Salpingo-Oophorectomy

Salpingo-oophorectomy is the removal of the fallopian tube (salpingectomy) and ovary (oophorectomy). (See the image below.) A unilateral salpingo-oophorectomy is appropriate for patients in whom an ovary is unable to be preserved, including cases of ruptured ectopic pregnancy with an inability to achieve hemostasis without removal of the tube and ovary, adnexal torsion in which the ovary and tube are necrotic, a tuboovarian abscess not responsive to antibiotics, or a benign ovarian mass in which there is no remaining normal ovarian tissue able to be conserved. A bilateral salpingo-oophorectomy is generally one of three types: elective at time of hysterectomy for benign conditions, prophylactic in women with increased risk of ovarian cancer, or because of malignancy.

Relevant anatomy

The ovaries are the female pelvic reproductive organs that house the ova and are also responsible for the production of sex hormones. They are paired organs located on either side of the uterus within the broad ligament below the uterine (fallopian) tubes. The ovary is within the ovarian fossa, a space that is bound by the external iliac vessels, obliterated umbilical artery, and the ureter. The ovaries are responsible for housing and releasing ova, or eggs, necessary for reproduction. At birth, a female has approximately 1-2 million eggs, but only 300 of these eggs will ever become mature and be released for the purpose of fertilization.

The uterine tubes are uterine appendages located bilaterally at the superior portion of the uterine cavity. These tubes exit the uterus through an area referred to as the cornua, forming a connection between the endometrial and peritoneal cavities. Each uterine tube is approximately 10 cm in length and 1 cm in diameter and is situated within the mesosalpinx. The mesosalpinx is a fold in the broad ligament. The distal portion of the uterine tube ends in an orientation encircling the ovary. The primary function of the uterine tubes is to transport sperm toward the egg, which is released by the ovary, and to then allow passage of the fertilized egg back to the uterus for implantation.

For more information about the relevant anatomy, see Ovary Anatomy and Uterine Tube (Fallopian Tube) Anatomy.

Indications

Indications for salpingo-oophorectomy include the following:

• Elective: Removal of normal appearing ovaries and tubes at the time of a concurrent surgery, commonly a hysterectomy for benign disease, to decrease the risk of development of ovarian pathology, and decrease the need for future procedures

• Malignancy: Ovarian cancer, uterine cancer, or metastases to ovaries from a distant primary malignancy (gastrointestinal, breast, lung carcinoma)

• Risk reducing: Removal of ovaries and tubes in women genetically susceptible to ovarian cancer

• Benign adnexal mass

• Adnexal torsion

• Tuboovarian abscess

• Ectopic pregnancy

• Endometriosis

Contraindications

There are no absolute contraindications for a salpingo-oophorectomy. Severe pelvic adhesive disease may influence the approach to surgery. Risks of the procedure must be weighed against potential benefits for each individual patient.

Technical considerations

Best practices

The number of salpingo-oophorectomies performed as elective procedures is decreasing. ^[1] At this time, there is inconclusive evidence of the benefits versus the risks of undergoing an elective salpingo-oophorectomy in women who are not at increased risk of developing ovarian cancer. The lifetime risk of developing ovarian cancer in women who have no additional risk factors is 1 in 71. ^[2] A bilateral salpingo-oophorectomy has been demonstrated to decrease this risk; for every 220 bilateral salpingo-oophorectomies performed, one case of ovarian cancer will be prevented.

However, the decreased risk of developing ovarian cancer needs to be weighed against the effects of decreased hormone levels after salpingo-oophorectomy. ^[3] The American College of Obstetricians and Gynecologists recommendations state, “Strong consideration should be given to retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer.” ^[4]

Patients with known BRCA mutations, hereditary nonpolyposis colorectal cancer, invasive ovarian, or endometrial cancer are not candidates for ovarian conservation. ^[4] In BRCA-positive patients, the lifetime risk of developing ovarian cancer is 20-50%; a prophylactic salpingo-oophorectomy decreases the risk of developing ovarian cancer by 80-90%. ^[4]  In addition, prophylactic salpingo-oophorectomy reduces the risk of breast cancer in women with BRCA1 and BRCA2 mutations for 5 years after the procedure. ^[5]

Complication prevention

Although the incidence of injury to internal organs (bowel, bladder, ureter, blood vessels, and nerves) is rare, it does occur. Patients with prior surgeries, history of pelvic infection, endometriosis, or other causes of adhesive disease are at greater risk. Ureteral injury may occur by clamping, transection, and ligation of the ureter, kinking of the ureter resulting in obstruction, or disruption of the ureteral blood supply. ^[6]

A common location of ureteral injury is at the pelvic brim, where it is in close proximity to the infundibulopelvic ligament. Prevention of ureteral injury occurs by direct visualization, palpation, or possible ureteral catheterization with lighted stents. If there is a question of possible injury, a cystoscopy may be performed.

Risk factors for nerve injury include the length of procedure (over 4 hours), thin patient, improper positioning, self-retaining retractors, and extensive tissue dissection. ^[7] Common nerves injured during pelvic surgery include the iliohypogastric and ilioinguinal, genitofemoral, femoral, lateral femoral cutaneous, obturator, sciatic, common peroneal, and the brachial plexus. ^[7]

To minimize the risk of nerve injuries, the surgeon should ensure appropriate padding between the patient and the table, stirrups, and arm boards. If the patient is to be positioned in dorsal lithotomy position, minimal thigh abduction and external hip rotation should be used. If a procedure continues for more than 4 hours, it may be helpful to reposition the patient if possible.

Antibiotic prophylaxis is not required for a salpingo-oophorectomy, whether performed laparoscopically or open. However, when performed in combination with a hysterectomy, antibiotics are recommended for prevention of postoperative infections. In patients in whom there is a suspicion of infection, the addition of appropriate antibiotic therapy should be considered. ^[8]

Therapy required for prevention of deep venous thromboses depends on the type of procedure, the patient's age, and other risk factors. Low-risk patients may only require early ambulation, whereas patients who are at higher risk may require heparin therapy and intermittent pneumatic compression devices. ^[9]

Absorbable adhesion barriers are available and are used by some practitioners for the prevention of adhesion formation. There are several types of adhesion barriers available for use; some barriers have more supportive data than others. ^{[10, 11]}

Patient education and consent

Risks, benefits, and alternatives need to be discussed with the patient before surgery. The indication for the procedure, the patient’s medical history, age, reproductive status, and the patient’s own wishes all influence the decision on whether a surgeon attempts ovarian preservation or removal. Patients must be informed of the possible complications and the long-term effects of decreased hormone levels.

Postoperatively, patients should be educated on the typical course of recovery. Patients should be aware of signs of complications: fevers and chills, persistent nausea and vomiting, drainage from and redness of the incision, difficulty with bowel function, difficulty voiding, pain which is not resolving, chest pain, difficulty breathing, lower extremity swelling, or calf pain.

Patients should be aware of the need for long-term follow-up, especially after a bilateral salpingo-oophorectomy, to ensure proper monitoring for conditions related to a lack of hormones.

Premenopausal women who undergo a bilateral salpingo-oophorectomy may experience symptoms of surgically induced menopause, including hot flashes, night sweats, insomnia, and vaginal dryness. These patients may have the option of symptomatic relief with the use of various medications.

Options include hormone replacement with estrogen (patients who have had a hysterectomy) or estrogen and progestin combination (patients who have a uterus), antidepressants (selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors), clonidine, gabapentin, and alternative medications/herbal supplements (phytoestrogens, black cohosh, evening primrose, dong quai) ^[12] .

Patients need to discuss individual risks and benefits of medications and supplements to determine their best options since several factors including age, severity of symptoms, medical conditions, and breast cancer risk all influence decision making.

Equipment

Equipment for the abdominal approach includes the following:

• Scalpel

• Electrocautery

• Suction

• Self-retaining retractors

• Retractors

• Clamps

• Vessel-sealing devices

• Scissors

• Tissue forceps

• Needle drivers

• Sutures

Equipment for the laparoscopic approach includes the following:

• Stirrups

• Speculum

• Tenaculum

• Cervical dilators

• Uterine manipulators

• Scalpel

• Veress needle

• Trocars

• CO₂ insufflation

• Camera, scope, light source

• Laparoscopic instruments: scissors, graspers, dissectors, monopolar devices, bipolar devices

• Laparoscopic specimen bag

• Vessel sealing devices

Patient preparation

Anesthesia

The vast majority of cases are done under general anesthesia regardless of surgical approach. However, under rare circumstances, procedures may be done under regional anesthesia.

Positioning

Correct positioning is important to prevent nerve injury. Stretching and compression of nerves must be avoided when positioning the patient. For an abdominal approach, the patient is placed in a dorsal supine position. For a laparoscopic or vaginal approach, the patient is placed in dorsal lithotomy position. The patient’s hips are flexed with thighs moderately abducted, knees flexed, and dorsiflexion of the feet; there should be minimal external rotation of the hips.

Monitoring and follow-up

Premenopausal women who undergo a bilateral salpingo-oophorectomy are placed into surgical menopause. These patients need to be followed closely for health risks that have been associated with a lack of estrogen, including osteoporosis and cardiac disease. Patients therefore should be screened appropriately with bone density scans, cholesterol levels, blood pressure monitoring, and diabetes testing.

However, a study by Fakkert et al indicated that within the first 5 years after women with a BRCA mutation undergo risk-reducing salpingo-oophorectomy, bone mineral density and incidence of bone fracture are the same as in the general population. The study, which had a median follow-up period of 5 years, involved 212 women of premenopausal age who underwent risk-reducing salpingo-oophorectomy. The investigators determined that lumbar spine and femoral neck bone mineral densities did not fall below those of the general population, whereas the incidence of bone fractures (22 fractures in a total of 16 women) was no higher than that expected in the general population. Fakkert et al suggested that during the first 5 years after risk-reducing salpingo-oophorectomy, it may be acceptable not to intensively screen patients for osteoporosis. ^[13]

A study by Stuursma et al that included 199 women who had undergone risk-reducing salpingo-oophorectomy before 52 years of age reported that 69% of the women reported moderate or severe psychological, somato-vegetative and urogenital menopausal symptoms on the Menopause Rating Scale an average of 7.9 years after the procedure (57% reported severe urogenital symptoms and 25% reported severe psychological and/or somato-vegetative symptoms. Psychological menopausal symptoms were the only symptom to show improvement after 10 years. ^[14]  

Complications

Complications may include the following:

• Vascular injury and bleeding

• Injury to adjacent organs (bowel, bladder, ureter)

• Injury to nerves

• Infection

• Deep venous thrombosis

• Adhesion formation

• Incisional hernia

• Ovarian remnant syndrome

• Anesthesia complications

Approach considerations

An abdominal approach may be preferred if the patient has known or suspected severe adhesive disease, a large adnexal mass, or if there is a high suspicion of malignancy. ^[15] A laparoscopic approach may be appropriate in cases with low risk of malignancy and smaller sized adnexal mass. ^[15] A laparoscopic approach is beneficial in that it decreases blood loss, length of hospital stay, and recovery time. A vaginal approach is the least common approach ^[16] and is only used when a salpingo-oophorectomy is done concurrently with a vaginal hysterectomy.

Abdominal approach

The patient is transferred to the operating room table and placed under general anesthesia.

A pelvic examination is performed to determine uterine position, size, shape, and mobility, and to palpate the adnexa. A Foley catheter is normally placed to gravity to drain the urinary bladder throughout the procedure. The patient is positioned in a dorsal supine position and the patient's abdomen is prepped and draped in a sterile fashion.

A transverse or vertical incision may be chosen depending on the indication for surgery, the patient's body habitus, and the preference of the surgeon. The advantages of a transverse incision include improved cosmetic results, a stronger incision with decreased wound dehiscence, and decreased postoperative pain. Disadvantages of a transverse incision include increased blood loss and hematoma formation, increased risk of nerve injury, decreased exposure of the upper abdomen, and longer procedure time.

Advantages of vertical incisions include faster entry into the abdominal cavity, decreased blood loss, decreased risk of nerve injury, and the ability to significantly extend the incision if improved exposure is required, as for surgical staging in cancer cases. Disadvantages of a vertical incision include poor cosmetic results, weaker incision with increased risk of wound dehiscence, and increased postoperative pain.

After the abdomen is entered, the abdomen and pelvis are explored. Care should taken to carefully inspect the uterus, the bilateral ovaries and tubes, the small bowel, colon, omentum, and peritoneal surfaces for any abnormal findings.

A self-retaining retractor is often used to aid with exposure. The bowels are then packed to allow for adequate exposure of the pelvis.

The infundibulopelvic ligament should be identified. The infundibulopelvic ligament contains the ovarian vessels encased in peritoneum. Both the right and left ovarian arteries originate off of the aorta. The right ovarian vein drains into the inferior vena cava while the left ovarian vein drains into the left renal vein. The ureter lies in close proximity to the infundibulopelvic ligament and must be identified prior to clamping and transection of the infundibulopelvic ligament to avoid injury.

To aid in identification of the ureter and to drop the ureter deeper into the pelvis, the posterior peritoneum is opened. This is done by lifting the peritoneum anteriorly with Debakey forceps and making a small superficial incision in the posterior peritoneum. This incision is extended superiorly parallel to the infundibulopelvic ligament. Care must be taken to remain superficial and to avoid the ovarian vessels. Once the peritoneum is opened and reflected, the ureter is more readily identified.

When locating ureters, it is helpful to look for their peristalsis, which can be elicited by gently "strumming" the ureter. The ureters may be most evident where they cross over the iliac vessels, at the level of their bifurcation from the common iliac to the external and internal iliac vessels. The left ureter may be more difficult to visualize secondary to being covered by the sigmoid colon. Once detected at the pelvic brim, they can be followed down the lateral pelvic side wall until they enter the cardinal ligament underneath the uterine artery.

After identification of the ureter, an avascular window in the posterior broad ligament is identified and opened using sharp, blunt, or electrocautery dissection. The infundibulopelvic ligament is clamped through this window using two curved hysterectomy clamps (Zeppelin, Heaney, or Masterson). The first clamp is positioned laterally while ensuring the ureter is at a safe distance. The second clamp is placed approximately 1 cm medial to the first clamp.

The infundibulopelvic ligament is then sharply transected between the two clamps with curved Mayo scissors and then suture ligated using 0 delayed absorbable suture. The proximal end of the infundibulopelvic ligament is often doubly ligated, first using a free tie and then suture ligated ensuring hemostasis of the uterine vessels. The specimen end may also be suture ligated to prevent back bleeding and avoid excess clamps, improving visualization. Alternatively, the infundibulopelvic ligament may be clamped, ligated, and transected with a vessel sealing device.

Once the infundibulopelvic ligament has been transected and secured, the portion of the broad ligament attached to the fallopian tube is taken down. This may be accomplished with either electrocautery of the broad ligament paralleling close to the fallopian tube, by clamping then transecting with suture ligation, or with the use of a vessel sealing device.

With the ovary and tube now detached from both the infundibulopelvic ligament and the broad ligament, the remaining attachment is now to the uterus. The ovarian ligament attaches the ovary to the uterus and the fallopian tube attaches to the uterine cornua. This entire pedicle (ovarian ligament and fallopian tube) is clamped, sharply transected, and suture ligated; alternatively, the pedicle may be clamped, ligated, and transected with a vessel sealing device.

Once the tube and ovary have been removed, they should be sent to pathology for tissue diagnosis. Often the pelvis is irrigated with warm saline to aid in the removal of any blood clots and debris.

The pedicles should be reinspected for hemostasis. After excellent hemostasis is assured, the self-retaining retractor is removed along with the laparotomy sponges used for packing the bowel. Care must be taken to ensure all sponges have been removed. The abdomen and pelvis should be inspected and a sponge count should be completed prior to closure of the incision.

Laparoscopic approach

The patient is transferred to the operating room table and placed under general anesthesia. The patient is then placed in the dorsal lithotomy position.

A pelvic examination is performed under anesthesia to determine uterine position, size, shape, mobility, and to assess the adnexa. A Foley catheter is placed to gravity to drain the urinary bladder throughout the procedure. The patient's abdomen, perineum, and vagina are prepped in a sterile fashion and the patient is draped.

A speculum is positioned to visualize the cervix and a uterine manipulator is then placed to aid with visualization and manipulation of the uterus during the case. Attention is then turned back to the abdomen for the placement of intra-abdominal trocars. Usually, the first incision is made with the scalpel in the infraumbilical fold. For a closed technique, the abdominal wall is tented while a Veress needle is carefully placed.

Once intraperitoneal placement is confirmed, the abdomen is insufflated with CO₂ gas. After insufflation, the Veress needle is removed and a trocar placed. The laparoscope is then introduced to confirm intraperitoneal placement.

The remaining trocars may now be placed under direct visualization. Care must be taken to prevent injury to blood vessels, especially the inferior epigastrics. Often transillumination of the abdominal wall can aid in avoiding injury to vessels. Additional trocars are placed depending on surgeon preference in the right lower quadrant, left lower quadrant, and/or midline suprapubic according to surgeon preference.

The peritoneal cavity should be inspected. See the images below.

For a prophylactic salpingo-oophorectomy, pelvic washings need to be collected and sent to pathology.

The uteroovarian ligament with the Fallopian tube are clamped, just distal to the uterine cornua, ligated, and transected with a vessel sealing device. See the image below.

When performing a prophylactic salpingo-oophorectomy the surgeon should remove the fallopian tubes to the level of the uterine cornua. ^[4]

The ureter should now be identified. In contrast to laparotomy, the ureter can usually be readily identified without reflection of the peritoneum. It is normally seen at the pelvic brim and can be followed inferiorly into the pelvis. See the image below.

Once the ureter is located and at a safe distance from the infundibulopelvic ligament, the infundibulopelvic ligament is clamped, ligated, and transected with a vessel sealing device. See the images below.

In prophylactic salpingo-oophorectomies, the infundibulopelvic ligament should be taken at the level of the pelvic brim. ^[4] The remaining mesosalpinx is dissected and hemostasis achieved.

The ovary and tube may be placed in a laparoscopic specimen bag and removed through a port site. If the ovary is unable to be fit through a port site, one incision site can be extended to allow removal of the ovary and tube.

Once hemostasis is ensured, the instruments and trocars are removed, the abdomen is desufflated, and the incisions are closed.