- Make a cruciate incision by incising the skin transversely and the anterior rectus fascia vertically.
- Insert a soft, sleeved, self-retaining retractor.
- Using a surgical adhesive, glue a large plastic wound dressing to the surface of the cyst to prevent leakage of contents into the abdominal cavity.
- Aspirate the cyst until it collapses and can be delivered, with the ovary, through the abdominal incision.
- After performing an extracorporeal cystectomy and/or adnexectomy, return the repaired ovary to the abdominal cavity.
Although laparotomy is still considered the standard for ovarian cyst removal, over the past 15 years minimally invasive surgery has gained wider acceptance in cases where preoperative assessment suggests an adnexal mass is benign.
Unfortunately, minimally invasive management of a large ovarian cyst (greater than 10 cm) is particularly challenging for several reasons:
- The cyst can rupture and spill its contents into the peritoneum,
- the cyst’s size limits the surgical field, and
- an unexpected malignancy may be revealed.
An innovative minilaparotomy technique for the removal of benign ovarian cysts offers the advantages of laparoscopic and laparoscopic-assisted procedures while bypassing the major disadvantages: the necessity for specialized and expensive equipment, lengthy operative time, and long learning curves.1 (The minimally invasive procedures currently available for the treatment of ovarian cysts include laparoscopic cystectomy, laparoscopic-assisted minilaparotomy cystectomy, laparoscopic-assisted vaginal cystectomy, combined percutaneous ultrasound cyst aspiration and laparoscopic cystectomy, transvaginal cystectomy, and the traditional minilaparotomy cystectomy.2-10)
The procedure is faster, less expensive, carries fewer potential risks than traditional alternatives, and offers these advantages:
- can be performed under regional anesthesia
- relies on standard open techniques
- uses inexpensive instrumentation
- is easy to learn
- can be used for very large cysts
- eliminates the risk of intraperitoneal spillage of cyst contents
- offers similar postoperative convalescence and mean time to return to work as laparoscopic or laparoscopic-assisted management of large ovarian cysts
General Ob/Gyns—not gynecologic oncologists—perform most surgeries on patients with adnexal masses, since ovarian cancer is relatively uncommon in the absence of preoperative risk factors for malignancy. Our approach offers an appealing option to Ob/Gyns reluctant to abandon routine traditional laparotomy for such ovarian cysts.
Selecting the right patient
Adequate preoperative assessment diminishes the risk of unexpected malignancy in a patient undergoing surgery for an ovarian mass to less than 1%.4 At this time, the combination of menopausal status, cancer antigen (CA) 125 level, physical examination, and ultrasound is the best strategy for evaluating the patient with an ovarian cyst.11
Signs of malignancy. Ultrasound features that suggest malignancy include irregular borders, thick septa, solid areas, internal and external excrescences, matted bowel, and ascites. Benign cysts, on the other hand, are usually unilateral and have regular borders, thin septa, no solid areas, and no internal excrescences.4 The measurement of blood flow within the mass by color Doppler may improve the accuracy of ultrasound in differentiating benign from malignant cysts.4,12
On physical examination, an adnexal mass that is fixed, irregular, or solid also suggests a neoplasm. An elevated CA 125 combined with a complex adnexal mass is likely to be associated with malignancy. The test is even more specific in postmenopausal women with adnexal masses.4,12
However, plasma levels of CA 125 also can be elevated in several benign gynecologic conditions such as endometriosis, simple ovarian cysts, pelvic inflammatory disease, ovarian torsion, fibroids, and in physiologic conditions such as menstruation and pregnancy.13
Anticipate the need to convert to laparotomy. Every patient’s surgical consent should include a possible conversion to laparotomy. To avoid incomplete surgical treatment and significant delays in proper therapy, a gynecologic surgeon experienced in the management of ovarian cancer should be readily available, in the event an unexpected malignancy is encountered. Ideally, the staging surgery and definite treatment should be performed at the time of initial minilaparotomy. Comprehensive surgical staging and treatment include thorough exploration of the pelvis and abdomen, omentectomy, pelvic and paraaortic lymph node sampling, multiple peritoneal biopsies and washings, bilateral salpingo-oophorectomy, hysterectomy, and debulking, when indicated.
Prepare for surgery with position, incision, and retraction
Before beginning, it is crucial to correctly position the patient, make the appropriate incision, and insert the right retractor.1
Position. After administering regional or general anesthesia, place the patient in a modified lithotomy, as for laparoscopic surgery. Tuck the arms alongside the torso and place the legs in boot stirrups. Avoid hip flexion and allow adequate thigh abduction to expose the vagina. Perform a careful pelvic examination to determine the size and mobility of the adnexal mass.
When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure
Place an indwelling transurethral catheter, and pass a sturdy, hinged uterine manipulator such as the Pelosi Uterine Manipulator (Apple Medical Corp, Marlboro, Mass) transcervically into the uterine cavity (FIGURE 1).