Is laparoscopy (minimally invasive surgical procedure) or laparotomy (open surgical procedure) preferred for removing a 5 cm ovarian cyst during the second trimester of pregnancy?

Laparoscopy is Preferred Over Laparotomy for 5 cm Ovarian Cyst Removal in Second Trimester Pregnancy

Laparoscopic surgery is strongly preferred over laparotomy for removing a 5 cm ovarian cyst during the second trimester of pregnancy due to consistently demonstrated shorter hospital stays, less postoperative pain, and lower risks of fetal complications. 1

Evidence-Based Rationale for Laparoscopy

Laparoscopy offers several significant advantages over laparotomy in pregnant patients:

• Maternal Benefits:

  • Shorter hospital stay (2.9 vs 5.8 days) 2
  • Significantly less postoperative pain (2.7 vs 5.9 on pain scale) 2
  • Less blood loss (43 mL vs 51 mL) 2
  • Reduced risk of postoperative adhesions (6.25% vs 53.3% for filmy adhesions) 2

• Fetal Benefits:

  • Lower risk of adverse fetal outcomes (0.4% vs 1.8% composite of fetal loss, premature delivery, and stillbirth) 1
  • No significant difference in neonatal Apgar scores or birthweights 2
  • 51% lower odds of preterm labor compared to laparotomy 1

Specific Considerations for Second Trimester Surgery

The second trimester is the optimal timing for non-emergent laparoscopic procedures during pregnancy because:

1. Improved visualization with moderate uterine size 1
2. Lower theoretical risk of miscarriage compared to first trimester 1
3. Lower risk of preterm labor compared to third trimester 1
4. Allows time for potential spontaneous resolution of the cyst 1

Technical Recommendations for Safe Laparoscopy

When performing laparoscopy for a 5 cm ovarian cyst in the second trimester, the following best practices should be implemented:

• Left lateral decubitus positioning to minimize uterine compression 1
• Port placement with careful consideration of uterine size 1
• Insufflation pressure less than 12-15 mm Hg to minimize fetal effects 1
• Intraoperative maternal capnography to monitor respiratory status 1
• Pre- and post-operative fetal heart rate monitoring 1
• Appropriate thromboprophylaxis (mechanical and chemical) 1

Common Pitfalls and How to Avoid Them

1. Risk of uterine injury: Use open (Hasson) technique for initial port placement rather than Veress needle 3
2. Pneumoperitoneum concerns: Maintain lower insufflation pressures (≤12 mm Hg) and monitor maternal end-tidal CO2 1
3. Cyst rupture risk: Use endobag technique to prevent spillage of cyst contents 4
4. Anesthetic concerns: Be aware of potential neurocognitive effects of general anesthesia, though human data is limited 1

Alternative Approaches in Special Circumstances

In cases where surgery is contraindicated or high-risk, consider:

• Ultrasound-guided fine needle aspiration for simple, unilocular cysts 5
• Ethanol sclerotherapy for select cases 6

However, these alternatives should be reserved for specific situations, as surgical removal remains the standard approach for most 5 cm ovarian cysts requiring intervention during pregnancy.

In conclusion, for a 5 cm ovarian cyst requiring removal in the second trimester of pregnancy, laparoscopy should be the preferred surgical approach when performed by an experienced surgeon at a facility with appropriate obstetrical, anesthetic, and neonatal support.