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Ovarian cystectomy - laparoscopic

If you are considering having an ovarian cyst removed or have an ovarian cyst operation planned, it is important to know all you can about it. This includes:
  • why you need this operation
  • what it will be like
  • how it will affect you
  • what risks are involved
  • any alternatives.
The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

What is the problem?

You probably have pains in your abdomen. Tests show you have a cyst in your pelvis, probably on your ovary. A cyst is the name for a swelling that contains liquid. A keyhole operation using a special telescope, called a laparoscope, will tell us more about the cyst.
We may have to remove the cyst only, or both the cyst and the ovary. We send the removed tissue for microscope examination to find out exactly what type of cyst it is.

What is an ovary?

You have two ovaries. To explain where your ovaries are and what they do, the best place to begin is the vagina. Your vagina is a tube about five inches long. It runs from just in front of your rectum up into your pelvis. It is just behind your bladder. You can feel your bladder in your lower abdomen when it is full of urine.
Ovarian cystectomy

At the top of your vagina is your uterus. It is about the size of your clenched fist. It is made of special thick muscle, but it is hollow inside with a special lining called the endometrium. The lowest part of your uterus, which juts into your vagina, is ‘the neck of the womb’, also called your cervix. Cervical smears are taken from the surface of your cervix.
The rest of your uterus is called the body. It thins out at the top to form two hollow tubes called the Fallopian tubes. You have a Fallopian tube on each side. These run sideways to end near your left or right ovary.
Your ovaries are slightly smaller than a golf ball. They lie deep in your pelvis just below your waist, about four inches from the midline of your abdomen. Your right ovary lies near your appendix. Your left ovary lies near your colon, which is part of your lower bowel that runs down to your rectum.
Your ovaries make hormones and contain tiny eggs, which are too small to see with the naked eye. After each period, follicles form on an ovary. These are tiny fluid filled bubbles on the ovary surface. About 12 days after each period, one egg matures on one of the follicles making it the ‘dominant follicle’. This dominant follicle grows and bursts releasing an egg, which passes down your Fallopian tube into your uterus. After the follicle releases an egg the ovary produces huge amounts of hormones to prepare your uterus for a pregnancy.

What do the ovaries do?

To understand what your ovaries do, you need to understand what happens during your monthly period, also called your menstrual cycle.
About once a month an egg grows and breaks free from one of your ovaries. This may give you some pain between periods. The egg moves into your Fallopian tube and travels down towards your uterus. At the same time, hormones from your ovary make the endometrium lining of your uterus thicken.
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If your egg is fertilised by a sperm it can lodge in your thickened endometrium. There it will produce hormones to make your uterus and lining grow massively to take the baby.
Often, your egg is not fertilised and so it dies. The hormones from your ovary change so that your endometrium also dies and is shed. You will have some bleeding from the raw endometrium for a few days. This is a typical period. The cycle then starts again for the next month.
After the age of about 45 years your ovaries stop making some of the hormones. Eggs are not released each month. Your endometrium will no longer be shed, so your periods stop. This is called the change, or the menopause. This change in hormone levels often causes hot flushes and dizzy spells. Sometimes your periods can become very heavy during this time.

What has gone wrong?

Part of the normal process of releasing an egg from your ovary is the development of follicles on your ovaries. A follicle is a tiny fluid filled sac. When the follicle bursts it releases an egg. Sometimes this monthly process goes wrong. If the follicle does not burst it may become a follicular cyst. This cyst may grow and fill with more fluid and perhaps blood. It can also secrete hormones that upset your menstrual cycle. An ovarian cyst develops.
Sometimes the cyst and ovary twist around the stalk that holds them. This twisting is called torsion and it can be very painful. If torsion stops the blood to your ovary it may die and need to be removed.
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An ovarian cyst may be benign tumour. A common benign tumour that appears on an ovary is a dermoid cyst. Dermoid cysts come from primitive skin tissues that have been present in the ovary from birth. The fluid inside is sebaceous material, like in a blackhead, and often contains hair. Dermoid cysts are more common in younger women, sometimes in both ovaries. Other cysts can be malignant tumours. These cancerous tumours are more often seen in older women. They vary in size but can be large, fifteen centimetres or more, before being detected.

The aims

We aim to examine inside your pelvis to confirm that the cyst is on your ovary. We will find out what type of cyst it is so we can decide on the best treatment. If you need a cystectomy, where we remove the cyst, we will leave you with as much healthy ovary as possible.
We do the operation using laparoscopic instruments. These are keyhole instruments that are put through small cuts in your abdomen. 

The benefits

Firstly, you have a laparoscopy. This is where we examine your ovaries with keyhole instruments. This should tell us exactly what has gone wrong so that you can get the best treatment. If we remove the cyst from your ovary, we send any removed tissue for microscope examination. If the cyst is somewhere else in your pelvis we can usually treat it as needed with the keyhole instruments.
A keyhole operation is usually less painful and recovery is faster than with an open operation to remove a cyst.

Are there any alternatives?

Ultrasound scans, x-rays, CT scans and MRI scans are alternative tests that may be used to examine your ovaries without an operation. These tests may show that you have a cyst and a laparoscopy is the best option for further examination and possible removal.
We believe that keyhole surgery is possible in your case. However, if the laparoscopy reveals that you have a very large cyst or ovary that we need to remove, we may need to convert to an open operation. This operation requires a large wound in your lower abdomen. You may also need an open operation if you have scarring in your pelvis from a past operation or infection. Open operations tend to be more painful with a slower recovery.

What if you do nothing?

If you do nothing, the cause of the cysts will remain in doubt. You may miss out on important treatment. Your symptoms will probably get worse.
You could develop serious complications such as bleeding into the cyst or twisting of the cyst cutting off its blood supply. This would leave no alternative but an emergency operation.
If an ultrasound scan shows that you only have a small cyst or cysts, less than a centimetre in diameter, they are unlikely to cause problems. These small follicular cysts do not cause symptoms and can often be ignored. You may need a repeat ultrasound to check this. If the cysts cause problems we usually need to operate to relieve the symptoms.
Author: Dr David Hutchon F.R.C.O.G.  Consultant Gynaecologist.
© Dumas Ltd 2006
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