An adnexal mass is an abnormal growth or lump near the uterus in the pelvic region. These masses primarily involve structures such as the ovaries and fallopian tubes [1]. Adnexal masses can encompass a broad spectrum of conditions, ranging from harmless cysts filled with fluid to more complex growths like benign tumors or dermoid cysts containing various tissue types [2]. They can vary in size and may cause symptoms like pelvic pain, bloating, or irregular menstrual cycles [3-4]. Diagnosing and characterizing adnexal masses is crucial to determine the appropriate management, whether it involves monitoring, medical treatment, or surgical intervention [3],[5]. The prevalence of benign adnexal masses is noteworthy, with studies indicating that up to 10% of women may develop such masses during their lifetime [3],[6],[7]. This high incidence underscores the significance of understanding their management, as it affects a substantial portion of the female population. While many benign adnexal masses remain asymptomatic and are incidentally discovered, others can manifest with various symptoms [8-9]. These symptoms may include pelvic pain, bloating, urinary frequency, and irregular menstrual bleeding (10). In some cases, these masses can twist on themselves (torsion), rupture, or grow to a size that causes discomfort and pain, leading to complications that necessitate intervention [11].

The management of benign adnexal masses has traditionally involved a conservative "watch and wait" approach for asymptomatic masses, with periodic monitoring through ultrasound examinations [3],[12]. However, surgical intervention has been the main treatment when symptoms or complications arise [13]. Historically, this involved open abdominal surgery, known as laparotomy, which often required larger incisions, longer recovery times, and increased postoperative pain [14].

Over the past few decades, laparoscopic surgery has emerged as an innovative and minimally invasive alternative for managing benign adnexal masses [15-16]. Laparoscopy involves small incisions through which a thin, flexible tube equipped with a camera and surgical instruments is inserted. This approach allows surgeons to visualize and remove the adnexal mass while minimizing trauma to the surrounding tissues [15-16]. The benefits of laparoscopic management are multifaceted. Patients who undergo laparoscopic surgery typically experience shorter hospital stays, reduced postoperative pain, faster recovery times, and improved cosmetic outcomes than traditional laparotomy [17-18]. Additionally, laparoscopy often results in less scarring, decreased risk of infection, and a lower chance of adhesion formation, which can be particularly important for women of reproductive age who wish to preserve their fertility [16],[17],[19]. Our cross-sectional study aimed to comprehensively evaluate the safety and outcomes associated with laparoscopic management of benign adnexal masses. We intend to investigate the operative outcomes and postoperative complications for individuals who undergo a laparoscopic approach.

Study Design and Settings

This cross-sectional hospital-based study was conducted over one year, from June 1, 2019, to May 30, 2020, and involved patients who underwent laparoscopic surgery for benign adnexal masses. The study population was selected exclusively from the attendees of the Gynaecologic clinic at Aswan University. The Ethics Committee of the Aswan Faculty of Medicine formally approved the research design (IRB: XX). The confidentiality of patient information was strictly upheld, with data reported in a de-identified manner. Informed consent was obtained from all participants, emphasizing their right to withdraw from the study at any point without impacting the quality of care received.

Inclusion and Exclusion Criteria

The study's inclusion criteria encompassed female participants aged 15 to 55, including childbearing (15-44 years) and perimenopausal (45-55 years) individuals with a Body Mass Index (BMI) ranging from 20 to 30, who were physically suitable for surgery. Conversely, exclusion criteria comprised post-menopausal women, those below 15, patients with contraindications for laparoscopy, and individuals with suspected malignancy confirmed through diagnostics like ultrasound, tumour markers, or family history.

Sample Size

The sample size for this cross-sectional study was calculated using the following formula:

Sample Size= Z²*P(1−P)/D²

A 95% confidence interval was selected, corresponding to a type 1 error of 5%. Z, the standard normal variance at a 95% confidence interval, was set at 1.96. P, the expected proportion of benign adnexal masses, based on previous studies, was determined. D, the expected precision error, was established at 5%. This calculation yielded a sample size of 40 cases for this cross-sectional study.

Data Collection

A comprehensive dataset was compiled for each patient, encompassing personal information, parity, chief complaints, menstrual history, obstetric history, current health status, past medical history, surgical history, and family medical history. A venous blood sample was collected from each patient to assess various parameters, including Complete Blood Count (CBC), Prothrombin Time (PT), Partial Thromboplastin Time (PTT), International Normalized Ratio (INR), kidney function, and liver function. Pelvic Ultrasound (U/S) was performed to diagnose adnexal masses.

Procedure

Preoperative Preparation: Informed consent was obtained from all patients, with comprehensive counselling covering therapeutic options, procedure risks, and the potential need for laparotomy or other surgical interventions. Bowel preparation was administered, and patients were instructed to fast for 6 hours before surgery. Antibiotic prophylaxis was administered to all patients before surgery, involving 2 grams of a first-generation cephalosporin. General anesthesia was induced, with continuous monitoring of maternal vital signs during the procedure.

Patient Positioning: Patients were placed in the dorsal lithotomy position after the induction of general anesthesia. Bladder catheterization was performed. Skin preparation included cleaning and draping of the abdominal skin with antiseptic solutions, followed by separate cleaning and draping of the vagina.

Surgical Steps: The surgical procedure included key stages such as Veress' needle insertion, carbon dioxide insufflation, insertion of the primary trocar and cannula, introduction of the laparoscopic telescope, insertion of secondary trocars, and the performance of laparoscopic procedures tailored to the specific type of benign adnexal mass encountered. Procedures ranged from cystectomy to ablation, depending on the nature of the mass.

Outcomes

Various surgical and postoperative outcomes were assessed, including operating time, conversion to laparotomy rates, and intra-operative and postoperative complications.

Postoperative Evaluation

Postoperative progress was evaluated about the severity and duration of pain, length of hospital stay, and the occurrence of fever and wound-related complications.

Statistical Analysis

Data collected was coded and analyzed using SPSS version 26 (IBM Corp., Armonk, NY, USA). Categorical data were presented as frequency and percentage, while contentious data were presented as mean and standard deviation (SD).

Participants' Baseline and Demographics: Our study included 49 participants undergoing laparoscopic management. Most participants (93.9%) were in the childbearing period (15-44 years). The mean participant age was 28.4 years, and the mean BMI was 23 Kg/m². Regarding obstetric history, most participants were multigravida and nullipara (40.8% and 46.9%), followed by uni-gravida and primipara (22.4%). (10.2%) of participants had experienced one vaginal delivery, and a similar percentage had undergone 3 or more vaginal delivery. Also, (34.7%) had a history of cesarean section. Regarding medical and surgical history, only one participant had a history of medical disease, and 3 had a history of abdominal or pelvic surgeries (Table 1).

Table 1: Participant’s demographics, obstetric history, medical and surgical history.

BMI: Body mass index, CS: cesarean section Clinical presentations of the studied population

Chronic pelvic pain was the most commonly reported symptom, affecting 69.4% of individuals. Primary and secondary infertility were reported in 24.5% and 20.4% of participants, respectively. Additionally, acute lower abdominal pain and dysmenorrhea were experienced by 16.3% of the cohort. Low-grade fever and accidentally discovered adnexal cysts were reported by 4.1% and 10.2%, respectively.

 Table 2: Clinical symptoms.

Results are not mutually exclusive as some respondents suffered more than one symptom. Figures in the column are not additive because many patients had more than one symptom

Ultrasound Diagnosis of Adnexal Masses and Type of Operations

Predominantly, 83.6% of cases exhibited uniocular cystic masses, while 16.4% presented with multilocular cystic masses. The most common procedure was ovarian cystectomy (49.0%). Adhesiolysis coupled with cystectomy was the second most prevalent intervention, accounting for 16.3% of cases. Detorsion of the ovary was performed in (8.2%) of cases. Salpingectomy, salpingopherectomy, and excision of paratubal cysts were conducted in 12.2%, 4.1%, and 4.1%, respectively (Table 3).

Table 3: Ultrasound diagnosis and management of adnexal masses.

Clinical outcomes and complications

The length of hospital stay in days demonstrated that most patients (83.7%) were discharged within one day post-surgery, with a small portion (8.2%) discharged on the same day or 2 days after the procedure. The mean length of stay was one day, within a range of 0 to 2 days. Operating room time, measured in minutes, exhibited a mean of 61.9 and ranged from 30 to 90 minutes. Surgical complications included a (6.1%) conversion to laparotomy and the intra-operative occurrence of sebaceous material spillage in (6.1%) of cases. Postoperative complications encompassed minor port site infections (4.1%), pain (6.1%), and fever (2%), with no reported mortality (Table 4).

 Table 4: Clinical outcomes and complications.

*Converted to laparotomy: 3 cases due to dense adhesion deep endometriosis.

Histopathology of Adnexal Masses

Functional (follicular) masses accounted for (18.4%) of cases, followed by endometriotic cysts (chocolate cysts) at (16.2%). Dermoids constituted (14.3%), while bilateral hydrosalpinx (hydrosalpinges) represented (12.2%) of cases. Serous cystadenoma and hemorrhagic corpus luteum cysts each were found in (10.2%) and (16.4%) of cases, respectively. Less commonly encountered were mucinous cystadenomas, paratubal cysts, and tubo-ovarian abscesses (pyosalpingx), each at (4.1%).

Table 5: Histopathology of adnexal masses.

This cross-sectional study showed that the most prevalent symptoms among them were chronic pelvic pain, followed by primary and secondary infertility, and acute lower abdominal pain. Ultrasound diagnoses mostly identified uniocular cystic masses, with multilocular cystic masses being less common. The predominant surgical intervention was ovarian cystectomy, with other procedures including adhesiolysis with cystectomy and ovary detorsion. Some participants experienced surgical complications like laparotomy conversion and intra-operative sebaceous material spillage. Post-surgery, a few reported minor port site infections, pain, and fever, but there were no fatalities. Histopathology most commonly diagnosed functional masses, endometriotic cysts, and dermoids. These findings underscore the need for tailored, minimally invasive laparoscopic approaches in managing adnexal masses in women of childbearing age, as they offer efficient outcomes with minimal complications and swift recovery [20-22].

Comparing our study's findings with previous research, several key insights emerge regarding laparoscopic management of benign adnexal masses. A successful laparoscopic completion rate of 81%, with 19% requiring conversion to laparotomy, primarily due to malignancies and dense adhesions. In contrast, our study maintained a laparoscopic approach for all 49 participants, highlighting the feasibility of this technique in a selected patient population, and only 6% converted to laparotomy [23].

Regarding outcomes, Serur et al. (2001) noted significantly shorter hospital stays (2 vs. 7 days) and operating room times (130 vs. 235 minutes) for laparoscopic cases compared to those converted to laparotomy, aligning with our findings of a mean one-day hospital stay and a mean operating room time of 61.9 minutes [23]. The meta-analysis conducted by Ye et al. (2019) also reported no statistical significance in fetal loss between laparoscopy and open surgery, which is consistent with our study's findings [24]. Benign masses were primarily treated with laparoscopy, while borderline and malignant masses often required laparotomy [25]. Our study, which predominantly involved benign masses, contributes to the existing knowledge by providing insights into laparoscopic management for this specific subgroup. Encountered ovarian malignancies in 1.5% of cases, with some patients undergoing staging laparotomy due to cyst rupture during surgery. Our study, which focused on benign masses, did not encounter malignancies, reaffirming the distinction between benign and malignant cases [26].

This study presents several strengths. Firstly, it was conducted over one year, providing a comprehensive assessment of laparoscopic management for benign adnexal masses within a reasonable timeframe. The involvement of 49 patients ensures a substantial sample size for meaningful analysis. The research adhered to ethical standards, with formal approval from the Ethics Committee, and participants provided informed consent. Detailed data collection, including history, examinations, laboratory investigations, and radiological assessments, contributes to the study's robustness.

However, certain limitations should be acknowledged. The study's single-center design may limit its generalizability to a broader population. The sample size, though meeting calculated requirements, remains relatively small, potentially affecting the ability to detect rare complications or outcomes. Finally, while efforts were made to minimize confounding factors, unmeasured variables may impact the results.

In conclusion, our study provides valuable insights into the baseline demographics, clinical presentations, and outcomes of 49 participants undergoing laparoscopic management for benign adnexal masses. Most participants were within the childbearing age range, reflecting the demographic most commonly affected by these conditions. Chronic pelvic pain emerged as the predominant symptom, underscoring the clinical significance of these masses. Ovarian cystectomy was the most frequently performed procedure, followed by adhesiolysis with cystectomy. Fortunately, most patients experienced a short hospital stay with minimal postoperative complications, highlighting the efficacy and safety of laparoscopic interventions. Our findings also shed light on the diverse types of adnexal masses encountered, with functional and endometriotic cysts being the most prevalent. This study contributes to the comprehensive understanding of laparoscopic management for benign adnexal masses and its clinical implications.

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