In gynecologic surgery, the management of ovarian masses often requires removal of both ovaries and fallopian tubes, especially when the pathology is bilateral or there is suspicion of malignancy. Bilateral salpingo-oophorectomy (BSO) is the surgical procedure involving removal of both ovaries and fallopian tubes. Traditionally, these specimens were removed through laparotomy or laparoscopic ports. However, with advancements in minimal access surgery, transvaginal retrieval has emerged as a safe, effective, and cosmetically superior method.

Indications for Bilateral Salpingo-oophorectomy

BSO is performed for several reasons, most notably when there is an ovarian mass. Dr. R.K. Mishra and other minimally invasive experts highlight the following indications:

Benign Ovarian Masses: Large cysts, dermoid cysts, or endometriomas that involve both ovaries.

Borderline Ovarian Tumors: For risk reduction and complete excision.

Malignancy Suspicion: When frozen section or preoperative imaging suggests malignancy.

Risk Reduction Surgery: In women with BRCA1/BRCA2 mutations or strong family history of ovarian and breast cancers.

Severe Tubo-ovarian Disease: Secondary to pelvic inflammatory disease or extensive endometriosis.

Preoperative Considerations

Imaging: Ultrasound, MRI, or CT scan to evaluate mass size, bilaterality, and suspicion of malignancy.

Tumor Markers: CA-125, CEA, and HE4 may guide management.

Counseling: Patients are counseled regarding surgical menopause, fertility implications, and hormonal changes.

Consent: Includes consent for conversion to laparotomy if malignancy or complications arise.

Surgical Technique
Patient Positioning and Anesthesia

The patient is placed in lithotomy position under general anesthesia.

Trendelenburg tilt facilitates exposure of pelvic organs.

Port Placement

Standard laparoscopic entry with 10 mm umbilical camera port.

Two or three accessory 5 mm ports in lower quadrants.

Exploration

Initial laparoscopy to evaluate ovarian mass, peritoneum, uterus, and surrounding organs.

Adhesions, if present, are released to mobilize the adnexa.

Bilateral Salpingo-oophorectomy

Step 1: Identification of infundibulopelvic ligament and ureter to prevent injury.

Step 2: Sealing and Division of infundibulopelvic ligament with bipolar cautery or ultrasonic shears.

Step 3: Dissection of mesosalpinx and detachment of ovary and tube.

Step 4: Repetition on contralateral side for bilateral removal.

Specimen Containment

Ovaries and tubes are placed in an endoscopic retrieval bag to prevent spillage of cystic content.

This is crucial to minimize peritoneal contamination in case of borderline or malignant pathology.

Transvaginal Retrieval

A posterior colpotomy (incision in the posterior vaginal fornix) is created under laparoscopic guidance.

The retrieval bag containing the adnexal specimens is guided into the vagina.

Masses are delivered intact or, if large, carefully morcellated inside the bag to prevent spillage.

Vaginal incision is sutured laparoscopically after specimen removal.

Advantages of Transvaginal Retrieval

No Abdominal Extension: Avoids enlarging abdominal ports for specimen extraction.

Better Cosmesis: No additional visible scars.

Reduced Postoperative Pain: Vaginal extraction is less painful compared to extension of abdominal incisions.

Safe Containment: Bag-assisted retrieval minimizes risk of spillage.

Shorter Recovery: Patients return to normal activities quickly.

Disadvantages and Limitations

Technical Expertise Required: Surgeons must be skilled in colpotomy and vaginal closure.

Limited by Mass Size: Very large ovarian masses may require careful morcellation.

Contraindications: Not suitable in women with vaginal stenosis, active pelvic infection, or those refusing transvaginal route.

Potential Complications: Vaginal cuff infection, dyspareunia, or injury to adjacent structures.

Postoperative Care

Early ambulation and pain control with non-opioid analgesics.

Oral intake resumed within hours.

Vaginal hygiene instructions provided to prevent infection.

Follow-up for histopathology results and counseling for hormonal therapy if premenopausal.

Oncological Safety

Dr. Mishra and leading gynecologic surgeons emphasize that oncological principles must always be respected:

Use of endobags to prevent tumor spillage.

Avoidance of uncontrolled morcellation if malignancy is suspected.

Sending specimens intact whenever feasible.

When malignancy is confirmed, staging or further oncological surgery may be required.

Conclusion

Bilateral salpingo-oophorectomy with transvaginal retrieval is a modern, minimally invasive approach that combines oncological safety with patient-centered benefits. It reduces abdominal trauma, improves cosmesis, and accelerates recovery, making it especially valuable for women undergoing surgery for ovarian masses.

When performed by skilled laparoscopic surgeons, this technique stands as a safe, effective, and elegant solution, reflecting the continuous evolution of gynecologic minimal access surgery.