CHAPTER 22 Any cystic mass of the ovary has the potential for malignancy. A frozen section should be performed when a conservative treatment plan has been selected. Cystectomy permits the cystic structure to be selectively removed while the residual ovarian tissue is preserved. Cystectomy may be performed for functioning cysts (follicular and corpus luteum), benign cystic teratomas, and endometriotic cysts. The technique for cystectomy is similar for all of the preceding conditions. The ovary is stabilized with placement of a Babcock clamp on the utero-ovarian ligament (Fig. 22–1). If the procedure is performed by laparotomy, then 3-0 Vicryl traction sutures may be placed into the ovarian tissue outside of the cystic area. The stitches are clamped with mosquito clamps and held by an assistant. A 1 : 200 vasopressin solution is injected into the stretched-out capsule of the ovary, which overlies the cyst (Fig. 22–2). An incision is made into the capsule with an energy device (laser or electrosurgical) or knife (Figs. 22–3 and 22–4). The incision between the cyst wall and the ovarian capsule provides a plane that can be dissected on either side of the initial incision (Figs. 22–5 and 22–6). The incision may be extended at will to facilitate separation of the cyst from the ovarian capsule (Fig. 22–7A, B). The dissection continues to completely circumscribe the ovary (Fig. 22–7C). Finally, the base of the cyst is clamped or coagulated, and the cyst is removed intact and sent to pathology (Fig. 22–7D). Any ovarian cyst other than an obvious corpus luteum cyst should be sent for frozen section. The remaining capsular tissue is folded upon itself, and no sutures are placed. Alternatively, the excess capsule may be trimmed away and the ovary closed with 4-0 Vicryl. In some circumstances, particularly with endometriomas, difficulty may be encountered in stripping away the ovarian capsule from the cyst wall (Fig. 22–8). In these cases, the author has preferred to resect a portion of the ovary that includes approximately 50% of the cyst and then to vaporize the cyst lining from the inside. The technique is described as follows. The utero-ovarian ligament is grasped with Babcock clamps. Stabilizing sutures of 3-0 Vicryl are placed into the periphery of the ovary outside the field of proposed resection (Fig. 22–9). A carbon dioxide (CO2) laser or other suitable energy device is selected to cut the ovary. Alternatively, 1 : 200 vasopressin can be injected and a knife utilized (Fig. 22–10). The cyst is opened linearly and drained (Fig. 22–11A–C). A hemisphere of ovary is cut away (Fig. 22–12
Ovarian Cystectomy and Cystotomy
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