrigated andwashed, and during the surgery, anticancer drugsmust be administered, if necessary. We have not yetused the SAND balloon catheter for the laparoscopicsurgery of malignant cysts.

When the preoperative diagnosis criteria werestrictly observed,2,7 it was found that the SAND ballooncatheter for the laparoscopic surgery of ovarian cystswas extremely useful for aspirating the cystic ¯uid, andfor the irrigation and excision of the cyst.

ACKNOWLEDGEMENTS

We wish to thank Dr Saeki at NTT Kyoto Hospital,and Dr Ikuma at Takarazuka City Hospital, for techni-cal support which was invaluable in the preparationof this paper.

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