Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery--the best of both worlds

Abstract

Background/purpose: Cystic ovarian lesions can be massive, and preoperative evaluations can often not distinguish benign from malignant tumors. Up to 57% of malignant ovarian tumors have a cystic component. We present an approach to these neoplasms that adheres to oncologic principles using minimally invasive techniques.

Methods: A 5-cm Pfannensteil incision is performed followed by peritoneal washings. The mass is identified and dried. Dermabond (Ethicon, Johnson & Johnson, New Jersey) is applied to an area of the capsule (measuring 3 x 3 cm) and to a sterile plastic ultrasound bag. The bag is then applied directly to the exposed capsule. BioGlue (Cyrolife Inc, Kennesaw, GA) is then injected into and around the bag/mass interface and allowed to solidify. A veress needle decompresses the cyst, and the ovary is delivered out of the peritoneal cavity for either cystectomy or an oophorectomy. Routine surveillance of the omentum, lymph nodes, contralateral ovary, and peritoneal surface is then performed.

Results: Nine female patients (mean age, 14.1 +/- 2 years) were treated. All had normal alpha-fetoprotein and human chorionic gonadotropin. Computed tomographic scans demonstrated cystic lesions ranging from 8.9 to 27 cm in diameter (17.1 +/- 2.6 cm2). Operative procedures were: 4 salpingooophorectomies and 5 unilateral oophorectomies. In a single case, the contralateral ovary had a suspicious lesion, which was biopsied. No tumors spills occurred. The pathology included 2 simple cysts, 3 serous cyst adenomas, 3 mature cystic teratomas, and 1 immature teratoma with grade 2 to 3 immature elements. Peritoneal washings were negative. All patients were discharged within 48 hours and are well 15 months to 3.1 years postoperatively.

Conclusions: The containment of the ovarian cyst with the application of surgical adhesives and a plastic sleeve offers a significant advancement in our ability to safely treat these lesions. This approach markedly reduces the length of the surgical incision while insuring the prevention of peritoneal contamination with cystic fluid.