Listed below is the step by step procedure of oophorectomy:
- What is Oophorectomy?
- Why Oophorectomy is Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Oophorectomy
- Post Procedure
- Risks and Complications
What is Oophorectomy?
Ovaries form an important part of the female reproductive system. They are responsible for producing the hormones progesterone and estrogen, as well are the storehouse of eggs for fertilisation. A woman has two ovaries in the body. A situation may arise in which non-invasive treatments cannot recover the disturbances of the reproductive system.
Oophorectomy, also known as ovariectomy, is a surgical procedure in which one or both of a woman's ovaries are removed.
Why Oophorectomy is Required?
Reasons that may lead to removal of ovaries are as follows:
- Adnexal (Ovarian) Torsion: The ovary rotates at its own axis which decreases the amount of blood leaving from its tissue (venous return). This results in lower abdominal pain.
- Ovarian Cancer (Malignancy): An uncontrolled growth of cells that forms cancerous growths in the ovary. It accounts for 4% of all cancers in women.
- Benign ovarian tumors: Dermoid tumors and teratomas are the most commonly involved types.
- Endometriosis: The inner lining of the uterus is known as endometrium. But sometimes, the endometrium grows outside its confines of the uterine cavity along the fallopian tubes or the ovary itself. This causes pelvic pain and infertility.
- Metastasis: Cancers of the gastrointestinal tract or others may bring their deposits inside the ovary, causing secondary tumors.
- Tubo-Ovarian Abscess: It is a complication of pelvic inflammatory disease (PID) and forms as a capsule of pus inside the ovary after the infection between an ovary and its fallopian tube.
- Prophylactic Oophorectomy with/without Hysterectomy: Some women possess a mutated BRCA1 or BRCA2 gene. These mutations put them (especially perimenopausal women) at a higher risk of breast and ovarian cancer. If recognised at an early stage, the removal of ovaries reduces the risk of cancer by about 80-90%.
- Ectopic Pregnancy: The fertilised egg, implants itself anywhere else in the abdominal cavity, other than the uterus.
- You can make a list of all the questions you would like to ask your gynaecologist. You should ask about the procedure, risks, precautions and cost of the surgery. It is important that you remain fully aware of what is going to happen.
- Your doctor would ask about details of any previous disease you have suffered from and treatment taken. As the adage says 'Never lie to your lawyer and doctor,' tell him/her everything you remember. History of heart disease, liver and kidney problems, allergies, bleeding disorders and respiratory diseases are of particular interest to the doctor.
- Inform your gynaecologist of all the medications you have been taking. You should do this because certain drugs may have an effect on the outcome of the surgery. Blood thinners, such as warfarin, clopidogrel and ticlopidine or aspirin and other NSAIDS (Non Steroidal and Anti-Inflammatory Drugs and Analgesics) can further inhibit the clotting abilities of blood. It can become a hindrance during the surgical procedure because would not stop easily.
- If you are a smoker, you will need to stop it at least 6-8 weeks before surgery. Smoking inhibits the ability to heal quickly. If you still can't stop smoking, your doctor can provide you with a nicotine patch before the surgery.
- Lower your alcohol intake a few weeks before the surgery.
- Ovary removal surgery may trigger a few changes in your body. Your body should remain prepared to accept these new changes. You can start with regular physical activity some weeks before the 'procedure day.' Eat a healthy diet rich in fruits and green vegetables. Take foods which have high calcium and phosphorus content.
- If you are of reproductive age and plan for children later, discuss this with your gynaecologist. In some cases, only one ovary is removed. This way, your menstrual cycles remain normal and you can still conceive naturally. However, if both ovaries are removed but your uterus remains intact, you can go for ART (Assisted Reproductive Technology) to help you become a parent.
Before heading towards the final solution (surgery), your doctor would ask you to undergo a series of tests:
- Pelvic Exam: Your gynaecologist will palpate (feel) your lower abdominal and pelvic areas with his/her hands. Abnormal masses, cysts, tumors or scars of the uterus can be palpated for this way.
- Laparoscopy: It is a slightly invasive method of diagnosis. A small incision is made in the lower abdomen through which a laparoscope (a tube like device with camera) is inserted and the inside tissues are visualised on a monitor. Endometriosis can be diagnosed easily this way.
- Histopathological Studies: Tissue samples from the ovaries can be taken out using biopsy and taken to the lab for further studies under a microscope. Good confirmatory test for staging the cancer and endometriosis.
- Tumor Markers: These are a type of glycoproteins that are found in blood, urine or tissues in people with certain cancers. But it should be kept in mind that even though tumor markers are produced by tumor cells, they can be produced by the normal cells of the body too; either naturally or in response to malignancies.
Cancer antigen-125 (CA-125), beta human chorionic gonadotropin (Beta-hCG) are a few tumor markers of gynaecologic relevance.
It should be kept in mind that no tumor marker is entirely specific and its presence should always be correlated with other imaging and clinical findings.
- Ultrasonography: The routine standard of pelvic imaging. Sound waves are directed using a transducer on the pelvic region to check for any abnormalities in or near the ovaries. It is a useful tool in detecting Pelvic Inflammatory Disease (PID).
- Ultrasonography with Color Doppler Ananlysis: This technique is the best test to detect ovarian torsion. Apart from giving the extent of torsion, the Doppler analysis will give a real time report of the impairment of blood flow in the ovaries.
- Other Imaging Studies: Computed tomography scan (CT Scan) and Magnetic resonance imaging (MRI) are helpful in studying the ovaries. But these tests are not so commonly used as compared to ultrasonography.
Along with these tests, your anesthesiologist will order a general workup before the surgery to check your health status before the surgery:
- Blood tests: Blood sugar, blood urea, blood pressure (BP), bleeding and clotting time (BT, CT), erythrocyte sedimentation rate (ESR) are routinely performed.
- Urinalysis: Color and specific gravity of urine is evaluated. Presence of blood, pus cells, sugar and protein are looked into.
- Electrocardiogram: Measures the electrical activity of the heart and plots it on a graph paper.
- Imaging tests: Ultrasonography, CT and MRI scans are repeated one last time to get the latest update on the state of ovary(ies).
- Clinical examination: is repeated.
- Airway: The airway will be checked for suitability of intubation during anesthesia.
Day Before Surgery
- It is important that you come accompanied with a dear one, family or friend to be with you throughout the surgery.
- You can bring some loose, comfortable clothes and personal items like toiletries to the surgical center. Take along a few things to help you pass the time while in recovery like books, your I-pod, etc.
- Remember to keep all your valuables at home. Don't bring any jewellery or ornaments or wear any makeup and nailpolish. Deodorants and perfumes are best avoided.
- You would be asked not to eat or drink for at least 6 hours prior to surgery and eat a very light meal before those six hours.
- Your pubic or genital areas will be shaved before the surgery by the nursing staff.
- Take a nice bath before the day of surgery. Take care to clean the abdominal and genital areas well with a mild soap to cleanse it properly. This reduces the bacterial count and it becomes your own little contribution in reducing the risk of any infection after surgery.
- The nursing staff may give you an enema (fluid injection through your rectum) or some laxatives to clear your bowels before surgery.
- On the surgery day, the nursing staff would ask you to fill out all the documents and complete the paperwork.
- Your doctor would come and discuss the entire process of surgery one more time with you. Clarify any doubts that come to your mind.
- After discussing everything, you will be asked to sign a consent form. It explains the surgical procedure with associated risks and complications. Only after you are satisfied with the explanation and are ready to go ahead with the surgery, sign it.
- A small I/V line will be placed in your vein through which all medications (sedatives, antibiotics fluids) will be given to you. You would already be feeling drowsy before you enter the operation theatre.
- You will be draped in a clean surgical gown and taken to the operation theatre (OT). The OT is disinfected with all the instruments sterelised.
Methods/Techniques of Oophorectomy
Ovary removal surgery is of the following types:
- Unilateral oophorectomy: One ovary is removed.
- Bilateral oophorectomy: Two ovaries are removed.
- Salpingectomy: Fallopian tube(s) removed.
- Unilateral salpingo-oophorectomy: One ovary along with its fallopian tube is taken out.
- Bilateral salpingo-oophorectomy: Both the ovaries with their respective fallopian tubes are removed.
Based on the degree of surgical site being exposed, oophorectomy can be called as the following:
- Open abdominal surgery
- Laparoscopic oophorectomy
- Robotic surgery
Oophorectomy can be performed under both general and regional anesthesia.
In regional anesthesia, only the lower half of your your body will be made numb with the help of an epidural or a spinal nerve block. In this way, you will be awake. The anesthesiologist will give some sedative drugs to put you to sleep during the surgery. Lidocaine and ropivacaine are the preferred anesthetic agents for this type of anesthesia.
When you are given general anesthesia, the anesthetic agent will be administered in your body either with the help of an I/V line or by inhaling gases. General anesthesia relaxes all the muscles of your body completely and puts you in deep sleep. A tube will be put into your airway to help you breathe during the surgery. All your vitals (BP, pulse, heart activity, respiration rate) will be closely monitored by the anesthesiologist.
You will be made to lie on the operating table in a position which is a mix of lithotomy (lying on your back with your feet held apart) and trendelenburg position (body flat on the back with feet elevated by 15-30 degrees above the head level).
Open Abdominal Surgery
It is the conventional mode of surgery and removal of ovaries here is often performed in conjugation with total abdominal hysterectomy (TABH). Performed under general anesthesia, a large incision is given on the abdomen; either vertical or horizontal. A vertical incision gives more exposure to the surgeon. Now the major abdominal organs like liver, gallbladder, stomach, kidneys etc. are checked properly.
The ligaments surrounding these organs are gently manipulated and the peritoneum (covering) near the uterus is lifted. After proper exposure, the uterus and ovaries are removed by cutting off their attachments and blood supplies. The tissues are then packed and the incision is stitched (sutured).
The advantage of open abdominal surgery is that the ovaries can be removed even if they have had many previous adhesions.
This procedure is more painful and risky in comparison to its laparoscopic counterpart and poses higher post-op risks and complications.
It can be preformed under both general and local anesthesia. An instrument called a laparoscope is used. It is a lighted tube with a small camera attached at its end. Small incisions are made on the abdomen which will be the future ports of entry for the laparoscope and other surgical instruments.
The trocar (a three pointed surgical instrument used to gain entry and withdraw fluid) is first placed in the abdomen (in the area near your belly button) and then the laparoscope is inserted through it. The abdominal region is filled with carbon dioxide gas through a gas hose to allow for clear visualisation of the operative field.
The instruments are later inserted through different ports to manipulate the uterus and then the ovaries into a position for easy removal.
A robotic arm is used by the surgeon to perform the laparoscopic surgery. It uses several small incisions and may take more time than conventional laparoscopy.
On an average, the time taken to complete an oophorectomy procedure is about one to two and a half hours.
The recovery period after an oophorectomy is mostly dependent on the procedure performed.
If you are going to have an open abdominal surgery, you would be staying in the hospital for 2-4 days. Whereas if you are scheduled for a laparoscopic surgery, then only 1 day of post-operative stay is needed. If the laparoscopic surgery went well without any complications, you might as well be sent on the same day itself after the anesthesia wears off.
- After the surgery, you will be taken to a recovery room.
- The nursing staff will monitor all your vitals (blood oxygen, BP, pulse, temperature, etc.)
- Pain-relief medications will be given to help with the post-operative pain.
- You may feel some pain in your shoulders. This is because of the carbon dioxide gas used during the laparoscopic surgery. This is normal and will subside in a few days.
- Some discomfort around the incision area is common.
Take lots of rest for the initial few days. Slowly start walking everyday. This will prevent any clot formation in your legs and keep the bowel movements smooth.
You can climb the stairs if you want, but any heavy lifting or exercise should be resumed only after your doctor allows you to do so. Any sexual activity should be avoided in these days. Try not to use tampons or douche the vagina (washing with water and vinegar). Driving any vehicle should be considered only after 2-6 weeks of recovery. Deep breathing and relaxation exercises will help you get relief from any tension.
Your bowel movements may feel tighter. But don't strain your muscles. Drink more fluids, eat a fibrous diet and take medications on the advice of your doctor accordingly.
The bandages on the stitches can be removed after 24 hours, but the stitches will resorb by themselves (in case of laparoscopic surgery) or will be removed by the doctor (in case of open abdominal surgery) after 10-14 days. You can shower easily but avoid bathing in a tub. Always take care to keep your incision areas clean and dry.
Wear loose fitting clothes so that they don't irritate the skin. If you wish to apply any lotion or moisturiser near the incisions, ask for your doctor's recommendation first.
Some light vaginal discharge is normal after surgery. You will need to wear sanitary pads for a few days. You can shower within the first 24 hours after your surgery but are allowed to take a proper bath only 1 week after surgery.
Pain-killers are given to help you cope up with the post-operative pain. Stool-softeners are given to help with the constipation caused due to narcotic pain medications. Take your medications exactly according to the prescription.
With the ovaries removed, the levels of estrogen and progesterone will come down very quickly. Your gynaecologist may start hormonal replacement therapy (HRT) to control the hormonal levels.
For a complete and uneventful recovery, a period of 4-6 weeks is needed.
Risks And Complications
The risks of oophorectomy can be divided into two parts
- General Complications
- Complications associated with oophorectomy
- Anesthetic complications include the abnormalities arising due to anesthetic agent like nausea, vomiting, headache, respiratory depression and coma.
- Vascular risks include chances of formation of blood clots in the legs. This increases the risk of deep vein thrombosis.
- Risk of damage to other intra abdominal structures
- Internal bleeding
- Small bowel obstruction
Complications Associated With Oophorectomy
- There may be a decrease in libido (sex drive) and difficulty in attaining sexual arousal.
- Vaginal dryness is seen
- Increased chances of osteoporosis ( a condition in which bones become weak and brittle) due to sudden decrease in female sex hormones (estrogen, progesterone) which are responsible for maintaining bone strength and density.
- In cases where both the ovaries are removed (bilateral oophorectomy), the production of progesterone almost stops instantly. This situation is termed as surgical menopause. It is unlike natural menopause which happens gradually. Thus, symptoms of menopause like hot flashes, and vaginal dryness are seen.
- Depression and anxiety are common in women who are more prone to taking stress.
- Estrogen has a protective effect over the cardiovascular system. With the ovaries gone, the chances of being prone to heart diseases increases by about 7 times than those women who have not yet entered menopause. High blood pressure (BP), angina pectoris, heart attacks become more prominent in these cases.
- Memory problems
- Premature death
If you find any of the following signs, contact your doctor as soon as possible:
- Diarrhea that doesn't resolve within the normal time frame or bloody stools.
- A foul smelling or different coloured vaginal discharge
- Vaginal bleeding
- Pain does not subside even after taking the prescribed pain medications.
- Severe nausea or vomiting
- The incisions show signs of swelling, redness, bleeding or discharge.
You can discuss with your gynaecologist what sort of care you would need to take in the long run. You will be recalled after a period of 2 and 6 weeks post surgery to check your abdomen and pelvic region for healing. If any biopsy was done during the surgery, those reports would be discussed with you.
- When is a prophylactic oophorectomy done?
A. A prophylactic oophorectomy is recommended in women who are at a high risk of ovarian cancer. Ovaries can be removed as a preventive measure in women who are in their early forties and above and have children of their own.
- is it possible for a woman to conceive if one ovary is removed?
A. Yes, it is possible to conceive even after removal of one ovary, because the other ovary would continue to produce eggs.
- What diet should be followed after an oophorectomy?
A. You can have a simple, bland diet for the initial few days after surgery. Then include more fibrous sources and fluids to deal with post-operative constipation. After that you can resume your normal diet like before.
Oophorectomies today have become increasingly common in women in their perimenopausal period, be it due to any pathology or to decrease the risk of ovarian cancers. A routine gynaecological check up coupled with a healthy lifestyle can prevent many serious complications in the future. This article is a window to guide you with the technicalities of the surgery. It is by no means an exhaustive account and a detailed discussion with your gynaecologist will be beneficial.