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Ovarian CystectomyOvarian cystectomy is performed in those benign conditions of the ovary in which a cyst can beremoved and when it is desirable to leave a functional ovary in place. This is particularly true in

women of reproductive age. Pelvic surgeons continue to be amazed at how much functionremains in the smallest segment of healthy ovarian tissue. Therefore, if it is technically feasibleand where one is assured that there is no malignant tissue present, it behooves thoseperforming pelvic surgery to attempt to perform ovarian cystectomy in preference tooophorectomy, particularly in those patients who want to become pregnant.

The purpose of the operation is to excise an ovarian cyst without removing the ovary.

Physiologic Changes . The ovarian cyst is removed.

Points of Caution . The incision into the ovarian capsule must be made very carefully to preventrupture of the cyst.

Meticulous hemostasis must be achieved to avoid ovarian hematoma. This is best performedwith a running mattress suture as shown in Figures 10-12.

Technique

Patients with an adnexal mass should be placed

The patient can be changed to the supine positionor to the modified dorsal lithotomy position.

In general, a patient of menopausal age or above

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on the operating table in the dorsal lithotomyposition. A thorough examination under anesthesia is performed prior to opening theabdomen. The bladder should be emptied with acatheter. The surgeon should not be surprised to

see a patient who has been referred for ovariancyst who actually has a problem with urinaryretention.

The abdomen, perineum, and vagina aresurgically prepared. Although hysterectomy israrely required, a malignancy can occasionally beencountered that will necessitate removal of theuterus. For this reason, it is best to havepreviously prepared the vagina with an asepticsoap solution.

should have a lower midline incision for adnexalmasses. The incidence of malignant disease issuch that a lower midline incision will be required inthe course of surgery, and this overrides thecosmetic advantages of a transverse incision. It is

extremely difficult to adequately explore theabdomen for a malignant ovarian process through aPfannenstiel or transverse incision. For younger patients in whom the chance of a malignantdisease is quite low, a transverse incision or Pfannenstiel incision is acceptable. If a malignantdisease is encountered in this younger age group,the transverse or Pfannenstiel incision can beclosed and a midline incision can be made.

A lower midline incision is made.

The peritoneum is opened. The abdomen isthoroughly explored. Any suspicious tissue in the

upper abdomen or along the aortic lymph nodesshould be sent for a frozen section pathologicanalysis.

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A uterine elevator or a suture is placed in thefundus of the uterus to retract it anteriorly.Bilateral cysts are shown here: the one on the leftappears to be more polypoid; the one on the rightappears to be involved with significant amount of ovarian tissue.

The ovary is anchored by placing Babcock clampson the suspensory ligament of the ovary. A scalpelis used to incise the ovarian capsule near the baseof the cyst.

After incising the ovarian capsule with a scalpel,the surgeon uses delicate tissue forceps to

elevate the capsule and small Metzenbaumscissors to dissect the alveolar tissue between thecyst and the ovarian capsule. The margins of the ovarian capsule are held with

Allis clamps. An adhesion on the cyst can be usedto provide retraction, and the remaining cyst can bedissected out of the ovary with Metzenbaumscissors.

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The ovarian capsule and base of the ovary areshown after the cyst has been removed.Hemostasis within the bed of the ovary can becontrolled by clamping and electrocoagulatingsmall bleeders.

The hemostatic running mattress suture is placedwith a 3-0 synthetic absorbable suture starting atthe upper pole where the suture is tied.

The mattress suture of the ovary has beencompleted.

When the lower pole of the ovary has beenreached, the same suture is used to suture the

edges of the ovary in a running Connell invertingsuture.

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