Single incision laparoscopic surgery ovarian cystectomy in large benign ovarian cysts using conventional instruments.

We describe a technique for the management of large benign ovarian cysts by single incision laparoscopic surgery (SILS) through the umbilicus. The paucity of intra-abdominal working space in large ovarian cysts poses a technical challenge. Moreover, difficult convergence of operating instruments and competition for operating space outside the abdomen during the SILS makes the procedure quite demanding, especially with the conventional instruments. The concept of providing traction by taking sutures from the abdominal wall, as done in SILS laparoscopic cholecystectomy, was applied for SILS cystectomy in large ovarian cysts. Two sutures taken through the abdominal wall and then through the cyst wall provide excellent traction and "hang" the cyst from the abdominal wall, making it convenient to dissect and operate. This technique demonstrates that SILS ovarian cystectomy is feasible, safe and technically unchallenging even in large benign ovarian cysts.

INTRODUCTION

Management of ovarian cysts by laparoscopic surgery is well established.[1] In the last couple of years, published reports have led to keen interest in ovarian cystectomy by the single incision laparoscopic surgery (SILS) method.[2-4] However, SILS requires increasing technical skills and better instrumentation, preventing its widespread adaptation. We report SILS cystectomy in large benign ovarian cysts with conventional instruments made less technically unchallenging by an effective surgical technique via description of our experience in two cases, a chocolate cyst and a serous cystadenoma.

CASE REPORTS

Case 1

A 24-year-old unmarried nulliparous woman, of weight 54 kg and height 170 cm, reported pain and pressure symptoms in the lower abdomen for 8 months. The pain, increasingly progressive for 4 months, was continuous, moderate to severe in intensity and increased after defaecation, especially during menstruation. Her pain was associated with urinary frequency and urgency. The colour Doppler ultrasound showed a unilocular cyst, measuring 9.9 × 9.2 cm in size, and computer tomography showed a large unilocular cyst in the left ovary, measuring 10.1 × 9.5 × 7.2 cm in size, with minimal solid tissue [Figure 1]. Preoperative CA-125 levels were in normal limits (24 ng/ml). Right ovary and the uterus were normal.

Figure 1

CT scan showing a large left ovarian cyst

The bowels were prepared with oral polyethylene glycol (Peglec) a day before the surgery. The patient was administered general anaesthesia and positioned in Trendelenberg position with left side up. The umbilicus was everted and a midline vertical 2.5-cm incision was made inside the umbilicus. After retracting the edges of the incision, a 2.5-cm plane was created in the subcutaneous plane around the incision. One 10-mm port and two 5-mm ports were inserted as shown in [Figures 2 and 3]. A 10-mm, 30° telescope was inserted through the 10-mm port and other instruments were inserted through the 5-mm ports. Peritoneal and pelvic cavity inspection revealed a large left ovarian cyst occupying the whole of pelvic cavity [Figure 4]. Aspiration of the cyst produced 175 ml of chocolate-coloured dense fluid. A 2-0 silk suture on a straight 45-mm needle was inserted through the abdominal wall in the right iliac fossa. The needle was grasped through a needle holder inside the abdominal cavity and passed through the right edge of the collapsed cyst [Figure 5]. Similarly, a suture was taken through the left edge of the cyst from the left iliac fossa. On tightening both the sutures, the cyst was suspended from the abdominal wall [Figure 6]. A harmonic scalpel and a grasper were inserted through the 5-mm ports. The cyst wall was cut with harmonic scalpel (Ethicon Endo-surgery, Cincinnati, OH, USA) on coagulation mode, first vertically and then around the base of the cyst. The epithelial lining in the residual cyst was removed or electrocauterised with a monopolar cautery hook. The abdominal and the pelvic cavity were then washed with copious amount of saline and perfect haemostasis was assured. The excised cyst wall (in two pieces) was suspended from the abdominal wall from their respective sutures. After a complete visual inspection of the right ovary, uterus, pelvic and abdominal contents, the cyst wall pieces were removed through the 10-mm port. The sheath between the 10-mm port and one of the 5-mm ports was cut to enlarge the sheath incision to facilitate the cyst wall removal. The sheath was closed with 2-0 vicryl (Polyglactin) and the same suture was taken through the subcutaneous edge of both the skin incisions to facilitate the inversion of umbilicus. The final wound in the skin was 2.5 cm and was closed with 3-0 nylon suture. The cosmesis of the final wound was excellent [Figure 7].

Figure 2

Port position schematic diagram

Figure 3

Port positions

Figure 4

A large left ovarian cyst

Figure 5

Suture being passed through the right side of the cyst

Figure 6

Cyst suspended from the abdominal wall by two sutures

Figure 7

Final photograph of the abdomen after closure of the incision

The patient recovered well in the postoperative period. The patient was started orally after 6 hours, ambulated after 10 hours and was discharged after 24 hours.

Case 2

A 19-year-old girl, of 58 kg weight and 165 cm height, presented with a large cyst in the right ovary. She was asymptomatic, and during a routine health check-up, abdominal ultrasound revealed a 9.0 × 6.3 × 5.2 cm cyst, which was unilocular with minimal internal echoes. Serum CA-125 was normal (21 ng/ml). The uterus and the left ovary were normal. The SILS cystectomy was done under general anaesthesia by the same surgical technique as described above. The cyst had minimal adhesions and was filled with serous fluid. The patient had an uncomplicated postoperative recovery and was discharged the next day.

DISCUSSION

The SILS technique has the advantage of better cosmesis and less pain in the postoperative period.[5] Few reports have been published reporting SILS in benign ovarian cystectomy.[2-4] However, this technique of SILS ovarian cystectomy in large ovarian cysts using conventional and readily available instruments has not been reported so far. The suspension of the cyst through the abdominal wall makes the procedure less technically challenging to perform as it obviates the repeated need to hold and provide traction to the cyst wall. This reduces the number of instruments required. Secondly, after completion of the wall excision, the excised portions remain suspended from the abdominal wall, relieving the concern to keep them under vision so as not to “lose” them between the abdominal contents. Thirdly, due to excellent traction provided, the surgery can be performed by rigid conventional instruments. Due to these reasons, this technique makes SILS cystectomy quite easy even in large benign ovarian cysts.

There are few contraindications to SILS ovarian cystectomy. Most important would be a malignant ovarian cyst. One has to be particularly careful while aspirating the cyst with an aspiration needle as spillage of cyst contents in the peritoneal cavity while doing the same in a benign looking malignant cyst can have negative consequences. Other relative contraindications are moderate to severe endometriosis, previous pelvic surgery, bleeding diathesis and high anaesthesia risk (ASA Grade 3 or 4).

Using the described technique, we conclude that SILS is feasible and safe and should be adopted in treatment of large benign ovarian cysts. Prospective randomised controlled trials are needed to substantiate the benefits of SILS over conventional laparoscopy.