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Ovarian remnant syndrome is a troublesome condition that can be avoided if the operating surgeon pays attention to several factors that make the problem more likely, says Camran Nezhat, MD, of the Center for Special Pelvic Surgery in Atlanta. The syndrome can be surprising and difficult to diagnose because everyone expects there to be no ovary left to cause pain. But in premenopausal women who have had bilateral oophorectomy, a small fragment of functional ovarian tissue can remain and respond to hormonal stimulation. This fragment can grow, leading to cystic degeneration, hemorrhage, and pain, Nezhat says. Dense adhesions and distorted anatomy can make ovarian remnant syndrome more likely. The problem can be diagnosed on the basis of history and localization of pelvic pain. Some patients will have cystic adnexal structures or ill-defined fixed masses, Nezhat says, whereas others will have normal pelvic findings. Vaginal ultrasound can help determine whether an ovarian remnant is present, and low or borderline-low follicle-stimulating hormone levels after bilateral oophorectomy can be another red flag.
PROBLEM CAN BE PREVENTED: To avoid the problem, Nezhat says, surgeons should focus on the factors associated with ovarian remnant syndrome: inappropriate use of Endoloop suture during laparoscopic oophorectomy, multiple surgical procedures with incomplete removal of pelvic organs, densely adherent ovaries, and multiple ovarian cystectomies for functional cysts. Nezhat cautions that you must be careful with pre-tied sutures used for the infundibulopelvic ligament. Be sure they are placed below the ovarian tissue, he says. He prefers to use electrodesiccation and transection of the infundibulopelvic ligament or clips. If the ovary is densely adherent to the pelvic sidewall, Nezhat says, it is very important to perform retroperitoneal hydrodissection, meticulous adhesiolysis, and removal of the peritoneum underlying the ovary.
The need for restraint in managing functional cysts is underscored by the fact that some patients in our series had only a corpus luteum resected at first laparotomy, he says. Be sure to remove all the fragment. Once the condition is diagnosed, Nezhat says, the best course is removal of the ovarian fragment; hormonal suppression with oral contraceptives and GnRH agonist usually does not work. However, he says it is not unusual for women to undergo repeated operations for ovarian remnant syndrome, with a relatively high laparotomy complication rate.
The challenge and complications are directly related to the presence of extensive pelvic and abdominal adhesions from multiple previous operations, endometriosis, and pelvic inflammatory disease, Nezhat says. To improve the odds of success with the surgery, he says, consider using clomiphene citrate or human menopausal gonadotrophin to increase the size of the ovarian remnant. That will help confirm the diagnosis before surgery and also help you locate the remnant during the procedure.
Nezhat recommends using preoperative bowel prep of GoLytely, enemas, and oral metronidazole. Expect abdominal wall adhesions if the patient has had multiple laparotomies, as many of these patients have. If adhesions are expected, Nezhat suggests using an open laparoscopy or left upper quadrant placement with a mapping technique. Once all the instruments are inserted, lyse all the intra-abdominal adhesions and dissect the ovarian remnants. If the ovarian remnant is adherent to the lateral pelvic wall, inject the space beneath the peritoneum with lactated Ringer's solution and open the peritoneum to the infundibulopelvic ligament or its remnant. The adhesions should be lysed until you can trace the course of the major pelvic blood vessels and the ureter, Nezhat says. Desiccate the ovarian blood supply with bipolar forceps and excise the tissue, which should be submitted for histologic examination. If the remnant is adherent to the bowel, Nezhat advises lysing the adhesions using hydrodissection and a CO2 laser. Remove any ovarian tissue embedded in the muscularis of the bowel, skinning the mucosa beneath it. Imbricate the serosa and muscularis layers with one to three interrupted 4-0 polydioxanone sutures in one layer, Nezhat says.