Ovarian cysts are a common gynaecological problem. In the United Kingdom, they are the fourth most prevalent gynaecological cause of hospital admission [1]. By the age of 65 years, 4% of all women would have been admitted to hospital for this reason [1].

Increasingly, ovarian cysts are now managed laparoscopically rather than by laparotomy. The advantages of this approach include: decreased post-operative pain and discomfort, shorter duration of hospital stay and earlier return to normal activity.

One major limitation of the laparoscopic approach to an ovarian cyst has been the size of the cyst. There are two concerns associated with the laparoscopic removal of large (greater than 5 cm) ovarian cysts. First, ovarian cysts that are larger than 5 cm in diameter have been associated with a higher risk of malignancy [2–4]. Secondly, with a large cyst, there are several technical difficulties, including space constraints and the risk of inadvertent rupture during the insertion of the Veress needle or trocar.

It has been suggested [5] that large ovarian cysts can be successfully removed laparoscopically if certain measures are taken, including:

  • ascertaining the size and nature of the ovarian cyst preoperatively

  • use of open laparoscopy

  • intact removal of the cyst or ovary

  • careful aspiration of the contents of the ovarian cyst to avoid spillage

  • ensuring the abdominal incision is large enough, and avoiding enlarging the incision during retrieval of the specimen

  • thorough peritoneal lavage at the end of the surgery, especially if spillage has occurred

We describe a technique of laparoscopic assisted extra-corporeal cystectomy for very large ovarian cysts without spillage of cyst contents. This method was used successfully in four patients.

Case Reports

Patient 1

A 26–year-old single Chinese girl was seen for the complaint of lower abdominal swelling of two months’ duration. Apart from feeling that her pants were getting tighter, she had no other symptoms. Her general health was good and there was no significant family history of cancer. There was no bowel or urinary disturbance and her periods were regular. Abdominal examination revealed a uniform cystic mass arising from the pelvis, equivalent to the size of a 26- to 28-week gravid uterus. Abdominal ultrasonography showed a unilocular cyst measuring approximately 22 cm in diameter without septae or echogenicity. There were no surface excrescences. Colour Doppler examination of the cyst revealed no abnormal vasculature. The right ovary was normal in appearance and there was no ascites. The liver was also normal. An Intravenous Urogram (IVU) showed a large pelvi-abdominal mass displacing bowel gas superiorly and laterally. The renal pelvi-calyces were distended due to compression by the pelvic mass, but no obstruction was seen. A chest X-ray was unremarkable and her serum tumour markers (CA125, CEA, αFP and βHCG) were all within the normal range.

The patient was counselled that the standard treatment was a midline laparotomy. However, she wanted a laparoscopy for cosmetic reasons and objected strongly to this. She was offered a laparoscopic guided aspiration followed by extra-corporeal cystectomy but was also cautioned that if the frozen section showed malignancy, a formal laparotomy would be required.

Surgery

After anaesthesia, an open laparoscopy was performed. An intra-umbilical vertical incision about 1 cm in length was made and the abdominal wall was opened in layers. After the abdominal cavity was entered, the laparoscope was introduced with its trocar and the abdominal cavity was insufflated. Leakage of carbon dioxide was checked by a purse string suture around the trocar. The abdominal cavity was systematically inspected. The cyst was found to be arising from the left ovary and was about the size of a 26- to 28-week gravid uterus. The surface was smooth. There was a small amount of physiological straw-coloured peritoneal fluid. The liver and sub-diaphragmatic surfaces were smooth. The stomach, intestines, paracolic gutters and right ovary were unremarkable. A 5-mm ancillary port was placed in the right iliac fossa and peritoneal fluid was aspirated for cytology. A 16-gauge Cook aspiration needle (which is usually used for oocyte retrieval in assisted reproduction) was inserted into the abdominal cavity in the suprapubic area under laparoscopic guidance. The cyst was punctured with the needle with a suction cannula placed next to the puncture site to prevent spillage. The Cook needle was chosen because of the surgeon’s familiarity with the needle and also because the needle was sharp, making puncture of the cyst easy and decreasing the likelihood of spillage. A total of 3500 millilitres of clear fluid was aspirated. When the cyst was totally collapsed, it was held at the puncture point with forceps to prevent spillage when the Cook needle was withdrawn. A 1.5-cm midline suprapubic incision was made and a 13-mm trocar was introduced. The ovary was grasped at the previous puncture point and eased out of the abdominal cavity. As soon as a part of the ovary was out of the abdomen, it was lined with moist gauze to prevent any spillage. The opening into the cyst was enlarged and the inner lining of the cyst was lavaged and aspirated a few times. The ovary was then totally delivered out of the abdomen and an extra-corporeal cystectomy was performed. Haemostasis was secured and the ovary was reconstituted with a 4/0 prolene suture. It was then returned into the peritoneal cavity. Care was taken to moisten the ovarian surface to avoid desiccation throughout the procedure.

The abdominal cavity was then copiously lavaged and a Redivac drain was inserted before closure of the abdominal wounds. Frozen section examination of the specimen revealed a benign mucinous cystadenoma.

Post-operative course

The patient did not require post-operative opiates and was ambulating on the first post-operative day. Post-operative pain was minimal and she was discharged on the second post-operative day. Paraffin sections confirmed the presence of a benign mucinous cystadenoma. Upon review 4 weeks post-operatively, the wounds had healed well and the patient was very satisfied with the cosmetic results. The suprapubic incision was well concealed by her hairline.

Patient 2

A single nulligravid 35 year old Indian lady, with no significant past medical or family history of note, was seen for progressive abdominal distension of six months’ duration. This was associated with exertional dyspnoea. Her periods were regular and she did not have any urinary or bowel symptoms. On examination, the abdomen was distended by a large pelviabdominal mass that reached the level of the xiphisternum. An ultrasound examination showed a large mass arising from the pelvis and measuring 25 by 18 cm. There were some internal septations and fine internal echoes, but no solid areas were noted. The left ovary was not seen and the right one was normal. Both kidneys were unremarkable with no evidence of hydronephrosis. A chest x-ray was unremarkable. The ovarian tumour markers were all in the normal range.

Like the previous patient, she was counselled for a midline laparotomy, which she refused as cosmesis was a concern. Consent was obtained for laparoscopy-guided aspiration followed by extra-corporeal cystectomy, with a view to a formal staging laparotomy if the cyst should prove to be malignant.

Surgery

An open laparoscopy was performed, with leakage of pneumoperitoneum being prevented by a purse string suture around the laparoscope trocar. Systematic examination of the abdominal cavity revealed a left ovarian cyst equivalent in size to a 28-week gravid uterus. Its surface was smooth and there was no ascites. The uterus, right ovary and fallopian tubes were normal, and the rest of the intraperitoneal survey was unremarkable.

A Cook aspiration needle was inserted suprapubically into the abdomen under laparoscopic guidance, after a 5-mm ancillary port was placed in the left iliac fossa to allow placement of a suction cannula. Peritoneal fluid was sampled. The cyst was then punctured with the Cook needle, with the suction cannula placed next to it to prevent spillage, and drainage was commenced. A total of 4.2 litres of fluid was drained. The cyst was found to be septated with two main locules. The larger one contained slightly blood-stained fluid, whilst the smaller one contained clear mucinous material. The cyst was drained without spillage and was delivered through a 2-cm minilaparotomy incision in the suprapubic area. An extra-corporeal cystectomy was performed. After securing haemostasis, the ovary was reconstituted with a Vicryl 0 and Prolene 3/0 suture and returned into the abdominal cavity. Again, the peritoneal cavity was generously lavaged and a drain was inserted. Frozen section examination revealed a benign mucinous cystadenoma.

Post-operative course

Except for a low-grade temperature, the patient’s postoperative recovery was uneventful. Paraffin sections confirmed that the cyst was a benign cystadenoma and the peritoneal fluid was negative for malignancy. At outpatient review four weeks later, she was well and satisfied with the operative results.

Patient 3

The patient, a 23-year-old single Chinese lady, was referred from the surgeon after a year’s history of abdominal distension and occasional pain. The episodes of pain had been getting more frequent in the past few weeks. A CT scan had revealed a 20-cm left ovarian cyst and bilateral hydronephrosis. The cyst was clear, with no solid components. The right ovary was normal and the rest of the pelvis and abdomen were unremarkable. There had been no other symptoms and a systematic review yielded no other complaints. Abdominal examination revealed a non-tender pelviabdominal mass arising from the left iliac fossa and extending to the xiphisternum. The patient’s serum tumour markers were all normal. Ultrasonography confirmed the presence of a 20- by 13-cm left ovarian cyst. There was no abnormal vasculature on colour Doppler examination.

Surgery

After counselling, an open laparoscopy was performed. There was a large left ovarian cyst which was smooth in outline and mobile with no associated adhesions. The right ovary, uterus and fallopian tubes were normal and the liver and intra-peritoneal survey were unremarkable. There was minimal peritoneal fluid, which was taken for cytology. Again, a Cook aspiration needle was used to drain the cyst under laparoscopic guidance, with measures taken to eliminate spillage from the aspiration site. The aspirated material consisted mainly of chocolate-coloured fluid, suggesting the presence of stale blood or an endometriotic cyst. The left ovary and cyst were then delivered through a suprapubic mini-laparotomy and an open cystectomy was performed. The ovary was then closed and returned to the peritoneal cavity. Frozen section examination revealed a benign mucinous cyst and the operation was completed.

Post-operative recovery

The patient was found to pale post-operatively. Her abdomen remained soft, however, with no evidence of peritonism. The haemoglobin level was 6.1 g/dl. This had dropped from a level of 9.9 g/dl pre-operatively and was presumed to have been due to bleeding into the ovarian cyst, as her abdominal drains had yielded minimal fluid post-operatively. She was given two units of blood transfusion which brought her haemoglobin level to 8.2 g/dl.

The patient was discharged on the third post-operative day. She was well at the outpatient review one month later. Histological examination of the operative specimen confirmed that it was a benign mucinous cystadenoma with no evidence of borderline change or malignancy. The peritoneal fluid was also negative for malignancy.

Patient 4

The last patient was a 16-year-old Chinese girl who was admitted to the paediatric surgical department after complaining of lower abdominal discomfort of one day’s duration. She had also experienced a lower abdominal mass that had slowly increased in size over three to four months. There was no history of medical or surgical problems. Her periods were regular and unremarkable except for mild dysmenorrhoea, and she denied previous sexual activity. Her urination and bowel movements were unremarkable. On examination, she was comfortable and not tachycardic. There was a regular, non-tender pelvi-abdominal mass that reached the level of the umbilicus. A CT scan of the abdomen and pelvis revealed a large cyst, measuring 20- by 10- cm, arising from the left ovary and occupying the entire pelvis and lower abdomen, with extrinsic compression of the ureters. The right ovary was slightly bulky and some free fluid was seen in the pelvis and right paracolic gutter. The renal collecting systems and upper ureters were distended. No retroperitoneal lymphadenopathy was detected. The liver, spleen, pancreas, both kidneys, lung bases and bone shadows did not show any focal lesion. The patient’s CA 125 level was 39.1 U/ml (the normal adult non-pregnant range being 0 to 35 U/ml); whilst the other ovarian tumour markers (CEA, αFP and βHCG) were normal. The patient and her parents were counselled for a laparotomy, but they refused, opting instead for a laparoscopy, with recourse to a staging laparotomy should the cyst prove to be malignant. The patient’s haemoglobin level was 8.7 g/dl, and this went up to 10.6 g/dl after pre-operative blood transfusion.

Surgery

After anaesthesia was induced, an open laparoscopy was performed in a similar manner as for the other three patients. After peritoneal insufflation, a large left ovarian cyst was found, with some endometriotic deposits on its surface. The left fallopian tube was stretched over the cyst, and the cyst was incarcerated in the Pouch of Douglas. There were multiple deposits of endometriosis over the uterus, right fallopian tube, right ovary and pelvic cavity. The right ovary contained three to four small endometriotic cysts and was adherent to the ovarian fossa. The liver, spleen and sub-diaphragmatic surface were all normal. A minimal amount of peritoneal fluid was found, and this was collected for cytology.

The ovarian cyst was drained with a suprapubic Cook’s needle. About 2 litres of chocolate-like material was removed before the cyst was partially decompressed and exteriorised through a suprapubic mini-laparotomy. Further decompression was possible after the adhesions between the cyst and Pouch of Douglas were freed. The cyst was then completely delivered and an open cystectomy was performed. Whilst the cyst was sent for frozen section, the left ovary was reconstituted and replaced into the abdominal cavity. The rest of the operation consisted of: ablation of the endometriotic deposits, adhesiolysis of the area around the right tube and ovary, and right ovarian cystectomy. Frozen section of the specimen revealed a benign cyst with haemorrhage.

Post-operative recovery

The patient made an uneventful post-operative recovery. Her haemoglobin level was 9.17 g/dl on the first post-operative day. She was discharged on the third day and was well at review. Histological examination of the operative specimen showed an endometriotic cyst. The other specimens (right ovarian cyst and peritoneal fluid) were also negative for malignancy. The patient is currently well and has been given GnRH agonist treatment in view of her severe endometriosis. At her latest review (six months after surgery), she has not had any symptoms and there has been no recurrence of the cyst on ultrasound examination.

Discussion

The laparoscopic approach to ovarian cysts offers patients the benefits of less post-operative pain, faster recovery and earlier return to normal activity. Laparoscopic management of ovarian cysts is commonly restricted to cysts less than 10 cm in diameter. A large ovarian cyst poses the following problems:

Insufflation and trocar insertion cannot be performed in the usual manner as inadvertent cyst rupture may occur.

The space constraint makes instrumentation difficult and cystectomy without rupture impossible.

There is a higher risk of malignancy in a larger cyst with a concomitant danger of iatrogenic spillage of malignant cells during a cystectomy.

If the cyst is mucinous, spillage may cause pseudomyxoma peritonei, which can be chronic and debilitating as well as potentially fatal.

In these patients, open laparoscopy was performed to avoid inadvertent puncture of the ovarian cyst. After a pneumoperitoneum had been established, laparoscopy allowed easy assessment of the entire abdominal cavity. The subdiaphragmatic surface, liver, paracolic gutters, peritoneal surfaces, stomach, intestines, ovarian cyst capsule and contralateral ovary could all be inspected. Peritoneal fluid and washings were also taken in anticipation of a possible need for staging.

Nagele and Magos [6] described a technique of ultrasound-guided drainage and laparoscopic excision of a large ovarian cyst. We chose laparoscopic-guided aspiration of the ovarian cyst because it offers the following advantages:

It allows assessment of the abdominal cavity and ovarian cyst prior to cyst puncture.

Puncture with a sharp needle under laparoscopic guidance with a suction cannula continuously aspirating in the immediate vicinity of puncture eliminates the risk of spillage.

Even after laparoscopic drainage of the cyst, laparoscopic excision of such a large cyst still carries a risk of spillage of cyst contents and dissemination of cells. The significance of this spillage in cases of malignant cysts is controversial. The concern about spillage of tumour cells and its possible worsening of prognosis arose from early studies of tumour rupture. Dembo et al. [7] studied the rate of relapse in 519 stage 1 epithelial ovarian cancer patients by logistic regression and multivariate analysis. The only factors that influenced tumour relapse were tumour grade, the presence of dense adhesions, or the presence of large volume ascites. Intraoperative rupture of tumour did not influence the rate of relapse or prognosis. The results from two other studies also suggested that inadvertent rupture of the cyst does not worsen the prognosis. Sevelda et al. [8] studied the survival of patients with moderately and poorly differentiated stage 1 ovarian carcinoma. They concluded that there was no difference in the 5-year survival rate between the patients who had intact removal of the cyst compared with those with intraoperative cyst rupture. However, all of the patients in the study received postoperative abdominal radiotherapy. Another study [9] looked at the 10-year survival of three groups of patients with stage 1 and 2 ovarian cancers. The survival rate for those with intact tumours was 78%, for those with punctured cysts it was 87%, and for those with ruptured cysts it was 84%. A slightly higher number of those with ruptured or punctured cysts (90%) had postoperative adjuvant treatment compared with those with intact cysts (77%). The decision for postoperative adjuvant radiotherapy was made only because at the time of the study there was an ongoing trial for early serous ovarian carcinomas. Essentially, patients with endometrioid, clear-cell and undifferentiated tumours were randomly allocated to the treatment arm, while patients with mucinous well-differentiated tumours did not receive any treatment. The authors concluded that neither intraoperative puncture nor rupture of the cyst had any impact on survival. On the other hand, it has been reported [10, 11] that intraoperative rupture of stage 1 ovarian cancers appeared to worsen the prognosis. Sainz de la Custa et al. [11] reported that only one of the 36 women with intact stage 1a tumours had recurrence compared with four of the 29 with ruptured stage 1c tumours. However, the relatively small numbers in these two studies do not allow firm conclusions to be drawn. A larger study that was recently undertaken [12] showed that the degree of differentiation was the most powerful prognostic indicator of disease-free survival (moderate vs well differentiated hazard ratio 3.13 [95% CI 1.68–5.85], poorly vs well differentiated 8.89 [4.96–15.9]), followed by rupture before surgery (2.65 [1.53–4.56]), and rupture during surgery (1.64 [1.07–2.51]). In all four of our patients, it was ensured that the suction cannula was constantly aspirating in the immediate vicinity of the cyst puncture site so as to minimise the risk of spillage. Furthermore, after the cystectomy was performed, whilst the surgeons were awaiting the results of the frozen section, copious peritoneal lavage and drainage was carried out.

Intraoperative spillage of a mucinous cystadenoma may also theoretically cause pseudomyxoma peritonei. However the risk of this is very low. Pseudomyxoma peritonei is usually already present at the time of entry into the abdomen and is almost always associated with a mucinous cystadenocarcinoma [13–15]. In our series, we decided to err on the side of caution and perform an extra-abdominal cystectomy for each patient.

Goldenberg et al. [16] reported a combined laparoscopic and extra-abdominal microsurgical technique for ovarian cystectomy. However, they used the technique to simplify the laparoscopic procedure and to achieve a microsurgical effect of ovarian reconstruction. They used this technique for smaller cysts. Our report is the first in the literature using this method to perform cystectomy on large ovarian cysts (>20 cm in diameter) without spillage.

In all our patients, pre-operative Doppler ultrasound evaluation of the ovarian cysts showed benign features with no low resistance flow within the cyst wall. It has been demonstrated in a study of 64 adnexal masses, including 11 ovarian malignancies, that pre-operative evaluation with Doppler ultrasound and vascular score can accurately predict the malignant nature of ovarian masses [17].

Whilst laparoscopic drainage of large ovarian cysts, followed by laparoscopic extra-abdominal cystectomy, may be considered to be a controversial approach to managing large ovarian cysts, we believe that, with careful pre-operative evaluation and meticulous attention to avoid spillage during surgery, the benefits of minimal access surgery can be offered to a patient despite the size of the ovarian cyst. This technique may be advocated for large unilocular cysts which appear benign at pre-operative and laparoscopic evaluation.