Laparoscopic Excision of Retroperitoneal Adnexal Cyst

Study Objective: To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with previous abdominopelvic surgery. Design: Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. Setting: Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery.1 Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy.2 Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery.2 This patient is a 53-year-old postmenopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent excision of an 8 cm retroperitoneal left adnexal cyst (Still 1). Interventions: Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: 1. Use of advanced laparoscopic techniques, such as the "push and spread" method and quick bursts of bipolar energy to prevent injury to vessels, bowel, and bladder 2. Use of traction and counter-traction techniques to aid in dissection 3. Knowledge of retroperitoneal anatomy and avascular spaces to assist with dissection (Still 2 and 3) 4. Early ligation of the infundibulopelvic ligament to minimize blood loss 5. High ligation of the infundibulopelvic ligament and complete ureterolysis from the level of the pelvic brim to the bladder to completely excise ovarian tissue Conclusion: Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses because dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High and early ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant. Journal of Minimally Invasive Gynecology (2023) 30, 615 -615. (c) 2023 AAGL. All rights reserved.