The decision to proceed with surgical exploration in a patient with a pelvic mass should be based on presenting symptomatology or the potential for a reproductive cancer. Ovarian cysts represent one of the most common findings encountered on pelvic examination and ultrasonography, and the combination of historical intake and physical suggestion is often sufficient to the physician and patient with a sound working diagnosis. Not infrequently, however, do we rely on ultrasound features to confirm the diagnosis and provide appropriate counseling with regard to the risk of a pelvic malignancy. Such characteristics include size >10 cm, bilaterality, complex sonographic appearance with solid component (especially if Doppler flow is present within solid areas), mural nodules, or ascites. Protocols with more detailed and quantifiable descriptors such as morphology indices (MIs) have been validated, and more specific imaging modalities such as magnetic resonance imaging (MRI) have been proposed as better predictors of malignancy than transvaginal ultrasound. Notwithstanding, the Agency for Healthcare Research and Quality (AHRQ) reported on the various testing parameters surrounding different means of measuring risk of cancer and concluded that no individual test was superior to the other.

Patients may be categorized based on native risk factors, the presence of pain and whether the ovarian cyst was documented incidentally. It may be more appropriate to triage a symptomatic patient or one with features suggestive of a malignancy to surgery, but there is a definite role for expectantly managing patients who have been diagnosed with an ovarian incidentaloma. Large cancer-screening studies such as the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer-screening trial confirmed our inability to adequately screen populations for ovarian cancer without incurring more harm onto patients with no real disease. For the purposes of this chapter, we are assuming surgical management of a benign process for which ovarian cystectomy is planned.

For surgical planning, we find it useful to have a good understanding of what potential surgical obstacles exist for any given patient. For example, if a patient has significant dysmenorrhea and is found to have a homogeneously complex ovarian cyst, she is more likely to need extensive surgical resection for advanced-stage endometriosis. This may require a longer operating room booking time, preoperative consultation with a surgeon if rectal involvement is suspected, and perhaps psychological preparedness on behalf of the surgeon. Alternatively, if the patient is young, asymptomatic and has a complex mass suggestive of a mature cystic teratoma (Figure 7.1), the approach to her surgery may be different. Being able to provide a younger woman, whose ultimate goal may be to preserve fertility, with an accurate diagnosis and treatment plan to either remove the cyst or ovary itself is critical during the preoperative period.

If there is any concern of a possible malignancy, preoperative referral to and evaluation by a gynecologic oncologist is highly recommended since the original plan of an ovarian cystectomy may subsequently become a staging procedure whereby preserving reproductive function may or may not be an option. Involving the oncologist early in the process will ensure a more rapid response if malignancy is suspected or encountered at surgery. As indicated above, notwithstanding the technologies we currently have in place, the ability to correctly predict cancer risk is imperfect, and an occult malignancy may be uncovered during surgery. How the gynecologist approaches these varying scenarios changes based on the environment where he or she works, along with the ready availability of an oncologist. If at the time of initial surgical inspection, there is a suggestion of malignancy, obtaining pelvic washings and terminating the procedure may be warranted without addressing the mass if it appears unruptured. This will allow for expedited referral and reoperation by the appropriate surgeon. If, however, the process appears to be disseminated, then biopsy of suspicious lesions should also be performed. In the ideal setting, when an intraoperative oncology consult is available and preferably has been planned, and the patient appropriately counseled and consented, then staging could be performed concomitantly.

1. Port and instrument placement: Initial port placement depends on the location and size of the mass, similar to when treating a patient with an endometrioma (see Chapter 10). If possible, use of open-access technique will facilitate retrieval of larger cysts due to the larger fascial defect created, especially if cyst rupture is not desired.

2. Initial pelvic assessment: Upon entry into the peritoneal cavity, the first step should be to obtain pelvic washings with at least 200 ml of normal saline. This should be done in order to best evaluate for a priori microscopic, extra-ovarian seeding should the mass represent a cancer. After the remaining ports are placed, comprehensive evaluation of the abdomen and pelvis should then ensue. Assuming a benign process, the focus should then turn to the cyst itself.

3. Restoration of normal anatomic landmarks: The next step should then be to restore normal anatomy if distorted by adhesions, all the while identifying the course of both ureters and the sigmoid colon, rectum, and larger vessels. Most ovarian or tubal adhesions may be dissected bluntly, but if more dense, then sharp dissection with minimal energy application may be required (see Chapter 24). Once freed from its attachments, the ovarian cystectomy can then be performed.

4. Ovarian cystectomy: In general, once the ovarian cyst is freed from surrounding adhesions (Figure 7.2) in smaller cysts, an ovarian epithelial (cortical) incision should be directed along the longitudinal axis of the ovary to avoid extension toward larger vessels (Figure 7.2b). We typically recommend use of cold scissors to incise the ovarian epithelium since it minimizes injury to functional reproductive tissue and allows clear access to the correct surgical planes. In contrast to removal of an endometrioma (see Chapter 30), the enucleation of a benign ovarian cystectomy is relatively more simple. Alternatively, if the cyst is larger, and the amount of thinned out and fibrotic ovarian epithelium overlying the cyst is significant, it may be preferable to incise the cyst circumferentially at the interface between the normal ovarian cortex and the fibrotic epithelium, thereby minimizing the amount of fibrotic material left attached to the remaining ovary (Figure 7.2c).