TITLE: 

"Fine-Tuning Laparoscopic Technique in unilateral hemi-oophorectomy with contralateral oophoropexy:” Insights from surgical fertility preservation in a 16-year-old with perineal rhabdomyosarcoma 

DESIGN:

Case report 

OBJECTIVE : 

To describe the laparoscopic techniques to optimise fertility preservation outcomes and minimise the risk of iatrogenic Premature Ovarian Insufficiency,in a postpubertal girl with high risk fusion-positive perineal rhabdomyosarcoma undergoing chemotherapy and pelvic irradiation 

FINDINGS:

Here,a four port laparoscopic entry technique was employed. Left sided hemi-oophorectomy was performed due to higher irradiation dose to this side.A 2-3mm rim of ovarian cortical tissue was preserved,and division of the ovarian artery from the Infundibulopelvic Ligament(IPL) was performed as the last step in the hemi-oophorectomy procedure. The ovary was carefully extracted to minimise crush injury. 

Contralaterally, the IP ligament was dissected at the level of the pelvic brim to mobilise the ovary, after exploring the pelvic side wall. The peritoneal incision was extended both cranially and to the ovarian ligament. Thereafter, the fallopian tube was divided from the IPL. This allowed the ovary to be pedicled upto the level of the pelvic brim and outside the field of radiation. 

The procedure was uneventful and the patient was discharged within 24 hours. 

CONCLUSIONS:

In this case, retaining both the fallopian tubes allowed the option of natural fertilisation and thereby a possible spontaneous future pregnancy. It may also influence endometrial health,given tubal contribution to uterine blood flow.Emerging research suggests the fallopian tubes may contain stem cells or signalling mechanisms that could aid ovarian tissue function if re-implanted,,though evidence to this is currently limited. 

Ovarian cortical rim preservation allows endogenous hormone production and allows natural conception in some cases, given primordial follicular viability is maintained.Also,compared to a complete oophorectomy, this procedure is less invasive. However, the risk of adhesion formation and vascular compromise to residual ovarian tissue cannot be ignored. 

This approach is particularly beneficial in prepubertal girls or in postpubertal patients with aggressive disease in whom treatment start cannot be delayed. 

WIDER IMPLICATIONS OF FINDINGS:

Currently, there is no universal consensus regarding ovarian tissue retrieval techniques for fertility preservation or optimum strategies to allow fertility preservation alongside endogenous hormonal production.More research,including longterm follow up,is needed to determine the safety and efficacy of these surgical techniques.