Chapter 11.1 Ovarian Cystectomy. Operative Techniques

Chapter 11.1 Ovarian Cystectomy. Operative Techniques

GENERAL PRINCIPLES

Definition

■ An ovarian cyst is a fluid-filled sac located on the surface or within the wall of the ovary. Simple cysts contain serous fluid with no opacities or solid elements, whereas complex cysts contain semisolid or solid elements.

Differential Diagnosis

■ Benign ovarian: functional cyst, endometrioma, mature teratoma, serous cystadenoma, mucinous cystadenoma.

■ Benign tubal: tubo-ovarian abscess, ectopic pregnancy, hydrosalpinx, paratubal cyst.

■ Malignant ovarian: germ cell tumor, sex cord–stromal cell tumor, epithelial carcinoma of ovary or fallopian tube, metastatic tumors.

■ Nongynecologic: diverticular or appendiceal abscess or mucocele, bladder or urethral diverticulum, peritoneal inclusion cyst.

Anatomic Considerations

■ Major considerations in planning the surgical approach include patient habitus, history of prior abdominal or pelvic surgery, and comorbidities predictive of pelvic adhesive disease and risk of intraoperative injury to adjacent structures.

■ Most patients, including those who are morbidly obese, are good candidates for minimally invasive surgery if there is a low suspicion for ovarian malignancy. Laparoscopic ovarian cystectomy with or without robotic assistance has been shown to reduce postoperative morbidity and recovery time compared to laparotomy.

Nonoperative Management

■ Asymptomatic simple cysts up to 10 cm in diameter, coupled with a normal CA125 level, may be expectantly managed, even in postmenopausalpatients.1

■ Symptoms that may be related to an ovarian cyst include pelvic or lower back pain, dyspareunia, abdominal distension, and urinary frequency or urgency. For patients with mild symptoms, conservative management may include pelvic rest and over-the-counter analgesics.

■ Most functional cysts, including corpus luteum, theca lutein cysts, and ovarian follicular cysts, may have increased vascularity, internal lace-like patterns, multilocular components, or they may be thin walled and unilocular.2 Fortunately, they usually spontaneously resolve within 3 months. For patients presenting with symptomatic functional cysts, ovulation suppression with combination oral contraceptives may reduce the frequency of functional cysts and associated symptoms; however, oral contraceptives have not been shown to accelerate the resolution of existing functional ovarian cysts.3

■ For patients with symptomatic, multiple functional cysts due to infertility treatment, ultrasound-guided cyst aspiration may be used to reduce symptoms pending the natural resolution of the cysts.

■ Percutaneous drainage of cysts per ultrasound guidance is generally not effective in long-term resolution of nonfunctional cysts, and may be complicated by hemorrhage and injury to adjacent structures.1

■ The most common benign complex cysts are mature teratomas or dermoid cysts and ovarian endometriomas. For detailed management of an ovarian endometrioma, see Chapter 12.

■ In asymptomatic women with ultrasound findings that are pathognomonic for dermoid cysts,2 expectant management may be offered if there are no other circumstances or signs that indicate risk for malignancy.4 In a study of women who were expectantly managed, over 75% were followed without need for surgery for a median period of 12.6 months. Ovarian cystectomy was more likely undertaken in younger women, women of increasing parity, past history of ovarian cyst, bilateral ovarian cysts, or larger size of ovarian cyst.4

■ When there is a high suspicion for malignancy, a careful presurgical evaluation should include an assessment of the patient’s genetic risk, imaging studies, and serum tumor markers.

■ Ovarian cystectomy is contraindicated if a mass is suspicious for cancer based on transvaginal ultrasound findings, CA125 levels, and/or clinical assessment. For suspected malignancy in women desiring fertility, preoperative or intraoperative consultation with gynecologic oncology as well as with an infertility specialist is recommended to optimize patient’s treatment and to preserve fertility when possible.

IMAGING AND OTHER DIAGNOSTICS

■ Transvaginal ultrasound is the primary modality for evaluation of ovarian cysts. Management of an asymptomatic cyst is largely based on ultrasound findings, which include the size and echotexture of the ovarian cyst, laterality, and any signs that increase likelihood of malignancy, such as thick (greater than 3 mm) septations, mural nodules, irregular borders, complex internal elements with Doppler flow, and free fluid in the pelvis. Unilocular cysts with thin walls, regular borders, and no internal echoes are very likely to be benign.

■ CT and MRI of the pelvis should not be used routinely. They should be reserved for evaluating the pelvis for metastatic disease or to determine the etiology of nonovarian adnexal masses, such as pedunculated leiomyomata.

■ Tumor markers: CA125 may be helpful in preoperative evaluation of ovarian cysts particularly in postmenopausal patients. A normal value for CA125 is less than 35 units/mL. CA125 is elevated in 80% of patients with epithelial ovarian cancer but is normal in 50% of patients with ovarian cancer isolated to the ovary. The specificity of CA125 for ovarian malignancy is lower in patients of reproductive age, as CA125 may be elevated in benign conditions such as endometriosis and pelvic infection as well as in nongynecologic inflammatory conditions. The specificity and sensitivity of CA125 are the highest among postmenopausal women with an adnexal mass. Other tumor markers that may be helpful include quantitative beta human chorionic gonadotropin (beta-hCG), lactate dehydrogenase (LDH), and alpha-fetoprotein (AFP). Elevations in these markers may indicate increased risk for germ cell tumors, while elevation in inhibin A and B may indicate increased risk for granulosa cell tumor.

■ Cervical cultures: For patients presenting with pelvic pain suspicious for pelvic inflammatory disease, cultures should be collected and empiric antibiotic therapy is recommended per CDC guidelines. Surgical exploration may be necessary in patients with suspected tubo-ovarian abscess who do not improve clinically with conservative management.

■ For patients with suspected ectopic pregnancy based on menstrual history, imaging, and laboratory studies, evaluation should be undertaken for possible medical management, with surgical management reserved for those who are unstable or who do not meet criteria for medical management.

PREOPERATIVE PLANNING

■ A medical history should include information about menstrual pattern, contraceptive use, pregnancy, and gynecologic conditions including sexually transmitted diseases. A history of gastrointestinal, breast, or other pelvicmalignancy may indicate a risk of metastasis to the ovary. Advancing age and menopausal status increase the risk of malignancy in women with adnexal masses.1

■ A surgical history should include specific detail about prior abdominal and/or pelvic surgeries as well as anesthesia complications or concerns.

■ A family history should include specific detail about gynecologic, urologic, breast, and gastrointestinal cancers, and referral to medical genetics should be considered if there is suspicion that patient may be at risk for heritable cancers.

■ Prior to surgery, the patient should be counseled:

■ About nonoperative as well as operative treatments for her clinical situation. In general, ovarian cystectomy should not be first-line treatment for women of reproductive age with functional cysts unless there is suspicion for ovarian torsion or the patient has failed conservative management.

■ About the risks of surgery, which include anesthesia complications, hemorrhage and need for blood products, infection, intraoperative injury to gastrointestinal, genitourinary, vascular and neural structures, and unplanned oophorectomy and/or salpingectomy with potential impact on fertility.

■ Conversion to laparotomy may be needed to complete the procedure safely, and its effect on her postoperative course.

■ Incorrect laterality assigned in imaging reports occurs; therefore, the patient should be consented about this possibility and for removal of the affected adnexal cyst.

■ Ovarian cystectomy may require conversion to oophorectomy with or without salpingectomy if there is uncontrollable bleeding, suspected malignancy, abscess, or necrosis.

■ About the possibility of malignancy and any plan for intraoperative or delayed evaluation by a gynecologic or surgical oncologist in the event of malignancy. Unless there is a surgical emergency, primary excision of suspected ovarian malignancy should be undertaken by a surgeon with specialized training in evaluation and management of gynecologic cancers.

■ There is a potential to decrease fertility after cystectomy especially for endometriomas due to excessive use of electrosurgery or inadvertent removal of normal tissue.

■ Patients with significant comorbidities should undergo preoperative medical and anesthesia evaluation. For patients with significant comorbidities, surgery may need to be delayed to allow for proper preoperative optimization.■ Oophorectomy should be considered in perimenopausal and postmenopausal women undergoing surgery for ovarian cysts due to increased risk of malignancy with advancing age and as well as risk of recurrence of benign ovarian cysts.

SURGICAL MANAGEMENT

■ Ovarian cystectomy is the treatment of choice for symptomatic benignappearing cysts in women of reproductive age that do not resolve with conservative management.

Approach

■ Laparoscopic approach is the gold-standard approach for suspected benign ovarian cystectomy.

■ Laparotomy should be undertaken as clinically indicated due to large mass size, high suspicion for malignancy or known extensive adhesive disease, and other factors, such as combined cases for colorectal disease. Laparotomy should be the approach of choice if the surgical team has insufficient equipment, training, skill, and/or experience to safely attempt minimally invasive surgery.

■ Ultrasound-guided transabdominal or transvaginal drainage of cysts may be considered for preoperative preparation in cases of large cysts with lowsuspicion for malignancy or for management of symptoms in patients with multiple functional cysts resulting from ovulation induction for infertility.Procedures and Techniques (Video 11.1.1) Operative huddle and patient positioning and surgical preparation (please see Chapter 5). Laparoscopic ovarian cystectomy with or without robotic assistance 

Vaginal field

■ A Foley catheter should be placed sterilely in the bladder and secured to the drape to prevent traction on the urethra during the procedure. Position the urine collection bag so that the anesthesia team or circulating nurse can monitor the patient’s urine output during the procedure.

■ For patients with a uterus, place a Hulka tenaculum into the uterus for uterine manipulation.

■ A minimum of three trocars are used to perform ovarian cystectomy and include a 12-mm trocar to accommodate a tissue extraction bag. Two additional 5-mm ports are used to decrease neuropathic injury and do not require fascial closure. In pregnant patients, patients with a large pelvic–abdominal mass or those with a previous midline incision, a left upper quadrant primary entry is recommended.

Pelvic field

Inspect the pelvis and collect pelvic cytology. Irrigate the pelvis with saline and collect pelvic washings for cytology. Inspect all pelvic structures and assess for adhesions, endometriosis, excrescences, or implants suspicious for malignancy. Lyse adhesions only as needed to achieve visualization. If malignancy is suspected, seek intraoperative consultation with gynecologic or surgical oncologist prior to proceeding with ovarian cystectomy or oophorectomy. If surgical oncology is not available, abort the procedure after collection of photographs, washings, and nondisruptive tissue biopsies, and refer the patient to a gynecologic oncologist for primary excision and staging.

Inspect the adnexa and identify the ovary containing the cyst Using an atraumatic grasper, retract the utero-ovarian ligament. Identify the ipsilateral ureter and vasculature This ensures that these structures are safely away from the surgical field (Tech Fig. 11.1.1).

Tech Figure 11.1.1. Identify the ovarian cyst. Identify the ipsilateral ureter and vasculature to ensure that these structures are safely away from the surgical field. Identify an optimal area for ovarian incision Avoid the vascular hilum of the ovary (the meso-ovarium) and the ipsilateral fallopian tube (Tech Fig. 11.1.2).

Tech Figure 11.1.2. Identify the optimal area for ovarian incision. Avoid the vascular hilum of the ovary (the meso-ovarium) and the ipsilateral fallopian tube. Incise the ovarian cortex Incise with the use of an electrosurgical instrument such as a monopolar needle set at low power (10 W) or bipolar instrument (Tech Fig. 11.1.3).

Tech Figure 11.1.3. Incise the ovarian cortex with the use of an electrocautery electrosurgical instrument such as a monopolar needle set at low power (10 W) or bipolar instrument. Choose an instrument with a small contact point, as tissue damage increases with increasing area contact with the electrode.

The size of the contact point of the instrument to the tissue is important, as tissue damage increases with the increasing size of the electrode.5 The degree of tissue damage caused by electrical energy is also determined by the waveforms, the density of the current, and the duration of the energy application: longer application of current is associated with increased tissue damage.5 Increasing levels of power also increase the degree of tissue damage.5 Monopolar instruments such as monopolar needle, hook, or scissors should be used in pure cut or blended cut setting to dissect with minimal destruction of adjacent tissues. Pure cut setting has high-density, low-voltage current that minimizes thermal spread, while coagulation setting has low-density, high-voltage current with greater thermal spread and risk of destruction or injury to adjacent tissue. Blend 1 adds some coagulation effect to pure cut setting, while Blend 3 adds some cutting effect to a pure coagulation setting, while Blend 2 balances cutting and coagulation. In general, a lower power setting such as 45 W should be used, with increasing wattage only if a lower setting is ineffective. The harmonic scalpel, which cuts with high-frequency vibration, is also an option that minimizes damage to adjacent tissues.

Grasp the edge of the cortex with an allis, and extend the incision along the ovarian axis to expose the underlying cyst from pole to pole In some cases, the suction–irrigation cannula can be introduced in between the cyst and cortex and fluid introduced to develop the plane (Tech Fig. 11.1.4).

Tech Figure 11.1.4. Grasp the edge of the ovarian cortex and use a suction irrigator to irrigate and to develop a plane between the cortex and the cyst. Scissors or a monopolar needle may be used to extend the incision along the ovarian axis to expose the underlying cyst. Lyse adhesion to the ovarian cortex with a blunt probe or suction irrigator tip

■ Lysis of adhesions should be done before the cystectomy. The cyst wall easily yields to gentle pressure as there is little fibrosis compared to an endometrioma (Tech Fig. 11.1.5).

■ Excessive use of electrosurgery causes destruction of the ovarian stroma and decreases fertility.

■ Apply traction and countertraction (see Tech Fig. 11.1.6). Use blunt dissection and/or sharp dissection, applying electrocautery to bleeding vessels as needed while enucleating the intact cyst away from the normal ovarian stroma.

Tech Figure 11.1.5. Aqua dissection and adhesiolysis of the ovarian cortex with a blunt probe. Lysis of adhesions should be done before the cystectomy and easily yields to gentle pressure as there is little fibrosis.

Tech Figure 11.1.6. Apply traction and countertraction. Use blunt dissection and/or sharp dissection, applying electrocautery to bleeding vessels as needed while enucleating the intact cyst away from the normal ovarian stroma. Use traction and countertraction to enucleate the intact cyst away from the normal ovarian stroma (Tech Fig. 11.1.6) Continue to bluntly enucleate the cyst until all ovarian attachments are lysed (Tech Fig. 11.1.7).

Tech Figure 11.1.7. Bluntly enucleate the cyst. 

Place the cyst in a tissue extraction bag (Tech Fig. 11.1.8) To facilitate removal from the abdominal cavity, the tissue extraction bag may be partially exteriorized at the skin, carefully opened to expose the surface of the cyst, and the cyst fluid may then be evacuated with a syringe or other suction device. If possible, cyst contents should not be allowed to spill into the peritoneal cavity due to risk of dissemination of an undiagnosed malignancy. Although we perform morcellation of the cyst within the tissue containment bag, be aware that the device manufacturer states that morcellation within the tissue extraction bag is not recommended. The manufacturer of the tissue extraction bag states that the surgeon should extend the abdominal wall incision to accommodate removal of the bag with the specimen intact.

Tech Figure 11.1.8. Place the cyst within an endocatch bag for removal. 

For complex cysts with solid components, such as mature teratomas, extend the port site to ensure the bag does not rupture due to compression of solid material in the cyst. Rupture of the extraction bag will result in spillage of the cyst contents, leading to prolonged evacuation of extruded material from the peritoneal cavity, possible dissemination of undiagnosed malignancy, and the potential for retained material from a ruptured tissue extraction bag. Irrigate the cyst bed and achieve hemostasis

■ Use sparse radiofrequency electrical energy to achieve hemostasis. Sutures can be used within the cyst to achieve hemostasis. Do not place them through the cortex. Hemostatic agents such as FloSeal can also be used.

■ Once the cyst bed is hemostatic, it is not necessary to re-approximate the ovarian edges. Although some areas of the remaining ovary will be very thin, stromal tissue should not be removed or trimmed as this may reduce oocyte reserve (see Tech Fig. 11.1.9).

Tech Figure 11.1.9. Once the cyst bed is hemostatic, it is not necessary to reapproximate the ovarian edges. Although some areas of the remaining ovary will be very thin, stromal tissue should not be removed or trimmed as this may reduce oocyte reserve.

Irrigate and suction

■ Irrigate and suction the pelvis of any debris and perform a final survey to ensure no extruded material or foreign bodies remain.

■ Once hemostasis is confirmed, apply anti-adhesion barrier such as Interceed.

■ If you apply Interceed, the cyst bed must be perfectly hemostatic and irrigation fluid must be removed. The sheet of Interceed should be wrapped around the ovary alone. Do not wrap the tube with the ovary.

■ Allow the pneumoperitoneum to escape and perform the first instrument and sponge count.

■ Re-approximate fascial incisions greater than 10 mm and skin incisions.

■ Remove instruments from the vaginal field and confirm hemostasis.

PEARLS AND PITFALLS

Correct plane identification is crucial to complete cystectomy. Identify and grasp the cyst wall and excise it from the surrounding ovarian stroma using traction– countertraction. Large dermoid cysts often rupture after extensive manipulation. Reduce content spillage by quickly grasping and elevating the leading edge of the cyst wall to avoid further extrusion and contamination. It the cyst is moderate in size, suction the contents directly from the cyst itself and avoid spillage into the pelvic cavity. If the cyst is very large and there is the potential for continual spillage, use an Endo-loop to secure the cyst wall closed and continue with the cystectomy. Take the time to identify each plane. This improves surgical technique, reduces follicle damage, and decreases blood loss. About half of patients with ovarian torsion diagnosed at laparoscopy have had normal Doppler flow in an ovarian cyst demonstrated on a recent ultrasound study, so laparoscopy should be undertaken if there is a high suspicion for torsion based on clinical findings. Ovarian torsion typically presents with sudden onset severe pelvic pain and symptoms of peritoneal irritation such as nausea and/or vomiting. In some cases, patients will report similar episodes of pain for brief periods of time for days or weeks. Initial vascular findings in ovarian torsion include constriction in venous and lymphatic flow and may lead to ovarian edema, cyanosis, and tenderness to palpation. When encountering torsion in a patient at low risk for malignancy, detorsing the ovary should be undertaken followed by ovarian cystectomy to reduce risk of future torsion. Care should be taken to retain ovarian stroma even if tissue viability is questionable. Despite constricted blood flow, cyanotic ovarian tissue likely retains some viable stroma and should be salvaged to preserve ovarian function in women of reproductive age.

Unilocular cysts under 10 cm in diameter are generally benign, and in women with a normal CA125 level, it is permissible to drain the cyst laparoscopically to reduce morbidity from a large laparotomy incision. Make a small incision in the cyst surface with a laparoscopic scissor or monopolar instrument, then immediately insert a suction–irrigator tip in the cyst opening to quickly evacuate the cyst fluid. Cyst fluid is rarely helpful in histologic diagnosis and may be discarded.

POSTOPERATIVE CARE

■ Initial postoperative care is dictated by surgical approach and by intraoperative or postoperative complications. Please see postoperative care for laparoscopic surgery in Chapter 5. In general, patients should be routinely evaluated in the office anywhere from 2 to 6 weeks after surgery for inspection of the incision sites and to review pathology results with thepatient.

■ For patients undergoing uncomplicated, minimally invasive surgery, discharge to home with oral pain medication is expected within 4 to 6 hours after surgery. Patients who experience increased perioperative bleeding, intractable nausea and/or vomiting, pain not controlled by oral analgesics, insufficient urine output, or other symptoms that preclude discharge to home, extended recovery is indicated. All patients should be given explicit instructions and contact information to seek urgent follow-up care in the event of severe pain, intractable vomiting, heavy bleeding, wound dehiscence, fever, or urinary retention.

OUTCOMES

Drainage alone or partial excision of ovarian cysts increases the likelihood that cyst fluid will re-accumulate and that the patient’s symptoms will recur. Excision of an ovarian cyst with obliteration of any nonresectable cyst tissue reduces the likelihood of cyst recurrence. For patients with undiagnosed malignancy, spillage of cyst contents upstages the malignancy and worsens prognosis for survival. Therefore, ovarian cystectomy should not be performed in patients with multiple risk factors or signs/symptoms suspicious for malignancy. In young, reproductive-age women who desire fertility and suffer from symptomatic, large cysts, every attempt should be made to salvage remaining ovarian stroma.

COMPLICATIONS

■ Known risks of ovarian cystectomy by any approach include anesthesia complications; hemorrhage and need for blood products; infection; intraoperative injury to gastrointestinal, genitourinary, vascular, and neural structures; and unplanned oophorectomy and/or salpingectomy with potential impact on fertility.

■ In cases of excessive bleeding from the ovarian cyst bed, apply pressure to the area. If necessary, place a deep suture to re-approximate the tissue. If bleeding is localized and appears to be general oozing related to extensive dissection, consider applying a hemostatic agent like FloSeal. The ureter is at particular risk of injury if there are adhesions of the ovary to the pelvic sidewall. Adhesiolysis and retroperitoneal dissection may be necessary to expose the ovary prior to ovarian cystectomy. For information about dissection of an ovary encased with extensive adhesions, refer to

Chapter 11.3 Ovarian Remnant resection