JOURNAL OF GYNECOLOGIC SURGERY

Volume 32, Number 5, 2016 Original Articles

ª Mary Ann Liebert, Inc.
DOI: 10.1089/gyn.2016.0009

Should We Manage Large

Ovarian Cysts Laparoscopically?

P.G. Paul, MBBS, DGO, Gaurav Chopade, MBBS, MS, DNB, Saurabh Patil, MBBS, MS,
Tanuka Das, MBBS, MS, DNB, Manju Thomas, MBBS, MS, and Reena Garg, MBBS, DGO

Abstract

Objective: The aim of this research was to evaluate the feasibility and surgical outcomes of laparoscopic surgery for
large ovarian cysts in women <40 years of age. Materials and Methods: This was a retrospective evaluation
(Canadian Task Force classification 11-2 design) of 55 women (ages <40) with large ovarian cysts (‡10 cm) with
features suggestive of benign disease managed laparoscopically at Paul’s Hospital, in Cochin, Kerala, from July
2006 to April 2013. All patients were followed-up for a minimum of 1 year. Patients who were diagnosed as having
borderline ovarian tumors were evaluated for their present clinical status at the end of study. Results: Laparoscopic
surgery was performed successfully for all patients. The mean operative time, estimated blood loss, and hospital
stay were, respectively, 109.6 minutes (range: 40–255), 304.6 mL (range: 100–650), and 1.1 days (range: 1–3).
Conversion to laparotomy was performed in none of the patients. Five cases of borderline malignancy were
detected. Of these 5 cases; 3 underwent laparoscopic adnexectomy; 1 underwent bilateral cystectomy with staging
biopsies, conceived 3 months postsurgery, and subsequently underwent laparoscopic adnexectomy at another
center; and 1 underwent a unilateral laparoscopic cystectomy, and had a laparotomy and adnexectomy in another
institution after 1 month. Conclusions: The current study supports laparoscopic management of large ovarian cysts
as a technically feasible and effective method if proper case selection is applied. ( J GYNECOL SURG 32:251)

Keywords: large ovarian cyst, laparoscopy, borderline ovarian tumor

Introduction 2013 in the department of endoscopy, at the Centre for Ad-

vanced Endoscopy and Infertility Treatment, Paul’s Hospital,
L aparoscopic management of benign ovarian cysts is
considered the ‘‘gold standard’’ because of its known
benefits.1 However, most patients with large ovarian cysts are
Cochin, Kerala, India. The institutional ethics committee of
Paul’s Hospital approved the study.
Inclusion criteria were ovarian cysts of ‡10 cm and age
managed with conventional laparotomy. The technical is-
<40 years.
sues include trocar insertion, poor visualization, and diffi-
Exclusion criteria were patients with sonographic features
culty with enucleation and specimen retrieval. The potential
suspicious for malignancy, such as the presence of ascites,
risk of malignancy in a large ovarian cyst, and the risk of
solid areas, complex masses, thick irregular septa, and in-
spillage and upstaging or incomplete staging are other im-
ternal or external excrescences, as well as ovarian masses
portant concerns.2 These large ovarian cysts often occur in
with complex consistencies other than dermoid cysts. In ad-
younger women for whom conservation of reproductive func-
dition, patients with omental cake or pelvic or para-aortic
tion is a priority. This must be weighed against the low risk of
lymphadenopathy noted on computed tomography scans were
unsuspected malignancy.3
excluded from the study.
The aim of the current study was to evaluate the feasi-
bility and surgical outcome of laparoscopic surgery for large
Informed consent
ovarian cysts in women below 40 years of age.
All procedures followed were in accordance with the
ethical standards of the responsible committee on human
Materials and Methods
experimentation (institutional and national) and with the
This was a retrospective study of (Canadian Task Force Helsinki declaration of 1975, as revised in 2000. Informed
classification 11-2 design) of 55 patients with large ovarian consent was obtained from all of the patients who underwent
cysts managed laparoscopically from July 2006 to April cystectomy or adnexectomy with or without staging biopsies.

Centre for Advanced Endoscopy and Infertility Treatment, Paul’s Hospital, Cochin, Kerala, India.

251
252 PAUL ET AL.

Procedures grasper; traction and countertraction were applied to sepa-

rate the cyst from the ovarian tissue. Complete removal of
Data were evaluated for patient characteristics (age, body the cyst wall was performed. Enucleation was accomplished
mass index (BMI), parity, and previous surgeries) and op- gently near the ovarian ligament and hilum to avoid
erative details, such as duration of surgery, amount of fluid bleeding and injury. In any case when the cyst wall was
aspirated, estimated blood loss (EBL), type of surgery, in- firmly adherent to the ovary, it was excised with sharp
traoperative complications, postoperative events, conversion to dissection using scissors. A large endobag was used to
laparotomy, duration of hospital stay, and pathologic findings. collect the cyst specimen. Adnexectomy was performed by
A detailed history was taken for each patient regard- coagulating and dividing the infundibulopelvic ligament,
ing severity of abdominal pain, dysmenorrhea, dyspareunia, ovarian ligament, and the medial end of the tube.
bowel symptoms, infertility, previous abdominopelvic in- In cases of dermoid cysts, special precautions were taken
fections, and surgeries. Clinical examination, abdominal and to avoid spillage to prevent chemical peritonitis. A large
transvaginal ultrasonography was performed by the operating endobag was placed around each cyst and enucleation of the
surgeon prior to surgery. In celibate patients transabdominal cysts was carried out in the endobag, avoiding the spillage
ultrasonography was performed. Preoperative abdominopelvic of the sebaceous material and hair into the peritoneal cavity.
magnetic resonance imaging (MRI) was performed in cases The cyst wall and contents were placed in the endobag and
when suspicious sonographic features were detected. Color removed through a 10-mm trocar site after enlarging the
Doppler scanning was performed to look for low-resistance incision to 2–3 cm or by a colpotomy incision. The col-
flow patterns in patients with suspicion of malignancy. CA- potomy incision was sutured with 1-0 Vicryl. The peri-
125 testing was performed for all patients and, in selected toneal cavity was lavaged with several L of normal saline,
patients, testing was performed for alpha-fetoprotein, beta– and the floating sebaceous contents were aspirated first
human chorionic gonadotropin, and lactate dehydrogenase. from the surface.
Patients were admitted to the hospital on the day of sur- In cases when intraoperative findings were suspicious of
gery and kept nil per oral for 6 hours prior to surgery. Bowel malignancy, peritoneal washings were collected and multiple
preparation was performed for each patient, using a sodium peritoneal biopsies were taken from the pelvis and mesentery
phosphate solution enema. Antibiotic prophylaxis was ad- in the right and the left paracolic area and subdiaphragmatic
ministered at the time of induction of anesthesia. Procedures region, and an infracolic omentectomy was performed.
were performed under general anesthesia. All surgical pro-
cedures were performed by the first author.
In each patient, a pneumoperitoneum was created using a Postsurgical follow-up
Veress needle at the Palmer’s point, which is 3 cm below the The patients were discharged 1 day after surgery. All
left costal margin in the midclavicular line.4 Peritoneal entry patients were followed-up at 1, 6, and 12 months, and were
was accomplished with a visual technique, using a TER- evaluated for any symptoms and recurrences. Postal ques-
NAMIAN EndoTIPtm (Karl Storz, Tuttlingen, Germany) 3 cm tionnaires were sent to patients and telephonic inquiries
above the upper border of the mass. The secondary-port po- were made to learn about the patients’ clinical status.
sitions were modified according to the size and accessibility
of the mass. A three accessory-port technique was used, with
two ports in the lower quadrants lateral to the inferior epi-
gastric artery and the third port in the suprapubic area. Ab- Table 1. Patient Characteristics
dominopelvic inspection was performed to check for omental Variables N = 55
and bowel adhesions and to confirm the preoperative diag-
nosis. Peritoneal washings were taken for cytology testing. Age (years)
The ovarian cyst was punctured with a secondary trocar, Mean (range) 26.96 (15–38)
cyst fluid was aspirated, and the patient was kept in a reverse BMI (kg/m2)
Trendelenburg position to avoid spillage into upper abdo- Mean (range) 25.05 (18–42)
men. Then the cyst wall was inspected for solid areas and Parity
other signs of malignancy. Celibate 22 (40.00%)
Nulligravida 15 (27.27%)
A decision was made whether to perform cystectomy or
Parous 18 (32.73%)
adnexectomy with or without staging biopsy. Cystectomy Diameter of cysts (cm)
was performed in cases of patients with benign cystic tera- Mean (range) 13.9 (10–24)
tomas, endometriotic cysts, cysts without any suspicious solid 10 £ 15 33 (60.0%)
areas, and in patients who were desirous of fertility pres- 15 £ 20 16 (29.1%)
ervation. Adnexectomy was chosen when the benign nature 20–25 6 (10.9%)
of the cysts was doubtful and the contralateral ovaries were Symptoms
normal. Frozen section was not accomplished because of Abdominal pain 36 (65.45%)
unavailability. Infertility 7 (12.72%)
For performing cystectomy, a controlled tear of 1 cm was Dysmenorrhea 8 (14.54%)
Irregular cycles 4 (7.27%)
made on the edge of each cyst by traction with two graspers,
# of patients with previous surgery 12
rather than using sharp-cutting scissors. This step separated Previous one surgery 9
the cyst wall from the ovarian tissue. After identification of Previous two or more surgeries 3
the cleavage plane, the cyst wall was held with a toothed
grasper and the ovarian tissue was held with an atraumatic BMI, body mass index.
LAPAROSCOPY FOR LARGE OVARIAN CYSTS 253

Table 2. Operative Details plaints were abdominal pain in 65.45%, and dysmenorrhea in
14.54%, and 12.72% of the patients presented with infertility,
Variables N = 55 while 7.27% had irregular cycles. Twelve patients had his-
tories of previous surgeries. Fifty-two percent of the patients
Duration of surgery (min)
Mean (range) 109.6 (40–255) had CA-125 values >35 international units(IU)/mL, with a
Fluid aspirated (mL) mean value of 95 IU/mL, which was not statistically signif-
Mean (range) 1700.91 (500–6000) icant. Risk of Malignancy Index (RMI) scores of all the pa-
EBL (mL) tients were <200. The mean (range) ADNEX [Assessment of
Mean (range) 304.64 (100–650) Different NEoplasias in the adneXa] model score of all the
Type of laparoscopic surgery patients was 97.39% (95%–98.2%) benign.5
Unilateral cystectomy 23 (41.81%) The mean duration of surgery and EBL were 109.6 min-
Bilateral cystectomy 14 (25.45%) utes (range: 40–255) and 304.6 mL (range 100–650), re-
Unilateral cystectomy + 7 (12.73%) spectively (Table 2). The mean duration of hospital stay was
staging biopsy 1.1 day (range: 1–3). Two patients had postoperative fever,
Bilateral cystectomy + 2 (3.63%)
staging biopsy and 1 patient had a primary-trocar site infection. There were
Unilateral adnexectomy 5 (9.09%) no conversions to laparotomy and no major intraoperative
Unilateral adnexectomy + 3 (5.45%) complications. Laparoscopic surgical procedures performed
staging biopsy were as follows: unilateral cystectomy in 23 patients; bilat-
Right adnexectomy + 1 (1.82%) eral cystectomy in 14 patients; staging biopsy in 12 patients,
left cystectomy unilateral adnexectomy in 5 patients; and right adnexectomy
Hospital stay (days) with left cystectomy in 1 patient. Histopathologic exami-
Mean (range) 1.1 (1–3) nations of the cysts showed that 40.0% of the patients had
Histopathology endometriosis, 14.54% had serous cyst adenomas, 18.18%
Endometriosis 22 (40.00%) had dermoid cysts, 14.54% had mucinous cyst adenomas,
Serous cyst adenoma 8 (14.54%)
Mucinous cyst adenoma 8 (14.54%) and 9.09% had borderline tumors.
Mixed epithelial 2 (3.63%) Clinicopathologic factors are shown in Table 3. The
Dermoid cyst 10 (18.18%) proportion of patients with borderline malignancy was sig-
Borderline tumor 5 (9.09%) nificantly higher among those with cysts ‡20 cm but this
was not statistically significant.
min, minutes; EBL, estimated blood loss. There were 5 cases of borderline malignancy (Table 4). In
1 case, preoperatively, a 24-year-old female had normal
Statistical analyses tumor markers and no signs that were suggestive of malig-
All statistical analyses were performed with the IBM nancy on ultrasonography and MRI, but she underwent a
SPSS for Windows, version 20.0. An analysis of variance test bilateral cystectomy with staging biopsies, which, on his-
was used to compare the quantitative characteristics of the topathology testing, revealed a borderline mucinous tumor.
patients and the outcomes. A chi-square test or Fisher’s exact This patient conceived spontaneously 3 months after sur-
test was used to calculate the associations among qualitative gery, delivered normally, and subsequently had an open
characteristics, with significance set at p < 0.05. hysterectomy with a bilateral salpingo-ophorectomy in an-
other center for recurrence of the cyst.
Three other patients with borderline malignancy had
Results
normal tumor markers and no signs suggestive of malig-
Patients’ characteristics are shown in Table 1. The mean nancy noted on ultrasonography and MRI. These patients
age of patients was 26.96 years (range: 15–8). The mean BMI underwent laparoscopic adnexectomies, which, on histo-
was 25.05 (range: 18–42 kg/m2). Forty percent were celibate pathologic examination, revealed borderline mucinous tu-
and 27.27% were nulligravida. The mean diameter of the mors with foci of microinvasion. These patients did not
ovarian cysts was 13.9 cm (range: 10.0–24.0). Chief com- undergo any other surgeries or receive any chemotherapy

Table 3. Clinicopathologic Factors According to Cyst Size

Cyst size (cm)
(10 < 15) (15 < 20) (20–25)
Variables n = 33 n = 16 n=6 p-Value
Age (years, mean – SD) 29.82 – 5.71 23.56 – 6.26 20.33 – 4.89 <0.001
BMI (kg/m2) (mean – SD) 25.55 – 4.91 24.94 – 4.71 22.67 – 2.58 0.386
Multilocularity on ultrasonography 3 (9.1%) 3 (18.8%) 3 (50%) 0.054
EBL (mL, mean – SD) 288.79 – 77.81 312.50 – 69.52 370.83 – 143.54 0.092
Duration of surgery (min, mean – SD) 115.30 – 49.86 94.63 – 38.99 118.17 – 39.37 0.308
Hospital stay (days, mean – SD) 1.09 – 0.38 1.00 – 0.00 1.50 – 1.22 0.103
Borderline malignancy 2 (6.1%) 1 (6.3%) 2(33.3%) 0.045
SD, standard deviation; BMI, body mass index; EBL, estimated blood loss; min, minutes.
254 PAUL ET AL.

yrs, years, IU, international units; RMI, Risk of Malignancy Index; ADNEX, Assessment of Different NEoplasias in the adneXa; FTND, full-term normal delivery; mo, month; P, para; L, live.
salpingo-ophorectomy for recurrence
after this surgery. There were no recurrences noted on
follow-ups at 1, 6 and 12 months.
There was another 25-year-old patient who had unilateral
Follow-up (May 2014)

Laparotomy with adnexectomy

followed by total abdominal
Conceived after 3 mos, FTND,
laparoscopic cystectomy for a 20-cm multiloculated cyst

hysterectomy with bilateral

of cyst 1 mo after delivery;

no recurrence (after 3 yrs)

1 mo later (no recurrence

and, postoperatively, she had a prolonged low-grade fever
No evidence of recurrence

No recurrence (after 8 yrs)

No recurrence (after 3 yrs)

for 3 days with encysted fluid collection noted on postop-
erative ultrasonography, which was managed by antibiotics.
Her histopathology testing revealed a borderline mucinous
tumor. This patient underwent laparotomy and adnexectomy
(after 2 yrs)

after 8 yrs)
in another institution 1 month after the first surgery.
Clinicopathologic factors of patients with borderline ma-
lignancy are compared in Table 5. Borderline malignancy
was significantly associated with multilocularity on ultra-
sonography.
All of the patients were followed up for a period of 1 year
mucinous tumor

mucinous tumor

mucinous tumor

mucinous tumor

mucinous tumor
Histopathology

microinvasion
at 1, 6 and 12 months with clinical examinations, CA-125,

with foci of
transabdominal sonography, and transvaginal sonography.
Borderline

Borderline

Borderline

Borderline

Borderline
Table 4. Characteristics of Patients’ Borderline Ovarian Tumors

Only 1 patient with endometriosis had a recurrence of her

endometrioma and had repeat surgery.

Discussion
biopsies (23/2/2010)
with staging biopsy
Type of laparoscopic

Unilateral cystectomy

Laparoscopic surgery is considered the treatment of choice

Bilateral cystectomy
Right adnexectomy

Right adnexectomy

Right adnexectomy

in the management of small-to-moderate sized ovarian cysts,

(13/06/2012)
surgery

but experience related to laparoscopic surgery as a treatment

with staging

(7/11/2006)

(28/2/2006)

(5/8/2011)

modality for large ovarian masses remains limited.1

In the present study, 10 was used cm as a definition for a
large ovarian cyst as was done in a similar study.6 A ran-
domized prospective study by Yuen et al. in patients with
benign ovarian masses showed that laparoscopic surgery can
RMI Score/

reduce operative morbidity, postoperative pain, analgesics’

25/96.8

90/98.1

39/96.4

100/96.3
ADNEX

use, hospital stay, and recovery period.7 Several studies

Model

115/95

have reported on laparoscopic surgery for patients with large

ovarian cysts, but the numbers of patients included in these
reports were small.8–10
with thick septations

A patient’s age is an important consideration when

without solid areas

without solid areas

without solid areas

without solid areas

Ultrasonography

managing a large ovarian cyst. Cystectomy for manage-

Multiloculated cyst

Multiloculated cyst

Multiloculated cyst

Multiloculated cyst
multiloculated

ment of a large ovarian cyst is usually performed in young

findings

cyst without

women who desire to preserve their ovarian functions.11 In

solid areas

the current study, the mean age of the patients was 26.96
Bilateral

years (range: 15–38), compared to a study by Alobaid et al.

in which the mean age was 30.6 years.1 The chief complaint
was abdominal pain in 65.45% of patients in the current
study, which was similar to a study by Eltabbakh et al. in
diameter

which 69.7% presented with abdominal pain.2 Lim et al. had

(cm)
Cyst

23

10

20

19

11

29.6% patients presenting with abdominal pain and dis-

comfort as the chief complaints.12 In the current study, the
mean cyst size was 13.9 cm (range: 10–24), compared to a
(IU/mL)
CA-125

range of 13–14.6 cm in other studies.2,12

25

30

115

39

100

Peritoneal entry was accomplished using the TERNA-

MIAN EndoTIP to avoid inadvertent rupture of the cysts,
whereas Eltabbakh et al. applied an open technique using
Nulligravida

sterilized

a Hasson’s cannula.2 In patients who were desirous of fer-

Parity
Celibate

Celibate

tility preservation, cystectomy was performed after cyst

P2L2,
P1L1

aspiration. Stamatellos et al. described cyst aspiration in

large cysts to aid their removal laparoscopically after ma-
lignancy had been excluded.13 There are serious concerns,
(yrs)
Age

24

25

28

38

such as intraperitoneal spillage, which may cause pseudo-

myxoma peritonei or peritoneal seeding of cancer. There-
Patients

fore, treatment of a cyst must include careful and copious

peritoneal lavage performed immediately after the proce-
dure, using several L of irrigation saline.14 It has been
1

5
LAPAROSCOPY FOR LARGE OVARIAN CYSTS 255

Table 5. Clinicopathologic Factors of Patients with Borderline Malignancy

Borderline malignancy
Variables No (n = 50) Yes (n = 5) p-Value
Age (years, mean – SD) 27.06 – 6.68 26.00 – 8.28 0.742
BMI (kg/m2) (mean – SD) 24.92 – 4.56 26.4 – 6.10 0.505
Cyst size (cm, mean – SD) 13.69 – 3.73 16.60 – 5.77 0.12
Multilocularity on ultrasonography 7 (14%) 5 (100%) <0.001
EBL (mL, mean – SD) 290.60 – 65.23 445.00 – 148.32 <0.001
Fluid aspirated (mL, mean – SD) 1615.00 – 1165.72 2560.00 – 904.43 0.085
Operating time (min, mean – SD) 109.58 – 45.12 109.80 – 62.15 0.992
Hospital stay (days, mean – SD) 1.06 – 0.314 1.60 – 1.34 0.022
SD, standard deviation; BMI, body mass index; EBL, estimated blood loss; min, minutes.

shown that, with copious saline irrigation, postoperative
chemical peritonitis is <1%.15,16
The reverse Trendelenburg position is important at the
end of the procedure to optimize the results of lavaging. In
cases of dermoid cysts, the cystectomies were performed in
endobags to reduce spillage, whereas, in a study by Chong
et al., a puncture site on a cyst was held using a Kelly clamp
to prevent spillage.11 Irrigating the abdominal cavity with
several L of saline involves long operating time, which is a
limitation of the current authors’ technique. Conversion to
laparotomy occurred in none of the patients, whereas con-
version to laparotomy occurred in 4.9%–6.1% of patients in
other studies.2,12
In the current study, histopathologic examination revealed
benign tumors in 90.91% of the cases, and 5 cases (9.09%)
had borderline malignancy, which was high compared to the
3.7% reported by Lim et al.12 However, in the Lim et al.
study, the incidence of invasive epithelial ovarian carcinoma
was 2.5%, and, in the current study, there were no cases of
malignancy.12 All of the 5 cases of borderline malignancy
had no features (exclusion criteria) suggestive of malignancy
noted on preoperative workups, and their RMI scores were
<200.17 All borderline malignancy cases were multiloculated,
compared to 14% in the benign group, which was statistically
significant. Two of the borderline malignancies were >20 cm,
but this was not statistically significant, compared to the sizes
of the benign cysts.
According to Fauvet et al., borderline malignancy can be
managed by laparoscopic cystectomy or adnexectomy and
patient survival is not affected, although the chance of re-
currence was high in that study’s cystectomy group.18 How-
ever, tumor recurrence and metastatic disease are rare in
borderline mucinous ovarian tumors.19 In the current study,
there were 5 cases of borderline malignancy and 1 of these
patients underwent unilateral laparoscopic cystectomy and
another 1 underwent bilateral cystectomy with staging bi-
opsies. The former patient underwent laparotomy and ad-
nexectomy at another center 1 month later, while the latter
patient conceived 3 months postsurgery, and post delivery
she had an open hysterectomy with a bilateral salpingo-
ophorectomy for recurrence of her cyst. The other 3 patients
underwent unilateral adnexectomies with staging biopsies
performed in one of these procedures. These 3 patients were
normal at follow-up.
There was a recurrence of an endometriotic cyst in only 1
patient, who presented with primary infertility; she had to
undergo a repeat laparoscopic cystectomy 3 years after her
primary surgery.
Port-site metastasis after laparoscopic removal of malig-
nant tissue is another reported complication.20,21 In the cur-
rent cases, the ovarian cysts were extracted using an endobag
to prevent port-site contamination. None of these patients
developed metastatic lesions on trocar sites during the study’s
follow-up period.
Because of the potential risk of malignancy, selection of
patients for laparoscopic management of large ovarian cysts
is very important. It is generally agreed that ovarian cancer
should not be managed laparoscopically, especially when
operators are not able to perform the surgical procedure
without rupture.22 It is uncertain whether or not an intra-
operative rupture has the same prognostic significance as
ovarian-surface involvement and/or positive peritoneal wash-
ings in stage I ovarian cancers.23–26 However, most patients
with ruptured cysts need postoperative chemotherapy. The
new ADNEX Model scoring system can help to some ex-
tent in early detection of borderline malignancy. When an
adenexectomy is planned, use of an endobag helps pre-
vent spillage of contents. In cases of small cysts, enucleation
in toto helps prevent spillage. For large cysts, aspiration in the
reverse Trendelenburg position minimizes spillage risk.
Lecuru et al., in a retrospective multicenter study, sug-
gested that there was no difference in outcome after lapa-
roscopic management of ovarian cancer, but surgical staging
was suboptimal in a significant number of laparoscopically
managed cases.27 In the current study, laparoscopic staging
biopsies of ovarian cysts was performed in 12 cases (22.2%)
that had intraoperative findings that were suspicious of
malignancy. Exploration of the retroperitoneum for lymph
nodes was not performed, as MRI/CT scans did not reveal
any enlarged lymph nodes. However, in cases of malig-
nancy, this staging is suboptimal and was a limitation of the
current study. Nonavailability of frozen section was also a
limitation of the current study.
In the current study, a higher incidence of borderline ma-
lignancy was observed than had been seen in other studies.
The current authors agree that there could have been a se-
lection bias in the cohort, as the Paul Hospital center is
known for laparoscopic management in infertility and gy-
necology rather than gynecology/oncology. Thus, patient
selection was not optimal. When selecting patients for
management of ovarian cysts laparoscopically, the potential
risk of malignancy is a major concern. Large cysts with
256
multilocularity noted on ultrasonography scans should alert
clinicians to doubt the benign nature of such cysts. The role
of sonography has been emphasized in the recent ADNEX
Model scoring system. However, laparoscopic management
of large ovarian cysts is technically feasible if proper patient
selection is made.
Conclusions
The limiting factor for laparoscopic management of large
ovarian cysts is not cyst size but rather the potential risk
of malignancy, given that a higher incidence of borderline
malignancy was observed. Large multiloculated ovarian cysts
should be considered as potentially malignant and an oncol-
ogist should be consulted for an opinion. Adnexectomy may
be a better option for such cases, provided that the contralat-
eral ovaries are normal. The current study supports laparo-
scopic management of large ovarian cysts as a technically
feasible and effective method if proper case selection is made.
Author Disclosure Statement
The authors declare that they have no conflicts of interest.
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Address correspondence to:
P.G Paul, MBBS, DGO
Centre for Advanced Endoscopy
and Infertility Treatment
Paul’s Hospital
Vattekkattu Road
Kaloor, Cochin 682 017, Kerala
India
E-mail: drpaulpg@gmail.com
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