Neobook — clinical reference

Score a line on the outer layer of the serosa over the cyst with a gentle stroke of the scalpel, or if operating laparoscopically with a diathermy needle, then with scissors
Separate the serosa from the cyst wall & extend the incision carefully with McIndoe or laparoscope scissors through the hole but with scissor blades laid flat
Insert the back end of the scalpel at open surgery into the gap between the outer ovarian serosa and cyst, & strip the serosa off the cyst completely, or pull apart with laparoscopic graspers
Ligate or diathermize the vascular base of the cyst & remove it. If operating laparoscopically, removal in a bag is ideal. The cyst can be punctured in the bag, all fluid aspirated & the cyst wall retrieved. If there is no bag, & there is almost no chance of malignancy, the cyst can be punctured during or after separation from the ovary and retrieved. Wash out the abdomen thoroughly with Ringer’s Lactate (less adhesion formation)
Evert the ovary & apply diathermy to the bleeders
Use deep interrupted 2/0 polyglycolic sutures in the ovarian stroma to close the deep space of the defect & to ensure haemostasis
Serosa: secure a 2/0 or 3/0 monofilament suture inside the ovary at one end & then go ‘out to in’ – the ‘baseball stitch’ – on both sides with good bites along the defect with a continuous suture, leaving only external ovarian tissue exposed. Laparoscopically, the ovarian interior can be diathermized, which causes the edges to roll inwards lessening adhesions. Suturing is an alternative for the more experienced laparoscopist
If the cyst has ruptured, the cyst walls can still be stripped & steps 3 to 7 above followed
Whenever operating on an ovarian cyst, take peritoneal washings for cytology
Always wash out well before closing & ensure good haemostasis

This is said to be the pelvic operation most associated with postoperative adhesions. If the cyst is intact, it should be removed intact or in an ‘Endobag’ & the ovary put back together with sutures, or diathermied and left open but with edges inverted. Always wash out very thoroughly particularly with mucinous cysts (syrupy contents) or dermoid cysts.