Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Minimally Invasive Approach to the Large Ovarian Cyst?
- What are the Risks of Minimally Invasive Approach to the Large Ovarian Cyst?
- Video Transcript
Video Description
This video discusses the various levels and techniques of ultrasound in the setting of endometriosis and highlights specifics markers of endometriosis to investigate for.
Presented By
Affiliations
University of Toronto Obstetrics & Gynaecology
St. Joseph’s Unity Health Toronto
Watch on YouTube
Click here to watch this video on YouTube.
What is Minimally Invasive Approach to the Large Ovarian Cyst?
A Minimally Invasive Approach to the Large Ovarian Cyst involves using laparoscopy, where small incisions and a camera are used to view and remove the cyst. The procedure includes preoperative imaging, strategic port placement, careful cyst removal, and minimal recovery time, offering benefits such as reduced pain and quicker return to normal activities.
- Laparoscopy: Small incisions and a camera are used to view and remove the ovarian cyst.
- Preoperative Imaging: Ultrasound or MRI to assess the cyst.
- Port Placement: Strategic small incisions for optimal access.
- Cystectomy: Careful removal of the cyst, potentially aspirating if too large.
- Tissue Extraction: Cyst placed in a bag and extracted to prevent spillage.
- Closure: Incisions closed with sutures or surgical glue.
- Benefits: Reduced pain, quicker recovery, and minimal scarring.
What are the Risks of Minimally Invasive Approach to the Large Ovarian Cyst?
Risks of Minimally Invasive Approach to the Large Ovarian Cyst include:
- Infection: Potential for infection at the incision sites or within the abdomen.
- Bleeding: Risk of bleeding during or after the procedure.
- Injury to Surrounding Organs: Possible damage to nearby organs like the bladder, bowel, or blood vessels.
- Cyst Rupture: Risk of the cyst rupturing during removal, which could spread its contents and cause complications.
- Incomplete Removal: Potential for residual cyst tissue, leading to recurrence.
- Anesthesia Risks: Complications related to general anesthesia, such as allergic reactions or respiratory issues.
- Adhesion Formation: Development of scar tissue within the abdomen, which could cause pain or other complications.
Video Transcript: Minimally Invasive Approach to the Large Ovarian Cyst
Minimally invasive approach to the large ovarian cyst. The objectives of this video are to demonstrate a stepwise, minimally invasive approach to managing a large ovarian cyst. To illustrate techniques to minimise the risk of intraoperative spill. And to highlight best practices and common challenges associated with operating on a large ovarian cyst. In this video, we present the case of a 20-year-old gravida zero female who presented with intermittent right lower quadrant pain. Her past medical history was significant for polycystic ovarian syndrome, and she was on spironolactone.
Her surgical history was significant for a laparoscopy for ovarian torsion. At the time of the surgery in 2018, she had detorsion and bilateral ovarian cystectomies. Both cysts were found to be dermoid cysts. Her abdominal ultrasound demonstrated a left adnexal 19.1 by 12.1 by 8.0cm complex, multi-lobulated cyst with echogenic mural nodules that appeared vascular. There was also an echogenic solid lesion, measuring 5.8 by 5.0 by 4.9cm in the right ovary, most consistent with a dermoid cyst.
Informed consent was obtained for laparoscopic unilateral oophorectomy and possible contralateral ovarian cystectomy. We will now review the key steps used to perform a minimally invasive approach to a large ovarian cysts.
Step one, abdominal entry. Step two, decompression of the ovarian cysts. Step three, laparoscopic ovarian cystectomy or oophorectomy. Step four, extraction of the specimen and abdominal closure.
Step one, abdominal entry. One of the critical decisions in any surgical procedure is selecting the optimal incision location. For a minimally invasive approach, the optimal incision sites are an infraumbilical, supraumbilical, or mini-Pfannenstiel incision. This choice of location depends on factors, including the size of the ovarian cyst and patient body habitus. In this case, we opted to create an infraumbilical incision measuring 3.5cm.
The incision is carried down to the level of the fascia in the usual fashion. The fascia is then opened, and the peritoneum is entered sharply. The small wound protector-retractor system is placed, allowing for direct visualisation of the cyst.
Step two, decompression of the ovarian cyst. The goal of decompression is to drain the cyst with little to no spill. Draining the cyst reduces the size of the specimen to allow a laparoscopic approach, making the procedure less invasive. To reduce the chances of spillage, before beginning the draining procedure ensure you have the following equipment. A large bore needle, an additional 5mm smooth trocar or gallbladder trocar, and two separate section devices. In this case, we utilise a suction canister system and a fluid management system. Both suctions should be checked to be functioning well before starting cyst decompression.
After peritoneal fluid is collected and sent for cytology, the large bore needle is connected to one suction. The needle is then inserted into the cyst. To do this safely, ensure that the cyst is tense at the point of insertion. To expedite decompression, the additional 5mm port is attached to the second suction. It is also tested to be functioning well. The port with trocar is inserted into the cyst, and then connected to suction. It is important to remain patient while the cyst contents drain, to avoid unnecessary spillage.
As the cyst drains, use Allis forceps to elevate the cyst out of the abdomen to allow continued drainage, prevent spill, and to facilitate closure with an endoloop. Once the cyst is no longer draining, apply an endoloop to the openings to avoid spillage of cyst contents. Once applied, the cyst can then be returned to the abdomen.
Step three, laparoscopy. To establish pneumoperitoneum, cover the protector-retractor system. If a cover is not available, the retractor can be unrolled twice, twisted to close the defect, and rolled again. A small, thick glove can then be used to cover the protector-retractor system. Safe abdominal entry was insured with the use of an optical trocar in the left upper quadrant. Subsequent ports were placed under direct visualisation.
After an abdominal survey is completed, a cystectomy or an oophorectomy can be undertaken. A salpingectomy can be considered based on patient factors, such as age and desire for future fertility. In this case, we proceeded with an oophorectomy because of the large size of the cyst, and to prevent recurrence. Using a vessel sealing device, we ligated along the mesovarium.
Step four, extraction of the specimen and abdominal closure. Specimen extraction should be done in a bag. In this case, a large bag was required. The fascia of the umbilical incision was partially closed to insert a 15mm trocar. The specimen bag was introduced through this trocar, and the specimen was carefully placed into the bag. The fascial sutures in the umbilical incision were carefully loosened to bring the bag up to the skin.
A protector-retractor system was inserted into the specimen bag. The remaining fluid cyst contents were decompressed with suction where possible, more solution was used to extract solid components. The specimen was then sent to pathology for further evaluation. The remainder of the umbilical incision was closed in the usual fashion. The laparoscopy was re-inserted to inspect the umbilical closure and to ensure adequate haemostasis.
Post-operatively, the patient recovered as expected. She was discharged home on the same day. In summary, we have demonstrated the four key steps to the minimally invasive management of a large ovarian cyst, abdominal entry, decompression of the cyst, laparoscopic cystectomy or oophorectomy, and finally, extraction of the specimen with abdominal closure. Thank you to our patient, our collaborators, and to you for your time.