Oophorectomy

Anatomy and Physiology

Anatomy

The ovaries are the female gonads responsible for producing most of a female’s sex hormones and facilitating ovulation. In infants and young children, the ovaries are located intra-abdominally around the T10 vertebral level and have an ovarian volume of less than 2 cc.[4][5] As females mature through adolescence, the ovaries descend below the pelvic brim and increase in volume to approximately 10 cc on average.[5] In postmenopausal females, the ovaries remain in the same adult location; however, radiographically, they resemble the ovaries of a premenarchal female.

Blood Supply

The blood supply to the ovaries is primarily through the ovarian artery, which passes through the infundibulopelvic (IP) ligament (also known as the IP ligament or suspensory ligament of the ovary). There are also anastomoses with the ovarian branch of the uterine artery via the utero-ovarian ligament.[1] The ovarian artery is a direct branch of the aorta. The right ovarian vein drains directly into the inferior vena cava, while the left ovarian vein drains into the left renal vein.[1] Notably, the IP ligament is in close proximity to the ureter, fallopian tube, and iliac vessels, so care must be taken to avoid injuring these structures during an oophorectomy.

Lymphatics

The ovary has 3 primary lymphatic drainage pathways. The 2 most common routes are through the IP ligament to the paraaortic lymph nodes and through the ovarian ligament to the pelvic lymph nodes, including the internal iliac, external iliac, and obturator nodes.[6] A less common, although documented, drainage pathway is through the round ligament to the inguinal nodes.[6]

Histology

Histologically, the ovaries consist of the medulla, cortex, and mesothelium. The inner medulla is composed of ovarian stroma, which contains spindle-shaped fibroblast-derived cells and their collagen matrix, along with other active cell types such as smooth muscle cells and luteinized stromal cells.[5] Together, this forms a reticular matrix that intermingles with the cortex and intertwines with the follicles. The cortex houses hormonally active cells and serves as a reservoir of primordial follicles.

The follicles are formed in utero and, over time, undergo atresia or mature to ovulation. A follicle consists of a primary oocyte surrounded by a concentric network of hormonally active cells regulated by positive and negative feedback systems. The outermost layer of the ovary, the mesothelium, is composed of a single layer of flat to cuboidal or columnar epithelium.[5] Ovarian cancer originating from the surface epithelium is the most common type in women aged 20 or older, although neoplasms can develop in any cell line.[5]

Indications

Adnexal Masses

The management of adnexal masses depends on factors such as age, mass progression, radiographic characteristics, tumor markers, disease process, and symptoms.[7] If ovarian malignancy is suspected in an adult, a consultation with gynecologic oncology is recommended for treatment planning.[7] In pediatric and adolescent populations, managing suspected ovarian malignancies requires a multidisciplinary team approach. Regardless of the patient’s age, caution must be taken during oophorectomy for suspected malignancy to prevent intra-abdominal rupture and spillage of mass contents.[7]

Simple cysts in adults can be managed expectantly if asymptomatic and less than 10 cm, although they carry a risk of torsion.[7] Asymptomatic complex masses suspected to be teratomas or endometriomas can also be monitored with serial imaging, but they may eventually require surgery.[8]

Ovarian cystectomy or oophorectomy may be performed during pregnancy, ideally in the second trimester, if malignancy is suspected, the risk of torsion is high, or significant symptoms are present. When benign pathology is suspected, and an ovarian cystectomy is planned, there is an inherent risk of oophorectomy if the ovarian stroma is denuded, the mass cannot be fully excised, or bleeding cannot be controlled.

Torsion

If ovarian torsion is suspected, prompt surgical intervention with detorsion and possible cystectomy is necessary, especially if childbearing is desired. Untwisting the ovary and preserving its function helps maintain fertility. Oophorectomy should only be considered if the ovary is severely necrotic and friable.[9] In postmenopausal patients, salpingo-oophorectomy may be advisable due to the potential for malignancy and to prevent recurrence.[10]

Infection

Oophorectomy for pelvic inflammatory disease with tubo-ovarian abscess (TOA) is rarely indicated, as antibiotics remain the first-line treatment. Depending on the size of the TOA and response to antibiotics, fluid drainage may be considered.[7] A recent study compared laparoscopic drainage of TOA to image-guided (computed tomography [CT] or ultrasound) drainage and antibiotic therapy alone. The authors concluded that while antibiotics alone should be the initial approach, image-guided drainage combined with antibiotics is more effective than laparoscopic drainage.[11]

Elective

Elective bilateral salpingo-oophorectomy (BSO) involves the removal of both fallopian tubes and ovaries without a specific indication, and it is typically performed during a hysterectomy due to its surgical nature and convenience. This decision should be carefully discussed with the patient during the preoperative planning phase, as the risk of surgical menopause must be carefully considered. Performing a BSO for benign disease in women aged 65 or younger is associated with an increased risk of all-cause mortality.[12] 

Other recent studies have found that the removal of both tubes and ovaries during a nonmalignant hysterectomy is associated with increased all-cause mortality in women aged 50 or younger but not in those aged 50 or older. While BSO is associated with a reduced risk of ovarian cancer, the optimal age for performing an elective BSO during a hysterectomy remains controversial.[13][14]

Risk-Reducing

Risk-reducing BSO (which may also be unilateral) involves removing both fallopian tubes and ovaries to decrease the risk of re-operation or cancer. The risks of re-operation should be weighed against the risks of menopause, particularly in patients with a history of pelvic inflammatory disease, TOAs, endometriosis, pelvic adhesions, or primary dysmenorrhea.[1] Other candidates for risk-reducing BSO include individuals with hereditary syndromes, such as BRCA mutations, which significantly increase the lifetime risk of ovarian malignancy or hormone-sensitive breast cancers.[1] 

Fertility Preservation

Oophorectomy for ovarian tissue cryopreservation is still considered experimental for fertility preservation, although it is an evolving field. Since 2004, this technique has resulted in over 100 live births.[15][16]

Contraindications

No absolute contraindications exist for oophorectomy; however, as the ovaries provide essential hormones and fertility, the risks and benefits of the procedure, particularly in the case of bilateral oophorectomy, should be thoroughly discussed with the patient beforehand. Estrogens have complex, broad effects that are still being understood, yet they appear to have a key role in cardiovascular, bone, and psychosocial health.[17]

According to the Nurses’ Health Study, BSO performed during hysterectomy for benign pathology reduces the risk of breast and ovarian cancer but is associated with an increased risk of all-cause mortality.[12] Additionally, BSO increases the risk of both fatal and nonfatal coronary heart disease and lung cancer without improving survival.[12]

Specifically, in pediatric and adolescent patients with benign ovarian lesions, ovarian-sparing surgery should be prioritized.[18] In cases of ovarian torsion in young patients, the goal is a prompt surgical intervention with detorsion and, if necessary, cystectomy.[9] Oophorectomy should only be considered if it is absolutely unavoidable.[9]

Equipment

The following equipment is typically required for performing a laparoscopic oophorectomy:

• Laparoscopic monitor
• Laparoscope (5/10 mm, 0/30 degrees)
• Carbon dioxide source and tubing for insufflation
• Two 5 mm trocars
• One 5 mm to 12 mm trocar (umbilical, larger if removal of the adnexal mass is required)
• Atraumatic graspers
• Electrocautery or ligation device
• Endoscopic retrieval bag
• Scalpel (#11 or #15 blade)
• Forceps
• Needle driver
• Absorbable sutures
• Incision dressing of choice

Personnel

The following personnel are typically involved in a laparoscopic oophorectomy procedure:

• Operating surgeon
• Surgical assistant
• Scrub technician or scrub nurse

Preparation

Proper preparation is essential for a successful laparoscopic oophorectomy. Key considerations include:

• Ensuring the patient is medically optimized.
• Indicating preoperative antibiotics is unnecessary unless additional procedures are performed or an infection is suspected.
• Applying a grounding pad.
• Evaluating the need for Foley catheter placement.
• Positioning and cushioning the patient properly to prevent nerve injury.
• Using an anti-slip pad beneath the patient if necessary.
• Implementing sequential compression devices to the lower extremities, if indicated by institutional criteria, along with deep venous thrombosis prophylaxis.
• Maintaining an aseptic surgical field.

Technique or Treatment

Laparoscopic approaches should be preferred for oophorectomies unless there is a concern for malignancy or other factors that warrant an open approach.

Positioning

The need for vaginal access should be assessed. If access to the perineum or vagina is required for support, the patient should be placed in the modified lithotomy position with precautions to prevent injury. Otherwise, adnexal surgery can be performed with the patient in the supine position. The decision to place a Foley or urinary catheter for bladder drainage should be based on factors such as the procedure’s duration, the patient’s age, and the size of the mass.

Entry and Setup

Abdominal entry is typically performed through the umbilicus. However, if concerns exist regarding adhesions, abnormal anatomy, or the size of the adnexal mass, alternative sites such as Palmer’s point may be considered. Once intra-abdominal access is achieved, accessory trocars should be strategically positioned to optimize surgical efficiency and minimize the risk of injury. A comprehensive review of the anatomy of the anterior abdominal wall is essential to prevent vessel injury, particularly to the inferior epigastric artery, as well as nerve damage from trocars or an open incision. The patient is usually placed in the Trendelenburg position to enhance exposure of the pelvic viscera.

Surgical Steps

A right oophorectomy is generally easier to perform than a left oophorectomy due to the presence of the sigmoid colon. Multiple approaches exist for oophorectomy, with no single method proving superior. One approach begins with identifying the IP ligament, which contains the ovarian artery, along with the ureter. An incision is then made on the peritoneal surface—either with electrocautery or a sharp instrument—parallel to the IP ligament, between the ureter and the IP. Dissecting this retroperitoneal space increases the distance between the ureter and the IP ligament. Once adequately isolated, the IP ligament can be safely ligated.[1]

The mesovarium is then serially ligated up to the level of the utero-ovarian ligament, which is subsequently ligated. Once the ovary is free, it can be removed in a specimen bag or through a port site if feasible. Notably, this dissection does not include the removal of the fallopian tube. Alternatively, the adnexa can be elevated, and if the ureter is visible in the retroperitoneal space and positioned safely away from the operative field, the IP ligament can be ligated without retroperitoneal dissection.[1] Dissection would then proceed as previously described. Alternatively, if ergonomically favorable, the oophorectomy may begin with ligation of the utero-ovarian ligament, followed by serial ligation of the mesovarium, and conclude with ligation of the IP ligament.

Special Considerations

When performing a risk-reducing oophorectomy, ligating the IP ligament 2 cm proximal to the ovarian hilum is crucial to ensure no pathology remains. The tissue should be sectioned according to protocol by the pathology department to rule out malignancy.[1] For left-sided oophorectomy, mobilization of the sigmoid colon may be required to visualize all relevant anatomy.[1] When removing a benign ovarian mass, with or without oophorectomy, the mass should be placed in a retrieval bag and brought to the skin through a port, which may need to be extended. Notably, it is important to maintain the integrity of the retrieval bag during this process.[1]

Complications

Large Vessel

The risk of large vessel injury during gynecologic laparoscopic surgery ranges from 0.1% to 0.64%, making it a rare occurrence.[19] No surgical entry technique has been proven superior in preventing this complication.

Genitourinary Tract

Genitourinary tract injuries occur in 1% to 2% of gynecologic surgeries, with higher rates in patients with predisposing risk factors.[19] Unfortunately, most ureteral injuries go unrecognized intraoperatively, making heightened awareness during the postoperative period essential.

Nerve

Neuropathies occur in about 2% of major gynecologic surgeries.[20] Positional and retractor-related neuropathies occur more often in patients who are overweight or underweight, have preexisting mobility issues, undergo prolonged procedures, require steep Trendelenburg positioning, or experience frequent intraoperative repositioning.[19] Proper preoperative positioning is important to minimize this risk, although most of these nerve injuries improve or resolve over time.[19]

Clinical Significance

Oophorectomy is generally considered a low-risk, outpatient procedure, but its indications and long-term implications are significant. In cases involving adnexal masses, preoperative evaluation with imaging and laboratory data are improving, although it is not yet fully reliable in predicting tissue histology.[7]

Similarly, imaging is a helpful modality when torsion is suspected; however, this remains a clinical suspicion, with surgical confirmation occurring in only 50% of cases, indicating room for improvement.[9] Surgical techniques for ovarian tissue cryopreservation are still being investigated, and this form of fertility preservation remains in the experimental phase.[16]

Enhancing Healthcare Team Outcomes

Oophorectomy, whether performed alone or in conjunction with a hysterectomy, generally yields excellent outcomes. Most oophorectomies are conducted as outpatient procedures. Laparoscopic oophorectomy should be considered the standard approach unless an open technique is specifically indicated. As fertility preservation techniques continue to evolve, recommendations for oophorectomy may change, particularly regarding the starting point for dissection and whether electrocautery or sharp dissection provides better outcomes.[15][16]