Adnexal masses are a common gynecological finding in women of reproductive age and encompass a wide spectrum of conditions ranging from functional cysts to benign and malignant neoplasms. These masses often present a diagnostic and therapeutic challenge due to their varied etiology, overlapping clinical features, and the need to balance effective treatment with preservation of fertility. Accurate evaluation is therefore essential to guide appropriate management and to avoid unnecessary radical surgery in young women.[1,2] Traditionally, adnexal masses have been assessed using clinical examination, ultrasonography, and tumor markers. While these modalities provide valuable information, they may not always reliably differentiate benign from malignant lesions or determine the exact origin and nature of the mass. In such situations, direct visualization becomes crucial for definitive diagnosis and timely intervention.[3,4] Laparoscopy has emerged as a minimally invasive and highly effective tool in the evaluation of adnexal masses. It allows direct inspection of pelvic structures, assessment of mass characteristics, and simultaneous therapeutic procedures such as cystectomy or oophorectomy when indicated. Compared to laparotomy, laparoscopy offers advantages including reduced postoperative pain, shorter hospital stay, faster recovery, and better cosmetic outcomes, which are particularly important in women of reproductive age.[5] With increasing expertise and advancements in laparoscopic technology, its role in the management of adnexal masses has expanded significantly. Careful patient selection and adherence to oncological safety principles are essential to maximize benefits while minimizing risks. This article aims for laparoscopic evaluation of adnexal masses in the reproductive age group and study the spectrum of diverse pathology of adnexal masses in the reproductive age group.

This cross-sectional study was carried out in the Department of Obstetrics and Gynecology at Prathima Institute of Medical Sciences (PIMS), Naganoor, Karimnagar, after obtaining approval from the Institutional Ethical Committee. A total of 56 women belonging to the reproductive age group (18–40 years) were enrolled in the study. All selected participants had clinically suspected adnexal masses that were subsequently confirmed by ultrasonography. Inclusion Criteria Women aged between 18 and 40 years with clinically suspected adnexal masses were included in the study. Patients with ultrasonographically detected adnexal masses and those who failed to respond to medical or conservative management were also considered. Adnexal masses measuring between 5 and 10 cm with normal serum CA-125 levels and inadequate response to conservative treatment were included. Exclusion Criteria Patients with adnexal masses larger than 12 cm were excluded. Masses showing solid areas or thick septations on ultrasonography, or those associated with significantly elevated CA-125 levels (>200 mIU/ml), were not included. Pregnant women with adnexal masses, cases of ectopic pregnancy, and patients with contraindications to laparoscopy—such as morbid obesity (BMI >35) or underlying cardiac and pulmonary disorders—were excluded from the study. Clinical Evaluation and Investigations A comprehensive history was obtained from all participants, followed by a thorough general and systemic examination, including abdominal palpation to detect any mass. Per-speculum examination was performed to identify cervical or vaginal abnormalities such as infection, erosion, polyps, abnormal growths, discharge, or bleeding. Bimanual pelvic examination was conducted to assess uterine size, mobility, and the characteristics of the adnexal mass, including size, consistency, surface, mobility, tenderness, fullness in the fornices and pouch of Douglas, and the presence of nodules. Per-rectal examination was performed when clinically indicated. Routine laboratory investigations were carried out for all patients, along with chest X-ray and electrocardiography. A urine pregnancy test was done in cases where ectopic pregnancy was suspected. Ultrasonographic evaluation, preferably transvaginal ultrasound, was performed in the Department of Radiology at PIMS. The pelvis and lower abdomen were scanned in both longitudinal and transverse planes. Serum CA-125 levels were measured in all cases. Laparoscopic Procedure All patients underwent diagnostic and/or operative laparoscopy under general anesthesia using the open laparoscopy technique. A 10-mm Karl Storz laparoscope with a 30-degree viewing angle was used. A secondary port was inserted lateral to the rectus muscle to facilitate optimal visualization and comprehensive inspection of the pelvic peritoneum, along with manipulation of pelvic organs. When operative intervention was required, a third port was placed on the contralateral side. Based on intraoperative findings, procedures such as adhesiolysis, fulguration of endometriotic lesions, cystectomy, salpingectomy, salpingo-oophorectomy, or ovarian drilling were performed during the same session after obtaining informed consent. Resected specimens were sent for histopathological examination, which provided definitive confirmation of the nature of the adnexal mass. Data Collection and Analysis All observations and findings were documented using a pre-structured proforma. A master chart encompassing all relevant parameters was prepared for analysis. The results obtained were compared with findings from previously published studies and were discussed accordingly.

Table 1: Clinical Features (N = 56) Clinical Feature No. of Cases (n) Percentage Pain abdomen 20 36% Irregular cycles 7 12% Dysmenorrhoea 4 8% Dyspareunia 4 8% Infertility 7 12% Non-specific symptoms 14 24% Abdominal pain was the most common presenting symptom among patients with adnexal masses, followed by non-specific complaints. Menstrual disturbances and infertility were observed in a smaller proportion of cases, while dysmenorrhea and dyspareunia were less frequent. Table 2: Risk Factors and BMI Distribution (N = 56) Risk Factor No. of Cases (n) Percentage History of PCOS 4 8% History of PID 3 6% Ovulation induction drug usage 3 6% BMI Category < 18 (Underweight) 6 10% 18–24 (Normal) 37 66% > 24 (Overweight) 13 24% Only a minority of patients had identifiable risk factors such as PCOS, pelvic inflammatory disease, or prior ovulation induction therapy. Most patients had a normal body mass index, indicating no strong association between abnormal BMI and adnexal masses in this study population. Table 3: Bimanual Examination Findings (N = 56) Finding No. of Cases (n) Percentage Mass in fornices 13 24% Tenderness in fornices 27 48% Restricted uterine mobility 11 20% Nodules in pouch of Douglas 2 4% Bimanual examination commonly revealed tenderness in the fornices, while a palpable adnexal mass was detected in approximately one-fourth of patients. Restricted uterine mobility and nodularity in the pouch of Douglas were infrequent findings. Table 4: Ultrasonography Findings (N = 56) Structure Abnormality No. of Cases (n) Percentage Uterus Enlarged 1 2% Ovary Ovarian cyst 20 36% Torsion ovarian cyst 10 18% PCOD 10 18% Endometriotic cyst 2 4% Tubes Tubo-ovarian mass 7 12% Hydrosalpinx 3 6% Others Broad ligament fibroid 1 2% Para-ovarian cyst 2 4% Ultrasonography identified ovarian cysts as the predominant abnormality, followed by torsion cysts and PCOD. Tubal pathologies such as tubo-ovarian mass and hydrosalpinx were less common, highlighting the ovary as the most frequent site of adnexal pathology. Table 5: Laparoscopic Findings (N = 56) Site Finding No. of Cases (n) Percentage Ovary Ovarian cyst 13 24% Torsion ovarian cyst 10 18% Gangrenous ovarian cyst 2 4% PCOD 8 14% Endometriotic cyst 4 8% Dermoid cyst 1 2% Tubes Tubo-ovarian mass 4 8% Hydrosalpinx 6 10% Fimbrial cyst 2 4% Other Para-ovarian cyst 3 6% Broad ligament fibroid 1 2% Endometriotic nodules 2 4% Adhesions 11 20% POD Free fluid 13 24% Laparoscopy confirmed ovarian cysts as the most frequent intraoperative finding and provided additional information such as adhesions and free fluid in the pouch of Douglas, which were not consistently detected on ultrasonography. Table 6: Histopathological Findings (N = 56) Histopathology No. of Cases (n) Percentage Functional cyst 24 42% Hydrosalpinx 6 10% Endometriotic cyst 6 10% Para-ovarian cyst 4 8% Fimbrial cyst 3 6% Dermoid cyst 1 2% Fibroid 1 2% Mucinous cystadenoma 1 2% Histopathological examination revealed functional ovarian cysts as the most common diagnosis, followed by hydrosalpinx and endometriotic cysts, confirming the predominantly benign nature of adnexal masses in the reproductive age group. Table 7: Surgical Procedures Performed (N = 56) Procedure No. of Cases (n) Percentage Cystectomy 18 32% Salpingo-oophorectomy 16 28% Salpingectomy 9 16% Ovarian drilling 8 14% Adhesiolysis 2 4% Conversion to laparotomy 2 4% Fibroid removal 1 2% Cystectomy was the most commonly performed procedure, reflecting the emphasis on ovarian conservation in reproductive-age women. Laparoscopic management was largely safe, with minimal need for conversion to laparotomy and low complication rates.

The present study evaluated adnexal masses in 56 women of reproductive age using laparoscopy and demonstrated that the majority of adnexal masses in this age group are benign in nature and amenable to minimally invasive management. Ovarian cysts were the most common pathology identified on ultrasonography, laparoscopy, and histopathology, with functional cysts accounting for the largest proportion (42%). These findings are consistent with observations reported by Canis et al[1] who highlighted that benign ovarian cysts constitute the majority of adnexal masses in women of reproductive age and can be safely managed laparoscopically with appropriate case selection. A study conducted by Maroju Suguna and Avancha Rajeshwar[6] reported that functional ovarian cysts were the most frequently encountered pathology in their series of laparoscopically evaluated adnexal masses in reproductive-age women. Similarly, Gupta et al. [7]observed that most adnexal masses in younger women were non-malignant and could be safely managed using minimally invasive techniques when appropriate preoperative evaluation was undertaken. These findings reinforce the importance of careful patient selection using ultrasonography and serum CA-125 levels, as employed in the present study. The high proportion of benign lesions supports the growing consensus in Indian literature that laparoscopy is a reliable and safe modality for both diagnosis and management of adnexal masses in the reproductive age group, while also preserving ovarian function. In the present study, abdominal pain was the most frequent presenting symptom (36%), followed by non-specific symptoms and menstrual irregularities. Similar symptom patterns have been described by Nezhat et al[2] who reported pelvic pain as the predominant complaint in women undergoing laparoscopic evaluation for adnexal pathology. Infertility-related presentations in our study (12%) were also comparable to findings reported by Stratton et al[8] particularly in cases associated with endometriosis and tubal disease. Ultrasonography served as the primary diagnostic modality; however, laparoscopy provided superior diagnostic accuracy by identifying adhesions, endometriotic nodules, and free fluid in the pouch of Douglas that were not always evident on imaging. This diagnostic advantage of laparoscopy has been emphasized by Mais et al[3] who demonstrated higher sensitivity of laparoscopy compared to imaging alone in detecting endometriosis and subtle adnexal pathology. The rate of torsion ovarian cysts in the present study (18%) is comparable to that reported by Hibbard et al[4] who noted that adnexal torsion is most frequently associated with benign ovarian cysts in reproductive-age women. Early laparoscopic intervention, as performed in our study, facilitates prompt diagnosis and organ-preserving surgery. Laparoscopic findings in our study showed adhesions in 20% of cases and endometriotic cysts in 8%, which correlate well with reports by Nezhat et al[2] who described a high prevalence of adhesions and endometriosis detected during laparoscopy even in patients with minimal preoperative suspicion. The presence of free fluid in the pouch of Douglas in 24% of patients further supports the utility of laparoscopy in comprehensive pelvic assessment. Histopathological analysis confirmed the benign nature of most lesions, with functional cysts being the most common, followed by hydrosalpinx and endometriotic cysts. Similar histopathological distributions have been reported by Yuen et al[9] and Koo et al[10] reinforcing that malignancy is relatively uncommon in well-selected reproductive-age patients with normal CA-125 levels. Cystectomy was the most commonly performed procedure in the present study (32%), reflecting the emphasis on fertility preservation. This approach is in agreement with recommendations by Canis et al[1] and Querleu et al[11], who advocate conservative laparoscopic surgery whenever feasible in young women. Salpingo-oophorectomy and salpingectomy were reserved for cases with extensive disease or non-salvageable adnexa. The conversion rate to laparotomy was low (4%) and was mainly due to frozen pelvis, comparable to conversion rates reported by Chapron et al[5] who noted conversion rates between 3–8% depending on disease severity. Intraoperative and postoperative complication rates were minimal in the present study, consistent with findings by Johnson et al[12], who reported low morbidity associated with laparoscopic management of adnexal masses. An Indian study by Sharma et al.[13] reported cystectomy as the preferred laparoscopic procedure for benign adnexal masses, with favorable postoperative outcomes and minimal complications. Likewise, Patil et al[14] demonstrated that laparoscopic management of adnexal masses was associated with shorter hospital stay, faster recovery, and lower morbidity compared to laparotomy. The low rate of conversion to laparotomy (4%) and minimal intraoperative and postoperative complications observed in the present study are comparable to those reported in Indian series. Maroju Suguna et al. also reported low complication and conversion rates, attributing these outcomes to meticulous case selection and increasing surgical expertise. These similarities highlight that laparoscopic management, when performed in tertiary care centers with adequate facilities, is both feasible and safe in the Indian setting. Limitations The limitations of this study include a relatively small sample size and the exclusion of large and suspicious adnexal masses, which may limit generalization of results. Long-term follow-up regarding recurrence and fertility outcomes was also not assessed.

This study highlights the pivotal role of laparoscopy in the evaluation and management of adnexal masses in women of reproductive age. The majority of adnexal masses encountered in this age group were benign in nature, with functional ovarian cysts constituting the most common histopathological diagnosis. Careful preoperative assessment using clinical examination, ultrasonography, and serum CA-125 estimation enabled appropriate patient selection and contributed to favorable surgical outcomes. Laparoscopy proved to be a highly effective diagnostic tool by allowing direct visualization of pelvic structures and accurate identification of adnexal pathology, including conditions such as endometriosis, adhesions, and subtle tubal lesions that were not always apparent on imaging studies. In addition to its diagnostic value, laparoscopy offered the advantage of simultaneous therapeutic intervention, thereby reducing the need for multiple procedures. The predominance of conservative procedures such as cystectomy and ovarian drilling in this study reflects an emphasis on fertility preservation, which is of paramount importance in women of reproductive age. The low rate of conversion to laparotomy and the minimal intraoperative and postoperative complications observed further underscore the safety and feasibility of laparoscopic management when performed by experienced surgeons in well-selected patients. Overall, the findings of this study support laparoscopy as the preferred modality for the evaluation and treatment of benign adnexal masses in reproductive-age women. With proper patient selection, adherence to oncological safety principles, and availability of skilled laparoscopic expertise, laparoscopy offers excellent clinical outcomes, reduced morbidity, faster recovery, and optimal preservation of reproductive potential.

1. Canis, M., Rabischong, B., Houlle, C., Botchorishvili, R., Jardon, K., Safi, A., & Mage, G.Laparoscopic management of adnexal masses: A gold standard? Current Opinion in Obstetrics and Gynecology. 2002;14(4):423–428. 2. Nezhat, C., Nezhat, F., Silfen, S. L., & Nezhat, C. H. Laparoscopic management of ovarian cysts: Indications and results.Obstetrics & Gynecology. 1991;78(4):660–665. 3. Mais, V., Guerriero, S., Ajossa, S., Angiolucci, M., Paoletti, A. M., & Melis, G. B. Transvaginal ultrasonography combined with CA-125 for the diagnosis of ovarian cancer in women with adnexal masses. Human Reproduction. 1995;10(11):3153–3156. 4. Hibbard, L. T. Adnexal torsion. American Journal of Obstetrics and Gynecology. 1985;152(4):456–461. 5. Chapron, C., Querleu, D., Bruhat, M. A., Madelenat, P., Fernandez, B., Pierre, F., & Dubuisson, J. B. Surgical complications of diagnostic and operative gynaecological laparoscopy: A series of 29,966 cases.Human Reproduction. 1998;13(4):867–872. 6. Maroju Suguna, Avancha Rajeshwar. Laparoscopic evaluation of adnexal masses in reproductive age group. Scholars Journal of Applied Medical Sciences. 2018;6(7):2876–2881. 7. Gupta P, Rai R, Misra S. Laparoscopic management of adnexal masses in reproductive age group.International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2016;5(9):3025–3030. 8. Stratton, P., Winkel, C., Premkumar, A., Chow, C., Wilson, J., Hearns-Stokes, R., & Nieman, L. K. Diagnostic accuracy of laparoscopy, magnetic resonance imaging, and histopathologic examination for the detection of endometriosis. Fertility and Sterility. 2003;79(5):1078–1085. 9. Yuen, P. M., Yu, K. M., Yip, S. K., Lau, W. C., Rogers, M. S., & Chang, A. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. American Journal of Obstetrics and Gynecology. 1997;177(1):109–114. 10. Koo, Y. J., Kim, T. J., Lee, J. E., Kim, B. G., Lee, J. W., & Bae, D. S. Laparoscopic surgery for adnexal tumors: A comparison with laparotomy. Journal of Minimally Invasive Gynecology. 2011;18(1):45–49. 11. Querleu, D., & Leblanc, E. Laparoscopic surgery in gynecologic oncology. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2000;92 (1):53–59. 12. Johnson, N., van Voorst, S., Sowter, M. C., Strandell, A., & Mol, B. W. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database of Systematic Reviews. 2005;Issue 3:CD002125. 13. Sharma R, Sharma P, Singh A. Role of laparoscopy in the management of adnexal masses.Journal of Obstetrics and Gynecology of India. 2014;64(4):273–277. 14. Patil S, Kundaragi NG, Gokhale N. Laparoscopic management of adnexal masses: An Indian experience.Journal of Clinical and Diagnostic Research. 2015;9(6):QC04–QC07.