(3) A novel approach for controlled drainage of giant ovarian cysts through mini-laparotomy

Background: Large ovarian cysts in adolescents often present with low malignancy risk, prompting discussions about optimal surgical strategies. Minimally invasive methods aim to reduce complications, pain, hospitalization length, and scar appearance. As such, there is a desire to utilize less invasive approaches for the removal of large to giant masses. However, the advantages of minimally invasive surgery must be balanced with the risks of spillage, including malignant seeding and upstaging, chemical peritonitis, and recurrence.

A few minimally invasive techniques have been proposed, including adherence of surgical gloves or bandages, controlled drainage with catheters, or use of the Alexis laparoscopic system. These techniques are poorly standardized and can fail to remain adherent during the case. We aim to describe a unique approach for the safe drainage of giant ovarian cysts.

Case: We present four adolescents with giant ovarian cysts (10-30 cm) and low pre-operative concern for malignancy, who proceeded to surgery for definitive treatment of the mass and associated symptoms. In all cases, a 4-6 cm midline infraumbilical incision was used. After obtaining adequate exposure of the mass, we adhered the rigid ring of a sterile 3 cm silo bag designed for ventral wall defects (Image 1) to a dried surface of the mass using sterile surgical glue. After ensuring the glue was dry, we trimmed off the closed distal end of the bag to allow access to the cyst surface.

Through the constructed opening of the bag, the cyst was then entered sharply and contents were drained. In three cases, no spillage of contents was noted (Image 2) after multiple (1.9-5) liters were drained. In one case, there was minimal spillage noted due to malfunction of the suction device. In all but one case, the ovarian cortex was spared after cystectomy. In all cases, the bags remained firmly adherent to the ovarian cortex until the ovary and cyst could be exteriorized. There were no postoperative complications, and patients were discharged on postoperative days 0-2.

Comments: We introduce a safe, ovarian-sparing approach for extracorporeal drainage of giant adnexal cysts using a silo bag for spillage prevention through a mini-laparotomy incision. We believe this technique would be readily reproducible at many hospitals.