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Large cystic ovarian masses pose technical challenges to the laparoscopic surgeon. Removing large, potentially malignant specimens must be done with care to avoid the leakage of cyst fluid into the abdominal cavity.
We present the case of a large ovarian cystic mass treated laparoscopically with intentional trocar puncture of the mass to drain and remove the mass.
Large cystic ovarian masses can be removed laparoscopically with intentional trocar puncture of the mass to facilitate removal without leakage of cyst fluid.
However, challenges arise with the laparoscopic approach when large cystic ovarian masses are addressed. Removal of the mass intact is usually not possible, and care must be taken to avoid the leakage of malignant cells from the cyst in cases of malignancy.3,4 Also, chemical peritonitis may result from the leakage of benign cyst fluid into the peritoneal cavity.5,6
Several approaches to removing large cystic ovarian masses have been described. Drainage of the cyst either by ultrasound-guided paracentesis7 or by drainage during laparoscopy8 followed by oophorectomy or extracorporeal cystectomy9 are common surgical approaches.
A 37-year-old, para 4, patient presented for evaluation of increasing abdominal girth and abdominal pain. A computed tomography scan showed a very large simple cystic right adnexal mass filling the entire abdomen, measuring 27cm by 18cm by 22cm (Figure 1). The CA-125 level was 37 (normal range, 0 to 35 units/mL). Physical examination confirmed the finding of a large cystic abdominal mass that was freely mobile and separate from the uterine body. A benign serous cystadenoma was suspected from the clinical examination, CA-125 level, and imaging results.
The patient was taken to the operating room for surgical management. Laparoscopic access was obtained at the left upper quadrant. The mass filled the entire abdomen. The surface of the mass was smooth and regular and without excrescences (Figure 2). Direct laparoscopic visualization of the mass supported the clinical suspicion that the mass was benign. A second port site was placed just inferior to the umbilicus. A Step bladeless trocar system (Covidien. Mansfield, MA) access needle and sleeve were guided through a small skin incision and intentionally directed into the cystic mass under laparoscopic visualization. The access needle was removed from the sleeve, and the 5-mm dilating cannula was placed through the sleeve (Figure 3).
The suction irrigator was then advanced through the cannula to decompress and drain the cyst of approximately 5 liters of fluid without any spillage of the cyst fluid. The cannula was left in place throughout the salpingo-oophorectomy procedure to prevent any spillage of residual cyst fluid and was also utilized to manipulate the mass (Figure 4). Two additional ports were placed, one in the right upper quadrant and one in the right lower quadrant to complete the procedure.
The ovarian vessels were sealed and divided, and the salpingo-oophorectomy was performed. The specimen was placed into a specimen retrieval bag, and the cannula was removed from the cyst upon closure of the bag. The specimen was removed intact without leakage of any cyst fluid into the peritoneal cavity.
The patient was discharged home the same day. The final pathology report showed a benign serous cystadenoma.
Large ovarian masses pose a surgical challenge when addressed laparoscopically. Care must be taken to avoid cyst rupture to prevent the spread of malignant cells throughout the peritoneal cavity and to reduce the risk of chemical peritonitis.
The Step bladeless trocar system consists of an access needle inserted through a braided expandable sleeve. A dilating cannula is then placed through the sleeve after removal of the access needle. The braided contour of the expandable sleeve makes this trocar system ideal for the drainage of a large ovarian cyst. Once directed into the cyst, the small puncture site is dilated by the cannula with the braided sleeve in its expanded configuration. This gives a watertight seal and prevents the cannula from slipping out of the cyst.
This technique is an effective variation of the previously described methods for the removal of large ovarian cysts.
The intentional insertion of a dilating trocar directly into a large ovarian cystic mass should be considered as a method of laparoscopic removal to prevent leakage of fluid from the cyst.