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Ovarian & fallopian tube surgery

The Australian Centre for Female Pelvic and Vaginal Rejuvenation
The Australian Centre for Female Pelvic and Vaginal Rejuvenation

Indications for ovarian surgery

  • Ovarian cystectomy.
  • Ovarian cyst puncture.
  • Oophorectomy.
  • Ovarian transposition.
  • Endometrioma surgery.
  • Adhesion surgery.
Normal right ovary and fallopian tube
Normal right ovary and fallopian tube

Indications for fallopian tube surgery

  • Tubal occlusion.
  • Tubal removal (salpingectomy).
  • Hydrodistension with dye.
  • Excision paratubal and fimbrial cysts.
  • Adhesion surgery.
  • Tubal re-anastomosis.

Ovarian surgery

Simple ovarian cysts are fluid filled. They often resolve spontaneously. If they persist or cause pain they can be:

  • Incised
  • Drained
  • Removed (cystectomy)
Simple right ovarian cyst
Simple right ovarian cyst
Incision of cyst
Incision of cyst
Draining cyst
Draining cyst
Preparing for cystectomy
Preparing for cystectomy
Cystectomy complete
Cystectomy complete

Endometriomas are ‘chocolate’ filled cysts of the ovary. The dark material is altered blood which is thick and appears dark.

  • Small endometriomas can be drained
  • Larger endometriomas need to be removed (cystectomy)
Endometrioma
Endometrioma
Incising and draining endometrioma
Incising and draining endometrioma

Larger ovarian cysts may have solid components. Malignancy will need to be excluded. The most common benign tumour of the ovary in young women are dermoid tumours. Dermoid tumours may contain:

  • Hair
  • Teeth
  • Fat
  • Bones
  • Nails
  • Blood
  • Cartilage
  • Thyroid tissue
Oophorectomy for dermoid in progress
Oophorectomy for dermoid in progress
Oophorectomy completed
Oophorectomy completed

Most ovarian surgery should be performed via laparoscopy (‘key-hole’ surgery). This means that:

  • Recovery time for the patient is very much reduced.
  • The visible scars are much smaller.
  • The risk of adhesions associated with surgery are also less than when compared with open (laparotomy) surgery.
Massive dermoid tumour
Massive dermoid tumour

There is no normal ovarian tissue in this tumour and the whole tumour requires removal.

There are circumstances where open surgery (laparatomy) is preferable to laparoscopic surgery. In this case a massive dermoid tumour, filled with a variety of developmentally mature tissue is removed intact through a large open incision. There are two main advantages of open surgery in this situation:

  • No tumour contents are spilled in the abdomen or pelvis.
  • The tumour will not come out through a small incision.

Dr Onuma does not use morcellators for tissue extraction.

variety of factors can result in the formation of adhesions and every organ within the abdomen and pelvis can be affected. In this situation, the right ovary is found to be stuck to the right ovarian fossa by filmy adhesions. The patient has given a history of left iliac fossa pain. This pain was relieved after adhesiolysis.

Filmy ovarian adhesions
Filmy ovarian adhesions
Ovary mobilised after adhesiolysis
Ovary mobilised after adhesiolysis

Fallopian tube surgery

Female sterilisation is commonly achieved through occlusion of the Fallopian tubes. Application of a Filshie clip to each tube produces a crush injury, vascular compromise and death of the parts of the tube immediately compressed by the clip.

Fallopian tubes before occlusion
Fallopian tubes before occlusion
Filshie clip applied to left Fallopian tube
Filshie clip applied to left Fallopian tube
Filshie clip applied to left Fallopian tube
Filshie clip applied to left Fallopian tube

The surgeon checks that:

  • It is the fallopian tube (and not the round ligament) that has been occluded.
  • Occlusion is complete. i.e. the clip seen to cover the entire diameter of the tube.

Sometimes the clip may fall off and be found in the pelvis later on. This does not affect the prevention of pregnancy achieved by the procedure.

Evidence of past occlusion
Evidence of past occlusion
Clip being removed from pelvis
Clip being removed from pelvis

Recent evidence indicates that many ovarian cancers actually arise from cancerous cells from the fallopian tubes.

Salpingectomy is the removal of the fallopian tube. Indications for salpingectomy include:
  • Tubal sterilisation.
  • Management of a tubal (ectopic) pregnancy.
  • Prevention of ovarian cancer.

Endoloops are very efficient devices for occluding the fallopian tubes to allow them to be removed safely. If the purpose of removing the tube is prevention of ovarian cancer, then the tube needs to be removed entirely using an energy device (bipolar). Endoloops cannot be used to remove the whole tube.

The tube is grasped and checked to see if an Endoloop can be sited.

Traction on right fallopian tube
Traction on right fallopian tube

The Endoloop is placed over the tube and the pre-tied knot gradually pushed down onto the tube.

Tube being fed through an Endoloop
Tube being fed through an Endoloop

Once the knot is secure, the suture is cut. A second Endoloop is sometimes sited.

Endoloop tightened
Endoloop tightened

The tube is grasped and its entire length visualised. The tube is held well away from the pelvic sidewall.

Traction on left fallopian tube
Traction on left fallopian tube

Bipolar forceps grasp the tube. Electrical energy is passed to cauterise the tube.

Bipolar diathermy
Bipolar diathermy

The whole of the tube is excised and removed intact. A check is made to ensure that there is no bleeding.

Complete salpingectomy
Complete salpingectomy
Para-tubal cysts wrapped around ovary
Para-tubal cysts wrapped around ovary

Both the ovary and tube are functionally normal. Extensions from the outer layer of the tube have become wrapped around the ovary. These extensions are excised without any ovarian or tubal damage.

The fallopian tube is anatomically and functionally normal. There is a large para-tubal cyst around which the tube is wrapped. The cyst wall is excised without any damage to the fallopian tube.

Para-tubal cyst
Para-tubal cyst
Bilateral salpingo-oophorectomy preceding hysterectomy
Bilateral salpingo-oophorectomy preceding hysterectomy

During a laparoscopic hysterectomy and removal of tubes/ovaries, the upper pedicles involving the tubes & ovaries are often freed en-block before the upper attachments of the uterus.

Complex, bilateral ovarian cysts. No visual evidence of normal ovarian tissue but circulating oestrogen levels are within the normal range. The younger the woman, the more difficult the management.

Bilateral ovarian cysts
Bilateral ovarian cysts
Para-ovarian cyst
Para-ovarian cyst

Ultrasound is an excellent imaging modality for diagnosing ovarian and tubal pathology. However, the findings are often incorrect and direct visualisation, usually via laparoscopy is required for a final diagnosis ± treatment. In this case, a para-ovarian cyst was thought to be a fallopian tube cyst. It is easy to see how the mis-diagnosis was made.

Para-ovarian cyst removal
Para-ovarian cyst removal
Tissue biopsy is placed in a bag
Tissue biopsy is placed in a bag

Excised tissue specimens need to be sent for histological analysis. This requires removal from the pelvis. Usually this is done with a grasper and pulled out of one of the abdominal ports. If there is any suspicion that the specimen might contain abnormal cells, the specimen needs to be removed without allowing it to come into contact with the abdominal wall.

Specialised bags are passed through into the abdomen, the specimen placed into the bag and the bag closed. The bag is then withdrawn out of the pelvis. Sometimes the abdominal wound has to be slightly enlarged to allow intact, safe removal.

Bag is closed and prepared for removal
Bag is closed and prepared for removal

One of the methods of assessing fallopian tube function is by dye laparoscopy. Dye is passed through the cervix using a special cannula. The fallopian tube is observed through the laparoscope.

Blue dye spilling through tube into pelvis
Blue dye spilling through tube into pelvis

If the tube is patent, dye is likely to be seen spilling out of the end of the tube into the pelvis. Failure of dye to pass is not conclusive evidence that tubal blockage exists as this can occur during tubal spasm.

Case report

Clinical findings

Incidental findings:

  • Tubo-ovarian complex.
  • Omental adhesions of complex.
  • Adhesions of complex to abdomino-pelvic sidewall.
Significant other findings

Normal looking right ovary and small cyst on right fallopian tube.

Relevant history

This patient reported having had a left tubal pregnancy which had been managed by salpingectomy at open surgery. The histology was reported as a hydatidiform mole, a tumour with carcinogenic potential.

Outcome

Tubo-ovarian complex dissected away from omentum and pelvic sidewall. Vascular supply sealed with bipolar energy. Complex removed and sent for histological analysis.

The pelvis can be full of surprises. The surgeon has to be able to deal with a variety of findings.

Laser Vaginal Rejuvenation Institute of Adelaide
Laser Vaginal Rejuvenation Institute of Adelaide