Salpingo Oophorectomy

PREOPERATIVE
Patient Evaluation
T is surgery is typically per ormed to remove
ovarian pathology that has been evaluated sonographically. I anatomy is unclear,
magnetic resonance (MR) imaging may add
in ormation. As listed in Chapters 35 and 36
(pp. 742 and 761), tumor markers are selectively drawn prior to surgery i malignancy
is suspected.
INTRAOPERATIVE
Surgical Steps
Anesthesia and Patient Positioning.
Salpingo-oophorectomy per ormed via laparotomy typically requires general anesthesia to allow staging o the upper abdomen i
malignancy is ound. T e patient is supine.
A ter anesthesia induction, hair in the
planned incision path is clipped i needed;
a Foley catheter is inserted; and abdominal
preparation is completed. Because o a possible need or hysterectomy i malignancy is
ound, the vagina is also surgically prepared.
Abdominal Entry. Either a transverse or
vertical incision may be used or SO. Clinical
actors such as ovarian size and risk o malignancy in uence this selection, as discussed on
page 926.
Following abdominal entry, cell washings
rom the pelvis and upper abdomen are collected prior to ovarian manipulation. T ese
are sent or pathologic evaluation i cancer
is ound. T e upper abdomen and pelvis are
explored. Peritoneal or omental implants are
sampled and sent or intraoperative rozensection analysis.
Ureter Location. Because o its close

proximity to the IP ligament, the ureter is
identi ed prior to clamp placement. In many
instances, the ureter is seen beneath the posterior pelvic sidewall peritoneum. Here, it
can o ten be identi ed as it enters the pelvis and crosses over the common iliac artery
bi urcation just medial to the ovarian vessels.
In other cases, retroperitoneal isolation o the
ureter is required. For this, the peritoneum
within the area bounded by the round and
IP ligaments and the external iliac vessels is
tented with tissue orceps and incised. T is
rst peritoneal incision is extended cephalad
toward the pelvic brim (Fig. 43-6.1). T e
incision also later assists in isolating the IP
ligament or ligation. Once this peritoneal
window is open, blunt dissection is directed
deep, cephalad, and slightly medially through
gauzy areolar connective tissue (see Step 6 o
abdominal hysterectomy, p. 952). T e ureter
is typically ound attached to the medial lea
o the incised peritoneum.
Infundibulope lvic Lig ament. T e
adnexa is li ted rom the pelvis and inspected.
o isolate the IP ligament, a second peritoneal
opening is sharply created with Metzenbaum
scissors or electrosurgical blade. It is made
in the posterior lea o the broad ligament
below the IP ligament but above the ureter.
Consent
In general, serious complications with SO
are in requent but include organ injury,
especially to the ureter; hemorrhage; wound
in ection or dehiscence; and anesthesia complications. Ovarian pathology is the most
common indication or SO. T us, the possibility o cancer staging and a description
o its steps are explained. Moreover, malignant cyst rupture and spillage are risks, and
patients are in ormed that this will advance
the cancer stage (Chap. 35, p. 748). Many
women undergoing SO or ovarian pathology have associated pain. Although removal
o the ovary in most cases will be curative,
in other instances, pain may persist despite
SO. Last, i per ormed bilaterally, SO dramatically curtails estrogen production. T us,
a preoperative discussion o consequences, as
outlined on page 951, is recommended.
FIGURE 43-6.1 Retroperitoneal entry.
C
H
A
P
T
E
Removal o the ovary and allopian tube is

more commonly per ormed by laparoscopy.
However, laparotomy is typically indicated
i the potential or malignancy is great, i
the ovary is larger than 8 to 10 cm, or i
extensive adhesions are anticipated. With
either approach, the essential steps o salpingo-oophorectomy (SO) are: preventive
identi cation o the ipsilateral ureter, in undibulopelvic (IP) ligament ligation, combined
ligation o the proximal allopian tube and
uteroovarian ligament, and transection o the
intervening mesovarium and mesosalpinx.
Indications are varied and include suspicion
or ovarian malignancy, ovarian cancer prevention or at-risk women, large symptomatic
ovarian cysts in postreproductive emales, and
or reproductive-aged women, large, symptomatic ovarian cysts that are not suitable or
cystectomy.
Bowel preparation and antibiotics are typically not required preoperatively. I hysterectomy is required during ovarian staging,
antibiotics may be given intraoperatively.
Laparotomy dictates venous thromboembolism prophylaxis, and options are ound in
able 39-8 (p. 836).
Exposure. A sel -retaining retractor such

as an OConnor OSullivan or Bal our retractor
is placed, and the bowel is packed rom
the operating eld. T e a ected adnexa
is grasped and elevated rom the pelvis. I
extensive adhesions are ound, normal anatomic relationships are restored.
Salpingooophorectomy
Patient Preparation
43 6
935
Surgeries for Benign Gynecologic Disorders
Atlas of Gynecologic Surgery
936
FIGURE 43-6.2 Infundibulopelvic ligament ligation.
T is incision is extended medially beneath

the allopian tube and uteroovarian ligament
and toward the uterus. While remaining parallel to the IP ligament, it is also extended
lateral and cephalad towards the pelvic brim.
Ideally, the ureter is in view during this entire
incision.
As a result o both peritoneal incisions,
the IP ligament is isolated. T is vascular ligament is then clamped with a Heaney or other
sturdy clamp, and the clamp curve aces
upward (Fig. 43-6.2). O note, i SO is perormed or cancer risk reduction, the clamp
is brought across the IP close to the sidewall.
A single Kelly (pean) clamp is placed across
the IP at a distance medial to the Heaney
clamp. During completion o adnexectomy,
this medial clamp prevents back-bleeding
and is removed with the specimen.
As shown, the ligament is transected
between the Heaney and Kelly clamps. o
ligate the IP pedicle, a ree tie o 0-gauge
delayed-absorbable suture is placed around
the Heaney clamp. As the knot is secured,
FIGURE 43-6.3 Ligation of uteroovarian ligament, fallopian tube

ligation, and proximal adjacent mesovarium and mesosalpinx.
this clamp is opened and closed quickly,

that is, ashed. Next, a trans xing suture
is placed around the Heaney clamp (Fig.
40-22, p. 853). T is suture is placed below
the clamp yet distal to the rst ree tie to
avoid hematoma ormation by needle puncture o ovarian vessels. As this knot is cinched
in place, the Heaney clamp is removed.
issue between the stacked clamps is cut with

curved Mayo scissors to ree the adnexa.
T e reed adnexa is removed rom the operative site and sent to pathology or evaluation. I
malignancy is suspected, an intraoperative rozen section is requested. issue within each o
the remaining two clamps is individually suture
ligated with 0-gauge delayed-absorbable suture.
Fallopian Tube and Uteroovarian

Ligament. With the adnexa elevated, a
Heaney or similar clamp is placed across both
the proximal uteroovarian ligament and allopian tube. It also incorporates some o the
mesosalpinx and mesovarium. T e clamps
curve aces the ovary. Next, another clamp
enters laterally and is directed medially to
close around the remaining mesosalpinx and
mesovarium beneath the ovary (Fig. 43-6.3).
Again, the clamp curve aces the ovary.
Ideally, the tips o both clamps touch beneath
the adnexa. Above both o these clamps are
stacked second clamps, which lie a distance
above their partners and closer to the ovary.
Wound Closure. T e retractor and

packing sponges are removed rom the abdomen. T e abdominal incision is then closed
as described or vertical or P annenstiel incisions (pp. 928 and 930).
POSTOPERATIVE
Patient recovery is similar to that described
or laparotomy (p. 928). In reproductive-aged
women, i only one ovary is removed, hormonal and reproductive unction is preserved.
However, i both are excised, then surgical
menopause ollows, and hormone replacement
is considered (Chap. 22, p. 494).

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PREOPERATIVE

Ureter Location. Because o its close

FIGURE 43-6.1 Retroperitoneal entry.

Removal o the ovary and allopian tube is

Exposure. A sel -retaining retractor such

Surgeries for Benign Gynecologic Disorders

Atlas of Gynecologic Surgery

FIGURE 43-6.2 Infundibulopelvic ligament ligation.

T is incision is extended medially beneath

FIGURE 43-6.3 Ligation of uteroovarian ligament, fallopian tube

this clamp is opened and closed quickly,

issue between the stacked clamps is cut with

Fallopian Tube and Uteroovarian

Wound Closure. T e retractor and

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