Let Go of Ovarian Cysts with Innovative Laparoscopic Techniques
Ovarian cystectomy refers to the removal of an ovarian cyst or tumor while preserving the ovary. Every effort is made to preserve the ovary for patients who desire fertility. Considerations for ovarian cystectomy include:
- Patient’s age
- Possibility of malignancy
- Size of the cyst or tumor
Ovarian cysts are relatively common, but surgical treatment depends on whether or not you wish to maintain fertility, and also the condition of the cyst. When you visit The Center for Innovative GYN Care® (CIGC®) we will ensure that you are aware of all of your treatment options, as well as the potential risks and side effects of each. The type of surgery depends on whether or not a patient is able to maintain fertility and also the condition of the cyst. Our advanced laparoscopic techniques make it possible to perform complex GYN procedures, including a minimally invasive ovarian cystectomy, using just two tiny incisions. The procedure usually takes under an hour and most women are back to themselves in just days.
Ovarian Cystectomy Procedure
Masses of all sizes can be removed laparoscopically. Typically, one or two tiny (1/4 inch) incisions and one slightly larger (3/4 inch) incision are necessary for a cystectomy. The smaller incisions are located at the belly button and on the far right or left side in the bikini line. The larger incision is located just above the pubic bone and is used to remove the cyst. There is a risk of rupture of an ovarian cyst when performing cystectomy. In benign, or nonmalignant cases, this is of no concern. However, cysts or ovarian masses that are suspected to be cancerous may require complete removal of the ovary to avoid rupture. While not of immediate danger, if cancerous masses rupture, patients will require chemotherapy due to the spill of cancerous cells into the pelvis.
In order to remove the cyst from the body, the cyst is placed in a special bag. This allows for easy removal and prevents fluid from the mass from spilling into the pelvic cavity. Any masses suspicious for malignancy are sent for frozen section analysis. In frozen section, the mass is sent to the pathologist while the patient is still asleep on the operating room table. The pathologist carefully reviews the sections of the mass to rule out cancer.
The following video is a demonstration of removal of a large 16 cm ovarian mass at the time of hysterectomy. Three ports are used for this procedure, and some of the steps taken in the performance of a retroperitoneal hysterectomy are shown, such as ligation of the uterine artery. Once the uterus is detached, it is removed through the vagina. The ovarian mass is then placed in a bag, which is inserted through the vagina, and the opening of the bag brought outside the vagina. At that point, the mass is ruptured, with spill of fluid into the bag and not into the abdomen of the patient. This is important since some large masses in menopausal women (after change of life) such as in this case, have a higher incidence of ovarian cancer. This mass was benign. This type of surgery is almost always done with a large open incision, requiring 8 weeks of recovery time and significant pain. This patient went home the same day, and was back to work in 7 days using this DualPortGYN retroperitoneal approach.
What Are the Advantages of Ovarian Cystectomy?
The vast majority of ovarian cysts and masses in premenopausal patients are benign, making laparoscopy a great option for many patients. Minimally invasive ovarian cystectomy procedures allow patients to avoid large, open incisions.
Postmenopausal patients have an ovarian cyst incidence of 18 percent, and most are benign1, with cancer rates ranging from five to 20 percent depending on the study cited. Laparoscopy is of significant benefit for these patients as well, since it will prevent an open surgery, and recovery from open surgery can be increasingly difficult for older women.
The CIGC laparoscopic cystectomy is an outpatient procedure, with excellent pain control and rapid recovery. Most patients are back to work within seven days.
When Is a Patient Not a Good Candidate for Ovarian Cystectomy?
There are some scenarios in which an ovarian cystectomy may not be the recommended treatment. These can include:
- The ovarian cyst or mass is very large: As the cyst or mass grows, it replaces the normal ovarian tissue and with very large cysts, there is no normal ovarian tissue remaining
- Ovary is torsed (twisted): 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
- Postmenopausal: Removal of the entire ovary is preferred over ovarian cystectomy, 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
- Malignancy is suspected: Removal of the ovary is recommended to avoid the rupture and spill of cancerous cells into the pelvis
- The ovary should be sent for analysis during the surgery, and a staging procedure should be performed if cancer is confirmed
Ovarian Cystectomy Risks and Complications
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, since 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, 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.
Please note that ovarian cancer is a very rare disease, with the risk being only one in 78, or 1.34 percent in the general population2.
In properly selected patients, the treatment of ovarian masses with laparoscopy saves thousands of women every year the difficult recovery and increased complications associated with open surgery.
Ovarian Cystectomy Recovery
Recovery after ovarian cystectomy is relatively quick, since the incisions used are small and located cosmetically to decrease pain. Most patients are walking after the procedure the same day, and are back to work in three to five days, with many patients recovering faster.
Normal activities can be resumed relatively quickly after these procedures since the incisions are small, and are not through the muscle. Pain can be controlled with Motrin, although sometimes Tylenol 3 or other narcotics may be necessary.
Patients are encouraged to resume activities quickly, and get back to a normal lifestyle as soon as possible.
The CIGC Difference
Ovarian cysts are a relatively common condition, but that does not mean that you should get treatment from just anyone. If a relatively painless recovery and a low risk of complications are your priorities, it is important to find a GYN specialist, not generalist.
Many patients consider allowing their OBGYNs to perform their gynecological procedures, but the reality is that these doctors are generalists rather than GYN specialists. Their focus is on obstetrics, and GYN surgery is only a minimal portion of their practice. Therefore, they do not have the extensive training and experience that CIGC surgeons have.
At CIGC, our minimally invasive GYN specialists have made a commitment to surgery. We see more cases, treat a wider range of case types, and undergo more training than an OBGYN. Our surgeons have learned advanced techniques and procedures and can perform even the most complex surgeries with lower complication rates. We use our experience to decide whether you are a good candidate for ovarian cystectomy. Some patients are better suited for ovary removal and our doctors have the insight to make that decision, ensuring that you get the best possible outcome.
CIGC offers minimally invasive ovarian cystectomies while many clinics still perform open procedures — which result in severe pain, higher complication rates, and a longer recovery period. We are focused on laparoscopic procedures that are less expensive, less painful, and less risky. We prioritize your recovery, and laparoscopic cystectomies facilitate a relatively easy one.
Ovarian Cystectomy FAQs
An ovarian cyst is usually a benign collection of fluid in the ovary that is due to development of an egg in the ovary, also known as a follicular cyst. Other cysts form from overgrowths of cells in the lining of the ovary of different types, such as serous cysts from serous cells and mucinous cysts from mucinous cells. Endometriomas are cysts that develop from implants of endometriosis, in which old blood accumulates in the ovary, also known as chocolate cysts. Solid masses in the ovary can develop as both cystic and solid areas and are usually benign. Cancerous cysts of the ovary often have both cystic and solid components, and are considered complex in appearance.
Most cysts, such as follicular cysts, resolve on their own. Other cysts will continue to grow and require a cystectomy if they cause pain or appear complex or suspicious for malignancy. Complex cysts in patients of certain age groups are considered high risk masses for malignancy and must be removed. In general, any cystic mass in the ovary that has solid and cystic components needs to be further characterized and may require removal.
Ultrasound is one of the best tests to determine if cysts are complex or high risk. This is because the ultrasound transducer is placed directly near the cysts and can provide excellent images of the ovary. Other more expensive tests include MRI, which may be helpful for determining size and characterization of larger cysts.
Laparoscopic specialists can often perform cystectomies with minimally invasive approaches such as laparoscopy. This avoids a large open incision. Note that most OBGYNs will perform open surgery for larger cysts, and often convert laparoscopy to open surgery for more difficult procedures, such as the removal of endometriomas or cysts adherent to other structures. CIGC surgeons, for example, perform almost all cases requiring ovarian cystectomy laparoscopically. Very large ovarian cysts are removed by CIGC surgeons with specific techniques that avoid open surgery, remove the entire cyst, and allow patients to be discharged home the same day as the surgery.
At CIGC, cystectomies are usually performed using three incisions: two 5 mm incisions and one 10 mm incision. The camera incision site is at the belly button, and two additional incisions are located in the bikini line. The placement of these incisions allows for excellent cosmetic results and also decreases pain.
Ovarian cysts usually involve the outside lining of the ovary and then move into the ovarian tissue. In this regard, a cyst in the ovary is like an orange, with the peel of the orange being the ovarian tissue, and the meat of the orange being the cyst. “Peeling” the orange is performed laparoscopically, and the meat of the orange — the cyst — is removed, while the peel — the ovarian tissue — is retained. The peel is then sewn together, and the cystectomy is completed. This type of approach can be used for all ovarian cystectomies, large and small.
Bleeding during the removal of the cyst can occur. Sometimes, ovarian tissue is removed with the cyst, which can be avoided by using the “peel the orange” approach described above. Conversion to open surgery can be avoided if proper techniques are used, but does occur in some cases. In general, performance of the cystectomy by a laparoscopic specialist will allow for a better outcome and avoid open surgery in almost all cases.
Ready for a Consultation
If you’re considering an ovarian cystectomy, our specialists are ready to provide an evaluation of your symptoms and conditions and recommend an appropriate solution.
1 Torre LA, Trabert B, DeSantis C, et al. Ovarian cancer statistics, 2018. CA Cancer J Clin. 2018 Jul;68(4):284-96
2 Farghaly SA. Current diagnosis and management of ovarian cysts. Clin Exp Obstet Gynecol. 2014;41(6):609-12