Laparoscopic Ovarian Cystectomy

Overview

The majority of women will develop an ovarian cyst at some time in their life. Cysts typically generate little to no symptoms. If a cyst is causing pain or discomfort, surgical excision of the cysts may be the best therapeutic choice. Pelvic discomfort, especially during your period or sexual intercourse, is one of the signs of an ovarian cyst.

An ovarian cystectomy is a surgical procedure that removes a cyst from your ovary. Laparoscopic surgery is a type of minimally invasive surgery that requires only a few tiny incisions in your lower abdomen.

 

What is an Ovarian Cyst?

An ovarian cyst is a sac that grows on or within one or both of your ovaries and is filled with fluid or semisolid substances. The ovaries are tiny glands in your pelvis that contain egg cells and produce hormones like estrogen and progesterone.

There are several forms of ovarian cysts, the majority of which are painless and harmless (benign). Ovarian cysts seldom cause symptoms. You won't know until your clinician discovers one during a normal pelvic exam or imaging treatment.

Ovarian cysts can occasionally cause complications. Regular pelvic checks and communicating with your provider about any symptoms you may be having can help prevent cyst issues. 

 

Types of Ovarian Cysts?

The majority of ovarian cysts are functioning cysts. They develop in response to changes in your body during your menstrual cycle. Ovarian cysts can occur for reasons other than menstruation.

Functional cysts:

Functional cysts are the most frequent form of ovarian cyst and are not associated with any disease. They are caused by ovulation (the release of an egg from the ovary). These cysts may indicate that your ovaries are functioning normally. Without particular therapy, functional cysts normally decrease with time, usually within 60 days.

• Follicular cysts. A small sac in your ovary, called a follicle, releases an egg each month as part of your menstrual cycle. A follicular cyst forms when the follicle doesn’t release an egg. Instead, the follicle fills with fluid and grows bigger.
• Corpus luteum cysts. After the follicle releases an egg, it forms a hormone-producing group of cells called the corpus luteum. A cyst forms when fluid collects in the corpus luteum, causing it to grow.

Sometimes, functional cysts are called simple cysts.

Other cysts:

Not all ovarian cysts develop as a result of your menstrual cycle. They aren't always symptoms of disease, but your doctor may want to keep an eye on them to make sure they don't lead to complications. They are as follows:

• Cystadenomas. These cysts grow on the ovary's surface. They might be filled with thin, watery fluid or thicker, mucous-like fluid.
• Dermoid cysts (teratomas). Dermoid cysts are made up of cells that make up every form of tissue in the human body, including skin, hair, teeth, and even brain tissue.
• Endometriomas. These cysts contain endometrial tissue, the same tissue from which you bleed every month during your period.
• Cancer of the ovaries. In contrast to the previous disorders, ovarian cancer cysts (tumors) are solid masses of cancer cells.

 

Who is Affected by Ovarian Cysts?

An ovarian cyst can occur in anybody who has ovaries. Your odds happen as a result of:

• Age. If you haven't gone through menopause, ovarian cysts are more prevalent.
• Status of pregnancy. During pregnancy, cysts are more likely to develop and persist.
• Ovarian cyst history. If you've had an ovarian cyst before, you're more likely to get another.
• Current medical issues. If you have endometriosis, hormone difficulties, or are on ovulation drugs such as clomiphene (Clomid), you are more likely to develop an ovarian cyst.

 

Types of Ovarian Cystectomy Procedure

There are two main types of surgery to remove ovarian cysts or tumors:

1. Open ovarian cystectomy: Under general anesthesia, open ovarian cystectomy (the removal of ovarian cysts) or oophorectomy (the removal of the ovaries) entail an incision in the abdomen similar to that used for a Cesarean section. If at all feasible, the ovaries will be left intact. The doctor will go through the specifics of the procedure with you ahead of time.
2. Laparoscopic ovarian cystectomy: Laparoscopic ovarian cystectomy is a minimally invasive surgery that involves making tiny incisions in the belly in order to introduce a small camera and surgical equipment to record pictures that are then presented on a monitor. If the cyst is huge or numerous cysts are present, the cyst has ruptured, or there are problems, such as a suspected malignancy, an open operation may be required.

 

Indications for Laparoscopic Ovarian Cystectomy

The following are absolute reasons for ovarian cystectomy: definite diagnostic confirmation of an ovarian cyst, excision of symptomatic cysts, and exclusion of ovarian cancer. Other indications include cysts bigger than 7.6 cm in diameter, cysts that do not dissolve after 2-3 months of close monitoring, bilateral lesions, and ultrasound imaging results that differ from a typical functional cyst. It is important to note that both the patient's age at the time of identification and the kind of cyst might impact surgical indications, as discussed further below.

• Fetal:

Ovarian cysts in developing fetuses are more prevalent than previously assumed, thanks to prenatal ultrasound imaging. They have been detected on normal obstetrical ultrasonography in 30-70% of fetuses, with the incidence rising as the pregnancy progresses. They are often unilateral and frequently resolve on their own. They are the result of ovarian stimulation caused by a combination of maternal and fetal gonadotropins. Surgical intervention, including cyst aspiration, is seldom necessary.

• Neonatal:

Ovarian cysts are considered to form in newborns as a result of in utero hormonal stimulation. They are also more prevalent than previously believed. Ovarian cysts were found in around 30% of infants who underwent post mortem testing. The cysts are frequently detected by ultrasonography for unrelated reasons in the majority of infants. Many are simple cysts, while some are more complicated, making a benign diagnosis more challenging. They frequently regress spontaneously in the first 4-5 months after birth. Cysts larger than 5 cm in diameter are of concern in this age range because they are frequently torn and can self-amputate. 

• Prepubertal child:

Ovarian cysts are considered to form in newborns as a result of in utero hormonal stimulation. They are also more prevalent than previously believed. Ovarian cysts were found in around 30% of infants who underwent post mortem testing. The cysts are frequently detected by ultrasonography for unrelated reasons in the majority of infants. Many are simple cysts, while some are more complicated, making a benign diagnosis more challenging. They frequently regress spontaneously in the first 4-5 months after birth. Cysts larger than 5 cm in diameter are of concern in this age range because they are frequently torn and can self-amputate. 

• Menarchal adolescents and adults:

In menarchal teens and adults, benign ovarian cysts are extremely prevalent. Most regress within 2-3 months after being discovered, while some remain. Cysts bigger than 5 cm in diameter and complicated morphologic findings on ultrasonography are related with chronic ovarian cysts.

The sorts of cysts seen in reproductive-age females differ from those seen in children. Endometriomas and mature cystic teratoma (MCT) are the most prevalent benign ovarian cysts in this group. Endometriomas are very prevalent in menarcheal adolescents and adults, although they are uncommon in children. Endometrioma patients frequently complain with dysmenorrhea and dyspareunia. Pelvic discomfort, bloating, urine frequency, menstrual abnormalities, and/or constipation may also be present.

Torsed ovarian cysts in young women can cause nausea and vomiting as well as severe abdominal discomfort, necessitating surgical intervention. MCTs are the most frequent ovarian neoplasms in adolescents, accounting for over 70% of non-malignant ovarian neoplasms in women aged 30 and less. MCT patients are typically asymptomatic and arrive with unrelated problems. Indeed, the identification of MCTs is frequently an unintended consequence in this context. Abdominal discomfort is the most prevalent complaint among symptomatic people.

The most common benign ovarian cysts seen in pregnant women are MCTs and corpus luteum cysts. Acute complications have been reported to occur in less than 2% of these cases.  

• Postmenopausal:

Small (5 cm) unilocular ovarian cysts in postmenopausal women have a minimal risk of cancer. When the cyst is big (>10 cm), has complicated architecture (multilocular, thick septae, uneven cyst walls), or persists, the risk of malignancy rises to 6-39% in this group. CA 125 measures must be taken. Because menstrual irregularities and dysmenorrhea are no longer indices of pathology, many postmenopausal women with large ovarian cysts are asymptomatic. When symptomatic, they can cause urine frequency, constipation, and pelvic discomfort.

 

How to Prepare Before Laparoscopic Ovarian Cystectomy?

The treatment will be planned once you and your doctor have determined that surgery is the best option for you. Before the procedure, you will be given the following advice for preparing for surgery:

1. Arrive at the hospital at least four hours ahead of time.
2. To avoid aspiration while under general anesthesia, refrain from eating or drinking for at least eight hours before the surgery, or as directed by the doctor. Make sure you get enough of rest the night before the surgery.
3. Prior to visiting the hospital, refrain from wearing makeup or painting your nails. This allows the medical personnel to visually check your circulation during and after operation.
4. To avoid any loss, do not bring any jewelry or valuables to the hospital. Before entering the surgery room, removable dentures and contact lenses must be removed.
5. Before the operation, the doctor will examine your preparedness by ordering blood tests, a chest x-ray, and an electrocardiogram (EKG).
6. The doctor will make suggestions about the medications you are already taking. Some medications, such as blood thinners, aspirin, and supplements that might induce excessive bleeding, may need to be discontinued prior to surgery. The doctor will decide which medications to stop and which you can continue to take until surgery, generally with a little sip of water.
7. Avoid smoking for at least one week before the procedure.
8. A friend or family member should stay with you while you are admitted at the hospital.

 

The Laparoscopic Ovarian Cystectomy Procedure

There are several risks that are specific to performing an ovarian cystectomy that should be discussed with the woman prior to her procedure:

• Risk of oophorectomy.
• Risk of spread of undiagnosed malignancy.
• Risk of ongoing pain if pain is a primary symptom.
• Risk of recurrence of ovarian cysts.

Procedure steps:

1. The patient is in the lithotomy position. Routine skin preparation with alcoholic chlorhexidine and aqueous povidone-iodine for the vagina and vulva.
2. The uterine manipulator is inserted.
3. The surgeon's chosen technique of entry is used to produce pneumoperitoneum.
4. On the patient's left side, a 5 mm port is placed. The port is positioned 1 cm lateral to the surface landmark of McBurney's point, roughly one-third of the distance between the anterior superior iliac spine (ASIS) and the umbilicus. This avoids the inferior epigastric vessels that run along the anterior abdominal wall. The location of the port may vary based on the size of the cyst, previous procedures, and surgeon preference.
5. Two further 5 mm ports are placed – one on the right side and the other in the high-suprapubic position.
6. Holding the body of the ovary above the cyst, especially when dealing with a big and heavy cyst (such as a dermoid cyst), permits gravity and the weight of the cyst to aid with dissection.
7. The ovary can be healed once the cyst has been removed. Monofilament sutures, such as Monocryl®, are preferred. To establish haemostasis, the base of the ovary must be included. Alternatively, bipolar energy or haemostatic drugs such as Surgicel® can be used to achieve haemostasis. Bipolar energy haemostasis appears to have the biggest loss in ovarian reserve.
8. Examine the hemostasis. Although data is limited, consider using adhesion barriers. Close skin wounds and remove ports beneath eyesight.

 

What Should I Expect During Recovery?

It is common for your navel and belly to be uncomfortable and even bruised after the surgery. The gas inserted in your belly during the procedure may cause pain in your shoulders and back. Following surgery, you may experience vaginal discharge or spotting.

Your abdominal incisions will be closed with skin glue or stitches and may be covered with Band-Aids. Bandages can be removed 24 hours following surgery, and the adhesive or sutures will dissolve spontaneously.

Leave little bandage trips on your incisions, and they will fall off on their own. If they do not fall off after seven days, you can have them removed. Avoid bathing or swimming with your incisions. Have A shower, but don't massage your incisions.

You may feel more exhausted than normal in the first week following surgery. Take it easy for the first week, then gradually raise your activity level with brief walks and gentle exercise. When you are ready, you can resume sexual activity.

 

How Does an Ovarian Cystectomy Affect Your Sexual Health & Fertility?

If you have not yet reached menopause, your doctor will attempt to maintain your reproductive system by leaving one or both ovaries intact. This implies you can still produce eggs; however, removing one ovary may make it more difficult to become pregnant. In some cases, such as suspected or proven cancer, both ovaries may need to be removed, which means you will no longer be able to create eggs. Both ovaries may be removed if you have previously gone through menopause.

 

Risks & Complications

This procedure has a small risk of:

• Possible need for removal of the ovary.
• Bleeding during surgery, which may require a blood transfusion.
• Infection of the bladder or surgical site.
• Damage to surrounding organs (bladder, bowel, and ureters).
• Possible need for further surgery.

 

When To Call Your Doctor?

Call the doctor if you are not getting better or you have:

• Signs of infection, such as fever and chills.
• Redness, swelling, excessive bleeding, or discharge from the incisions.
• Pain that you cannot control with the medicine you have been given.
• Vaginal bleeding that soaks more than one pad per hour.
• Pain, burning, urgency or frequency of urination, or lasting blood in the urine.
• Swelling, redness, or pain in the legs.
• New or worsening symptoms.

 

Conclusion

Ovarian cysts are a typical reason for women to visit emergency rooms and gynaecology clinics. Up to 10% of women will undergo surgery for an ovarian mass at some point in their lives.   Laparoscopic surgery can be used to accomplish the majority of benign ovarian cystectomies. Basic studies are done in order to stratify the risk of ovarian cancer. In women under the age of 40, these will include a transvaginal ultrasound scan and tumor markers such as Ca125, HE4 and LDH, -FP and HCG to rule out germ-cell tumor.  CEA and Ca19.9 are also often sought, although their clinical utility is unclear. A gynaecological oncologist should be consulted if there are any concerns about cancer.

A laparoscopic ovarian cystectomy seeks to minimize blood loss, perform fast operation, and preserve ovarian tissue. It is critical to leave the cyst intact in order to minimize the spread of undiscovered cancer and, in the case of a dermoid cyst, to avoid chemical peritonitis. Endometriomas, on the other hand, can be burst.