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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Opening of outer ovarian surface
The outer ovarian surface can be opened using monopolar scissors. By opening up the blades and using just one tip, the
outer surface can be carefully opened using a cutting current (Tech Fig. 5.1.1). Ideally, only the outer surface is opened to
allow for the creation of a plane between the outer ovary and the cyst wall. In most cases, the cyst wall cannot be clearly
delineated until the cyst itself is entered.
Te ch Fig ure 5.1.1. Opening of ovary using monopolar scissors with cutting current.
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Developing plane between outer ovary and cyst wall
A Maryland grasper or other fine tip forceps can be used to bluntly dissect between the ovary and cyst wall (Te ch Fig.
5.1.2). If the plane does not develop easily, the level of dissection may be too shallow. The outer incision is further opened
as needed.
Te ch Fig ure 5.1.2. Blunt dissection between ovary and cyst wall.
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Opening of the cyst
Ideally a cyst would be excised fully without rupture by bluntly dissecting in the proper plane, but often this cannot be
accomplished. If a clean plane between the ovary and believed cyst wall is not easily found, the cyst may be purposefully
opened, if not already accidently opened (Tech Fig. 5.1.3). Cyst contents should be aspirated and irrigated from the pelvis.
Care should be taken with dermoid cysts to prevent unnecessary spillage of contents as this can lead to peritonitis and
adhesion formation.
2
In the case of a dermoid, it is recommended to use a large volume of fluid (>3 L normal saline) to
lavage the abdomen and pelvis to reduce adverse sequela.
Te ch Fig ure 5.1.3. Opening and draining of cyst contents.
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Dissecti ng cyst wall
Two graspers are used to hold the edge of the ovary while using a Maryland dissector to grasp the cyst wall and begin to
carefully pull it away from the ovary wall (Te ch Fig. 5.1.4). It is important during the dissection to keep the graspers close
to the area of dissection to promote the cyst peeling in the proper plane (Tech Fig. 5.1.5). Small areas of bleeding can be
cauterized with pinpoint monopolar or bipolar cautery.
Te ch Fig ure 5.1.4. Start ing to pull cyst wall away from ovary.
Te ch Fig ure 5.1.5. Maintaining close proximity of graspers to dissection plane.
Any significant bleeding suggests that the dissection has shifted away from the proper plane. In these cases, attempts
should be made to develop a plane closer to the cyst side. If a shallower plane is not easily identifiable, focus can shift to
dissecting at another location. Difficult areas of dissection often are easier to manage if the dissection shifts to another side
of the cyst. Approaching from another angle often allows restoration of the proper dissection plane.
Large areas of bleeding can be treated with bipolar electrocautery or suturing. Both methods are suitable and the superiority
of one method over another in regards to the effect on ovarian reserve is conflicting.
3,4
If electrocautery is used, judicial
use is recommended.
In some cases, an area of the cyst wall may not be able to be separated from the ovary without significant ovarian injury. In
these cases, it may be prudent to separate the cyst wall as much as possible, excise the cyst, and then use electrocautery to
destroy the remaining segment of cyst wall (Tech Fig. 5.1.6).
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Te ch Fig ure 5.1.6. Cauterized cyst wall remnant t hat could not be safely separated from ovary after majorit y of cyst was excised.
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Final hemostasis and closure
Irrigation and inspection of the ovary is performed to ensure that the cyst wall bed is fully hemostatic (Te ch Fig. 5.1.7).
Pinpoint cautery is used to obtain complete hemostasis.
Te ch Fig ure 5.1.7. Cyst wall bed after excision.
A small absorbable suture (4-0 Vicryl
®
, Ethicon, Inc., Somerville, NJ) is used to close the dead space after removal of a
large cyst. The suture can also reapproximate the edges of the ovary to lessen the exposure of raw edges to other pelvic
structures and subsequent adhesion formation
5
(Tech Fig. 5.1.8).
To help reduce the formation of adhesions, a barrier such as Interceed
®
(Ethicon, Somerville, NJ) is used to cover the ovary
and incision (Tech Fig. 5.1.9).
6
Te ch Fig ure 5.1.8. Sut ure closure of ovary edges.
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Te ch Fig ure 5.1.9. Covered left ovary and tube with Interceed
®
aft er cystectomy.
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PEARLS AND PITFALLS
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POSTOPERATIVE CARE
Patients desiring to conceive should consider that absorbable antiadhesion agents such as Interceed
®
can take up to 4
weeks to dissolve, and could interfere with normal tube–ovary interaction while still present.
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COMPLICATIONS
Destruction of normal ovarian tissue resulting in a decrease in ovarian reserve
Pelvic adhesion formation
Recurrence of the cyst
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