A novel minilaparotomy approach for large ovarian cysts
This alternative to laparoscopic and laparoscopic-assisted procedures retains the benefits of minimal access while circumventing the need for special equipment, long operating times, and an extended learning curve.
SUMMARY OF THE TECHNIQUE
- 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).
The cruciate incision. With a conventional scalpel make a small suprapubic transverse incision through the skin and subcutaneous tissue (FIGURE 2). After clearing subcutaneous fat from the midline, incise the rectus fascia and the peritoneum in a vertical direction.
A vertical skin incision can be selected if the preoperative workup suggests a later extension of the original minilaparotomy incision may be required, or if there is a prior vertical incision.
Retraction. Use a soft sleeve-type self-retaining plastic retractor, such as Mobius (Apple Medical Corp) (FIGURE 3 ). When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure of the pelvis (FIGURE 4).
During surgery it may be necessary to adjust the outer ring if the sleeve loosens. Narrow Deaver or Richardson retractors, if required, provide additional retraction. The bowel may be gently packed, if necessary, but typically it is adequately displaced by the large ovarian cyst.
The atraumatic retraction provided by the soft, self-retaining abdominal retractor minimizes the possibility of tissue trauma, nerve damage, bruising, and postoperative pain. At the same time, the continuous 360° retraction force on the incision maximizes surgical exposure, providing a significantly larger working area than conventional retractors. For example, when applied to a 6-cm incision, the self-retaining retractor creates a 28-cm2 exposed working area, compared with only 18 cm2 provided by a conventional 4-point metal retractor.
The adjustable height of the self-retaining retractor adapts to wounds of varying depth and works on virtually any tissue thickness—a feature that makes the device effective for obese patients. Further, by lining the abdominal incision, the retractor’s plastic sleeve protects the wound’s edges from contamination and potential implantation of malignant cells, making the device ideal for managing ovarian cysts.
FIGURE 1 Hinged uterine manipulator
The manipulator facilitates exposure of the cyst and contralateral adnexa, as well as uterine elevation/rotation.
FIGURE 2 Cruciate incision
Make a 2.5- to 5-cm suprapubic transverse skin incision. Using the Bovie device, incise the subcutaneous fat transversely along the full length of the skin incision down to the level of the anterior rectus fascia. Clear the subcutaneous fat from the midline superiorly and inferiorly to expose 5 to 6 cm of the rectus fascia in the vertical axis. Use blunt digital dissection to assist in mobilizing the subcutaneous fat. Incise the anterior rectus fascia vertically through the full length of the cleared area. Retract the rectus muscles from the midline to expose the underlying transversalis fascia and the peritoneum. Control small bleeding points with the Bovie device. Enter the peritoneum either digitally or with scissors above the bladder dome and extend the peritoneal incision to the full length of the fascial incision.
FIGURE 3 Self-retaining retractor
The retractor consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve.
FIGURE 4360° retraction force
Squeeze the inner ring of the soft, sleeve-type, self-retaining retractor into the peritoneal cavity through the cruciate abdominal incision and allow it to spring open against the parietal peritoneum. Make a digital assessment to ensure that viscera is not trapped between the inner ring and the abdominal wall. Place the entire sleeve on traction by lifting the outer ring. Then roll the outer ring onto the sleeve, collecting excess length, until it sits firmly against the skin. The atraumatic retraction provided by the sleeve-type retractor maximizes exposure of the pelvis. Note how a portion of the large cyst is clearly seen through the atraumatic, circular area of retraction.
Visually and digitally inspect the cyst and carefully evaluate the uterus, pelvis, and contralateral adnexa. Determine the extent of adhesions and any unexpected pelvic pathology. When needed, use traditional small retractors or gentle packing to gain additional exposure. If the cystic mass appears suspicious (internal and external excrescences on the cyst, ovaries, or peritoneal surfaces, or ascites), obtain pelvic washings with a suction-irrigation cannula, send the fluid for cytologic examination, and convert the minilaparotomy to a standard exploratory laparotomy. Extensive adhesions to the bowel, broad ligament, or pelvic sidewall and unexpected extensive endometriosis may also require a conversion to standard laparotomy.
Reduce cyst size by decompression
Simple aspiration is inadvisable. To remove a large ovarian cyst using the Pelosi minilaparotomy, reduce the size of the cyst to permit safe and effective mobilization and resection through the small abdominal incision. Simple aspiration of the cyst, with its potential for spilling the contents, is not a wise strategy for several reasons. First, many ovarian cysts contain functional epithelium with a high recurrence rate (8% to 67%). Second, studies show that 10% to 66% of ovarian cyst fluid aspirates initially diagnosed as benign actually are malignant. Further, relying on negative cytology from the aspirate of an ovarian cyst without tissue biopsy may delay appropriate surgery, and the puncture of an unexpected malignant cyst may seed the peritoneal cavity and possibly worsen the patient’s prognosis.11,12
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.