LAPAROSCOPIC
APPROACH IN THE OVARIAN VEIN SYNDROME
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ARAKÉN ALMEIDA, FRANCISCO CAVALCANTI, SÁVIO BARBOSA, ROBERTO COHEN, AMAURY MEDEIROS
Oswaldo Cruz University Hospital, Pernambuco University, Recife, Pernambuco, Brazil
ABSTRACT
Introduction:
The main objective of this article is to describe ureterolysis and ovarian
vein resection laparoscopic technique.
Surgical technique: With the patient in
a 45o flank position, 3 trocars are used, 1 of 12 mm in the umbilicus
for the optic passage, and 2 of 5 and 10 mm inserted in right hypochondrium
and iliac fossa, respectively, for the forceps and stapler passage. The
ureter and ovarian vein are identified after the mobilization of the colon.
Both structures are dissected, with one ovarian vein segment is resected
between metallic clips.
Comments: the ureteral approach by transperitoneal
laparoscopy and colon mobilization facilitates its dissection, identify
its relation to other structures, as well as making possible the concomitant
treatment of gynecological diseases. For the ovarian syndrome treatment,
ureterolysis and ovarian vein resection are performed, using only 3 trocars.
Owing to its simplicity, low morbidity, and good results obtained, this
procedure represents a good option for the surgical management of this
syndrome.
Key words:
laparoscopy; ovary; veins; syndrome; therapeutics
Int Braz J Urol. 2003; 29: 45-7
INTRODUCTION
The therapeutic procedure for the ovarian vein syndrome varies according to the intensity and urgency of the clinic presentation. In nulliparous women, non-pregnant multiparous women and in children, the treatment is conservative. Yet, pregnancy may promote an intensification of this condition, leading to the necessity of a surgical intervention (1). We present case report of 1 ovarian vein syndrome treated by laparoscopic approach, with surgical technique description.
CASE REPORT AND SURGICAL TECHNIQUE
A
26 years-old patient, 62 kg, 1.68 m (BMI = 22), with right lumbar pain
and 8 months recurrent urinary tract infections complaints, also with
obstetric history of 3 gestations, was submitted to ureterolysis and right
ovarian vein laparoscopic resection in our Unit, using the technique described
as follows. Diagnosis was established by intravenous pyelogram and computed
tomography (Figures-1 and 2).
Surgical technique: With the patient in
a 45° flank position, a 15 mm incision is performed in the umbilical
area, including skin and aponeurosis. After the peritoneum incision, the
Hasson trocar is inserted and fixed, allowing the 0° optic passage.
Insufflation is initiated, maintaining the pneumoperitoneum under a pressure
of 12 to 15 mm Hg. Under direct vision, 2 trocars of 5 and 10 mm are also
inserted at the level of the right midclavicular line, in hypochondrium
and iliac fossa, respectively, admitting forceps and stapler passage.
The surgical table is rotated laterally, maintaining the patient in a
45° left lateral decubitus. The incision in the Toldt line is performed,
mobilizing the colon medially. The ovarian vein plexus is identified,
considering its course and relation to the ureter. Both structures are
dissected, releasing the ureter and isolating the ovarian vein plexus,
in a sufficient extension for its transection between metallic clips,
approximately 2 cm above and below where it cross the ureter. The segment
of the ovarian vein is pulled out, and then both trocars are removed under
direct vision.
The pneumoperitoneum is reverted and the
10 mm aponeurosis incisions are sutured with absorptive suture. The adhesive
plaster is placed over the incisions after the skin is sutured with intradermic
stitches.
The procedure was performed in 45 minutes.
Per- and postoperative period were uneventful, and the patient progressed
well, without analgesic requirements in the immediate postoperative period,
being discharged 36 hours after surgery. In a follow-up of 18 months,
the patient remained asymptomatic, with negative uroculture results every
3 months and with no radiologic signs of ureteral obstruction (Figure–3).
COMMENTS
In
the ovarian vein syndrome, the symptoms appear usually in multiparous
women, being unusual in nuliparous women and children. It may also occur
during or immediately after labor, and in non-pregnant women before menstrual
period (2).
In 1996, Elashry et al. (3) published the
results of 6 patients with benign extrinsic ureteral obstruction, submitted
to successful ureterolysis by laparoscopic approach. In 4 cases, patients
presented retroperitoneal fibrosis, one case was due to ovarian disease,
and one case was the ovarian vein syndrome, the latter was the first case
reported in literature on a patient submitted to a laparoscopic surgery
management.
In 1998, Marcovich & Wolf Jr. (4) published
the second case of ovarian vein syndrome managed by ureterolysis and ovarian
vein laparoscopic resection, highlighting the benefits of this technique,
such as the diagnostic value of direct inspection of pathologic anatomic
conditions, the low postoperative morbidity related to pain reduction,
and the excellent cosmetic results.
Owing to its simplicity, low morbidity,
and good results attained, the laparoscopic approach represents a good
option for the surgical management of this syndrome.
REFERENCES
- Hubmer G: The ovarian vein syndrome. Eur Urol. 1978; 4:263-8.
- Dykhuizen RF, Roberts JA: The ovarian vein syndrome. Surgery Gynec Obstet. 1970; 130:443-52.
- Elashry OM, Nakada SY, Wolf Jr JS, Figenshau RS, McDougall EM, Clayman RV: Ureterolysis for extrinsic ureteral obstruction: a comparison of laparoscopic and open surgical techniques. J Urol. 1996; 156:1403-10.
- Marcovich R, Wolf Jr JS: Laparoscopy for the treatment of positional renal pain. Urology 1998; 52:38-43.
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Received: October 10, 2002
Accepted after revision: January 24, 2003
_______________________
Correspondence address:
Dr. Arakén Almeida
Rua do Paissandu, 667 / 13
Recife, PE, 52010-000, Brazil
Fax: + 55 81 3222-2024
E-mail: arakenaa@elogica.com.br