Ovarian cysts are relatively common, but surgical treatment depends on whether or not patients wish to maintain fertility, and also the condition of the cyst.
Ovarian cystectomy is the surgery of removal of an ovarian cyst or tumor while preserving the ovary. Every effort is made to preserve the ovary for patients who desire fertility.
Generally we try to remove only cyst inside the ovary, preferably by means of laparoscopy but there are some instances where it is not possible. In such cases we need to remove entire ovary for the benefit of the patient.
In case of a post-menopause lady, we prefer removal of the entire ovary especially if the cyst appears complex on the ultrasound. Preserving the ovary in a postmenopausal patient is of little benefit and the possibility of malignancy is greater than in younger patients.
If malignancy is suspected, we do removal of the ovary to avoid the rupture and spill of the cancerous cells into the pelvis.
While doing surgery we do frozen section examination of the ovary. The frozen section examination is an instant microscopic examination of the removed ovary to detect or rule out cancer. If cancer is confirmed we go ahead with a staging procedure. We take sample of the fluid present in the abdomen, sample of the omentum and lymph nodes are also excised during staging procedure. Sometimes if the ovarian cyst or mass is very large, it replaces the normal ovarian tissue. In cases of very large cysts, there is no normal ovarian tissue remaining. These are also candidates for removal of entire ovary.
If the ovarian mass or cyst caused the ovary to twist, this will cause the ovary to die because the blood supply to the ovary is cut off. In most cases, it is not possible to revive the ovary and the entire ovary has to be removed.
Ovarian cysts of all sizes can be removed laparoscopically. Typically, one 10mm incision is made near the belly button from which laparoscope goes inside to visualize the abdominal structures. Two to three 5 mm incisions are made on either side (on the far right or left side in the bikini line) to introduce operative instruments so as to carry out the operation. The cyst is carefully separated from the ovary so as to avoid puncture/rupture or bursting of it.
In order to remove the cyst from the body, the cyst is placed in a special bag called Endobags. Endobags are sterile bags made up of medical grade plastic. This allows for easy removal and prevents fluid from the mass from spilling into the pelvic cavity. Since the vast majority of ovarian cysts and masses in pre-menopausal patients are non cancerous, laparoscopy is a great option for many patients. Minimally invasive procedures allow patients to avoid large, open incisions for the removal of their cysts, thereby decreasing hospital stays, recovery times, and pain. Women who have laparoscopic cystectomy are discharged from the hospital the same day, with excellent pain control and rapid recovery. Most patients are back to work within seven days.
Rupture of an ovarian mass is possible with either laparoscopic or open surgical procedures. According to the medical literature, rupture rates are higher in laparoscopy than open procedures. For the reasons stated above, and that rupture poses no risk of harm in benign cases, laparoscopy should always be considered unless ovarian cancer is confirmed prior to surgery by imaging studies such as CT scan or ultrasound with elevated CA-125 (hormone marker for ovarian cancer) and a confirmed pelvic exam. In some cases, malignancy can be treated laparoscopically as well, but requires a complete assessment by a gynecologic oncologist.