[Ovarian cyst: surgical indications and access].

Laparoscopic treatment of adnexal masses is indicated when all criteria of a benign lesion are present: transvaginal ultrasound demonstrates a mass < 5 cm, with liquid or dermoid content, with less than 3 fine partitions (< 3 mm), a thin wall (< 3 mm), no vegetations, normal Doppler. Laparoscopy is also indicated for "benign" cysts measuring 5 to 10 cm if laparoscopy is feasible. Peroperative exploration is the rule. Since the benign or malignant nature of an ovarian mass cannot be determined macroscopically, precaution must be taken to avoid potential laparoscopic dissemination: use of an extraction pouch, instrument cleaning, cytotoxic agent (chlorexidine or povidone-iodine) for trocar tracts, prevention of gas leakage, 3-plane suture of trocar orifices measuring > 10 mm, short interval between laparoscopic diagnosis of cancer and onset of chemotherapy or complete surgery (1 week). In case of pre- or peroperatively suspected malignancy, cytology examination of the peritoneal fluid and careful peroperative exploration of the abdomen and pelvis with peritoneal biopsy as needed are required. Simple cystectomy or adnexectomy may be performed, depending on the age of the patient, while waiting for the final pathology report. Peroperative intraperitoneal rupture must be avoided, converting to laparotomy if needed. If several suspicious elements are found, median laparotomy is often recommended, particularly in case of suspected cancer with extra-ovarian involvement, or if there is a risk of peroperative rupture. Peroperative pathology of the adnexectomy specimen and peroperative exploration will depend on the operator's experience and the availability of pathology examination in the operating room. First line laparoscopy allows an analysis of the operability and choice of the most appropriate access.