ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10033-1496
Indian Journal of Sleep Medicine
Volume 15 | Issue 1 | Year 2022

A Laparoscopic Approach of a Very Large Ovarian Cyst in Young Female

Mukesh Carpenter

Department of Surgery, Alshifa Hospital, New Delhi, India

Corresponding Author: Mukesh Carpenter, Department of Surgery, Alshifa Hospital, New Delhi, India, Phone: +91 98999161704, e-mail: drmukeshcarpenter@gmail.com

How to cite this article: Carpenter M. A Laparoscopic Approach of a Very Large Ovarian Cyst in Young Female. World J Lap Surg 2022;15(1):58–64.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Large ovarian cysts are ovary tumors with diameters more than 10 cm. Nowadays days these cases are rarely seen because they are diagnosed and managed early due to the ease of access to good imaging modalities. Benign serous cystadenoma is the most common type of epithelial neoplasm with benign serous cystadenoma ¾ and mucinous cystadenoma ¼. During the surgical management of large ovarian cysts in young girls, the main goal to keep in mind is the preservation of the reproductive and hormonal function of the ovaries. In this paper, the author represents a case report of a young female diagnosed with a very large ovarian cyst with a diameter of approximately 30 cm managed using laparoscopic surgery.

Keywords: Benign ovarian cyst, Laparoscopy, Minimal access surgery, Ovary.

INTRODUCTION

The most common cause of pelvic masses in women is ovarian cysts and the majority of the cases can be seen in the fertile age-group. In India, it has been observed that nearly 10% of the female population undergo a surgical approach for ovarian cyst during her lifespan. Epithelial neoplasm of the ovary account for more than half of all ovarian tumors and almost 40% are benign tumors.1 Most of the large ovarian cysts are benign and are generally treated via. surgical excision such as cystectomy or salpingo-oophorectomy. At the early stage, most cases seem to be asymptomatic and cause symptoms only after reaching a stage of massive dimension. The clinical symptoms mainly include vaginal bleeding, progressive abdominal distension, early satiety, imprecise diffuse abdominal pain, constipation, vomiting, and recurrent micturition.2,3

Nowadays benign ovarian cysts of more than 10 cm are rarely encountered due to early diagnosis and treatment. Laparoscopy is the treatment of preference in most cases, but the size of the cyst can be a limiting factor.4 With the increased ovarian cyst size, the complication of a minimally invasive technique also increases due to problems in creating a pneumoperitoneum, decrease in visibility and surgical mobility. All the listed factors result in a high risk of intraoperative spillage. In literature, several case reports are present where different surgical techniques are used to reduce abdominal spillage, but these techniques are not suitable for a larger ovarian cyst that occupy the whole abdominal cavity. Sevelda et al.5 also state that the intraoperative rupture of ovarian cyst did not influence the prognosis. The author studied the survival of patients with moderately and poorly differentiated stage 1 ovarian carcinoma and concluded that no differences in the survival rate between the patients with intraoperative cyst rupture.6,7

CASE PRESENTATION

My patient is a 26-year unmarried female belonging to a middle-class family who came with complaints of progressive abdominal distension, vague abdominal pain, hyperacidity for a few months. She also gave a history of heavy flow during her last two menstruation cycles; her cycles are 28-days 3–4 days of bleeding. No bowel and urinary disturbance. No history of any gynecological malignancy in the family. No history of any surgical intervention in past.

On examination abdominal distended above the umbilicus bilateral flanks are full, fluid thrill present. Per vaginal examination fullness is present mainly on the right side. Her routine blood investigation and serum tumor markers were well within the normal range (Beta HCG—0.36 mIU/mL, CA125—8.6). Serum CA-125 assay is a useful tool that helps to distinguish between benign and malignant ovarian masses. The combination of normal findings at serum CA-125 assay, imaging, and clinical findings exclude the possibility of ovarian cancer.8

Ultrasound

A large anechoic mass with internal septation arising from the pelvis extending up to epigastrium and bilateral lumbar region approximate size 28 cm × 23 cm × 20 cm, volume approximate 4875 mL, displacing the bowel and other visceral organs. Bilateral ovaries are not separately visualized.

CECT Abdomen and Pelvis

Large nonenhancing capsulated thin-walled with internal septation tubo-ovarian cystic mass arising from the right side of pelvis size 30 cm × 22 cm × 23 cm, volume almost 5000 mL occupying whole abdomen extending up to epigastrium and bilateral lumbar region repelling the bowel and other visceral organs. Uterus pushed to opposite side left ovary visualized and appears normal. Adhesions present between tubo-ovarian mass, urinary bladder, and uterus as shown in Figure 1.

Figs 1A to C: Large tubo-ovarian cystic mass arising from the right side of pelvis occupying almost whole abdomen

The patient planned for a laparoscopic procedure after evaluation and preanesthetic checkup. Umbilical port placed using open technique luckily cyst was not punctured in this case. After creating pneumoperitoneum and inserting three accessory ports, the cyst was deliberately punctured and approximately 5 L cystic fluid drained after breaking internal septations; sample send for cytological analysis (Figs 2 to 5).

Fig. 2: Patient under general anesthesia (GA)

Fig. 3: Laparoscopic view of large ovarian cyst

Fig. 4: Ovarian fluid aspiration using a suction catheter

Fig. 5: Large ovarian cystic fluid

Adhesions present between the cystic wall and right side of bowel loops and rectum. The cystic wall is densely adherent to the urinary bladder and to the uterus. Very hard to find a plane between the urinary bladder and cystic wall. To make the plane visible urinary bladder was filled with 500 mL of saline meticulous dissection was done and slowly proceeded. Ovarian cyst wall dissected from the urinary bladder (Fig. 6).

Fig. 6: Adhesions between the urinary bladder and large ovarian cyst wall urinary bladder filled with saline

The ovarian cyst was removed after enlarging the left iliac fossa working port to 3–4 cm to remove an ovarian cyst in small pieces. Extracting such a large ovarian cyst through a small incision requires a lot of patience, zigzag movement helps in early extraction. Specimen send for histopathological examination (Fig. 7).

Fig. 7: Large ovarian cyst specimen

No bowel and bladder injury was encountered during surgery. The left side ovary and fallopian tube are normal. Through wash given using 8–10 L of normal saline. Drain placed in the pelvis (Fig. 8).

Fig. 8: Post-surgery with drain

The Postoperative patient extubated her vitals were stable.

Postoperative day-1 Hb—9.7 g drain was 600 mL vitals were normal with good urine output. The patient started on liquids after 8 hours of surgery and proceed to a soft diet for the next 24 hours. The postoperative day-2 drain was 400 mL vitals were stable with good urine output and the patient was ambulant tolerating oral soft diet. On postoperative day-2, the patient was discharged with drain and Foley’s catheter. The patient called for a review on postoperative day-5 her drain was 60 mL serous (day-3—280 mL, day-4—120 mL) urine output was good 2 L plus in 24 hours. Both drain and Foley’s were removed on postoperative day-5. Postoperative day-12 all sutures were removed as Figure 9. Histopathology report: benign serous cystadenoma.

Fig. 9: Minimum scar to the abdomen

DISCUSSION

In the last few years, surgical treatment has become less invasive and conservative. In today’s world, a laparoscopic method in the presence of assumed benign cysts has become a gold standard.9 In the case of laparoscopic surgery treatment depends on several criteria such as age, menstruation cycle status, size, and structure of ovarian cyst.

Minimal invasive surgical management for benign ovarian cysts has become popular nowadays. Various studies demonstrated a clear advantage of laparoscopy as compared to standard open surgery in terms of lesser amount of blood loss and analgesic requirement, better visibility during surgery, minimum postoperative pain, decreased days of hospital stay, and better cosmetic outcomes. The person can resume to normal activity early.10

During the surgical management of large ovarian cysts in young girls, the main goal to keep in mind is the preservation of the reproductive and hormonal function of the ovaries. Frequently cysts have dense adhesions with the ovary and persevering ipsilateral ovary could not be possible as encountered in this paper.

The laparoscopic approach for large ovarian cysts presents various difficulties.

The author has taken care of the hormonal and reproductive function of the young girl with a very minimal scar to the abdomen.

CONCLUSION AND RECOMMENDATION

Laparoscopic surgical management of very large ovarian cysts is a technically and surgically challenging task. The laparoscopic approach should be considered in young girls whenever feasible who have normal tumor markers and imaging modalities that suggest benign ovarian cyst.

REFERENCES

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