A novel minilaparotomy approach for large ovarian cysts

This technique, suitable for all ovarian cysts, makes it possible to aspirate a large cyst without leakage.

Whether spillage of cancer cells actually worsens the prognosis of a patient with a neoplastic cyst remains controversial because of conflicting study results. Nonetheless, the possibility of intraperitoneal dissemination of neoplastic cells from a ruptured cyst cannot be considered innocuous, and the potential negative effect on a patient’s prognosis should not be ignored.¹⁴ Make every attempt, therefore, to avoid rupturing the cyst and spilling the fluid into the peritoneal cavity.

A shared flaw plagues aspiration devices. Different devices are available for intraoperative cyst aspiration during laparoscopic, transvaginal, or laparotomy approaches.^3,4,6 In addition to long needles, drainage trocars, suction cannulas, and suprapubic bladder catheters, special aspiration instruments have been developed.¹⁵ They include a metal vacuum system with an aspirator trocar that seals the surface of the cyst, and a catheter system that pinches the punctured cyst wall between double balloons to prevent spillage.¹⁶ In addition, several commercial bags are available to prevent intraperitoneal spillage during removal of ovarian cysts.

All these devices have a universal flaw, however: After a thin-walled cyst initially is punctured, none of these products can prevent the spontaneous dehiscence of the cyst and the resulting spillage of its contents into the abdominal cavity. Vacuum systems work well for large cysts with smooth, round surfaces, but in those with irregular surfaces, both application and maintaining the seal are difficult.¹⁷ Fortunately, our technique makes it possible to aspirate a large ovarian cyst without leakage, and the method is suitable for all ovarian cysts regardless of surface type or wall thickness.

Glue the dressing to the cyst to capture leakage. Using a gauze pad, carefully dry the area of the ovarian cyst that is visible through the self-retaining retractor. Then generously spread sterile surgical glue such as Dermabond (Ethicon, Somerville, NJ) on the cyst wall surface (FIGURE 5A). Dermabond is the commercial name for 2-octyl cyanoacrylate, a sterile skin adhesive used as an alternative to stitches to close the edges of small wounds. It is similar to commercial adhesives such as Super Glue and Krazy Glue.

Remove the paper cover of a transparent plastic surgical dressing and place the adhesive side directly onto the glued cyst surface until you are sure the adhesive is completely fixed (FIGURES 5B AND 5C). The 35 cm x 35 cm Steri-Drape or the transparent Tegaderm (both from 3M Health Care, St. Paul, Minn) dressing is effective. A standard nonadhesive plastic dressing or a sterile plastic bag also can be used, as long as the free edges extend beyond the outer rim of the self-retaining retractor.

With a needle aspirator, pierce the cyst through the glued plastic dressing and carefully aspirate the fluid (FIGURES 6A AND 6B). Any leakage is trapped inside the plastic dressing rather than the abdominal cavity. Continue the aspiration until the collapsed cyst and ovary can be gradually delivered through the abdominal incision (FIGURE 6C). Note that the selfretaining retractor also protects the abdominal incision from potential contamination and implantation of neoplastic cells.

Once the cyst and ovary are extracted, you can readily perform an extracorporeal cystectomy, after which the repaired ovary is returned to the abdominal cavity. Be careful to avoid letting any fluid flow back into the peritoneal cavity during cyst removal. When indicated, an extracorporeal adnexectomy can readily be performed.

The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst.

Dermoid cysts require extra care. Preventing intraperitoneal spillage is especially important when removing a large dermoid cyst, to avoid the possibility of chemical peritonitis, dense adhesions, and fistulas. The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst. Quite frequently, a large-diameter suction cannula is required to remove the waxy contents. If the dermoid cyst is very large, aspiration alone will not empty it entirely. Complete emptying is not necessary, however. The primary goal of aspiration is to reduce the size and tension of the cyst to permit delivery through the abdominal incision.

Closing the cruciate incision is quicker and requires less exposure than a scaled-down Pfannenstiel’s incision.

Before concluding the procedure, irrigate the peritoneal cavity to remove any remnants of cyst contents that may have spilled—especially important with a dermoid cyst. Perform any additional indicated procedures through the minilaparotomy incision, such as a contralateral ovarian cystectomy, salpingo-oophorectomy, or hysterectomy. After the surgery is completed, remove the self-retaining retractor by hooking a finger through the bottom ring and pulling it gently out of the incision. Closing the cruciate incision is quicker and requires less exposure to complete than a scaled-down Pfannenstiel’s incision. Apply a vertical pressure dressing over the incision to prevent postoperative wound hematoma or seroma formation. Remove the dressing 24 hours later.