Box 24-1 Master Surgeon's Corner
Identify the ureter before dividing the infundibulopelvic (IP) ligament.
Divide the IP ligament at least 2 cm from the proximal ovarian border.
For prophylactic bilateral salpingo-oophorectomy, cauterize the uterine cornua to ablate the tubal remnant.
Unilateral salpingo-oophorectomy (USO) and bilateral salpingo-oophorectomy (BSO) are performed for a wide variety of indications. In gynecologic oncology, there is a fundamental distinction between USO/BSO performed for an identified lesion (eg, pelvic mass, ovarian cyst) and risk-reducing salpingo-oophorectomy (RRSO) performed to decrease the risk of subsequent ovarian and breast cancer in women at increased genetic risk. Indications for USO/BSO for symptoms or suspected ovarian malignancy are detailed more completely in Chapter 11. Recommendations for RRSO should be based on the individual woman's risk for ovarian cancer. In the recent report of the Society of Gynecologic Oncologists Clinical Practice Committee, Berek et al1 detail these risk groups. Women with BRCA1 and BRCA2 mutations may reduce their risk of an associated gynecologic cancer by 96% and their risk of an associated breast cancer by 50% to 80% by undergoing RRSO after completion of desired childbearing. Women without a germline mutation who are at higher than average risk because of a strong family history of breast or ovarian cancer may also benefit from RRSO, but the absolute risk reduction is less clear. In premenopausal women at average risk for ovarian cancer undergoing hysterectomy for benign disease, the decision for oophorectomy should be individualized based on the patient's personal risk factors.
Clinical outcomes after salpingo-oophorectomy as an isolated procedure are determined by both the surgical approach and menopausal status of the patient. Minimally invasive USO/BSO is generally an outpatient procedure with a short recovery period and low complication rate, whereas recovery after USO/BSO requiring laparotomy is longer as determined by the larger incision. Oophorectomy in premenopausal women results in menopausal symptoms in the majority of patients. Subsequent therapy for surgical menopause is determined by the severity of symptoms, specific risks related to hormone therapy, and patient choice. There are several studies suggesting an overall negative health impact when BSO is performed before the age of menopause. Among other findings, an observational study from the Nurse's Health Study found that women younger than 50 years who had BSO and never used estrogen had increased rates of all-cause mortality, coronary heart disease, and stroke.2
Preoperative evaluation for most patients consists of physical examination and radiologic and/or serologic studies. Pertinent examination findings include the size and mobility of a palpable mass, associated or referred pain symptoms, or the presence of adjacent cul-de-sac nodularity. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can each play a role in preoperative characterization of adnexal findings and associated abnormalities within and outside of the pelvis. Serologic studies can include both standard preoperative testing (eg, complete blood count, chemistry, ...