The cruciate incision. With a conventional scalpel make a small suprapubic transverse incision through the skin and subcutaneous tissue (FIGURE 2). After clearing subcutaneous fat from the midline, incise the rectus fascia and the peritoneum in a vertical direction.
A vertical skin incision can be selected if the preoperative workup suggests a later extension of the original minilaparotomy incision may be required, or if there is a prior vertical incision.
Retraction. Use a soft sleeve-type self-retaining plastic retractor, such as Mobius (Apple Medical Corp) (FIGURE 3 ). When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure of the pelvis (FIGURE 4).
During surgery it may be necessary to adjust the outer ring if the sleeve loosens. Narrow Deaver or Richardson retractors, if required, provide additional retraction. The bowel may be gently packed, if necessary, but typically it is adequately displaced by the large ovarian cyst.
The atraumatic retraction provided by the soft, self-retaining abdominal retractor minimizes the possibility of tissue trauma, nerve damage, bruising, and postoperative pain. At the same time, the continuous 360° retraction force on the incision maximizes surgical exposure, providing a significantly larger working area than conventional retractors. For example, when applied to a 6-cm incision, the self-retaining retractor creates a 28-cm2 exposed working area, compared with only 18 cm2 provided by a conventional 4-point metal retractor.
The adjustable height of the self-retaining retractor adapts to wounds of varying depth and works on virtually any tissue thickness—a feature that makes the device effective for obese patients. Further, by lining the abdominal incision, the retractor’s plastic sleeve protects the wound’s edges from contamination and potential implantation of malignant cells, making the device ideal for managing ovarian cysts.
FIGURE 1 Hinged uterine manipulator
The manipulator facilitates exposure of the cyst and contralateral adnexa, as well as uterine elevation/rotation.
FIGURE 2 Cruciate incision
Make a 2.5- to 5-cm suprapubic transverse skin incision. Using the Bovie device, incise the subcutaneous fat transversely along the full length of the skin incision down to the level of the anterior rectus fascia. Clear the subcutaneous fat from the midline superiorly and inferiorly to expose 5 to 6 cm of the rectus fascia in the vertical axis. Use blunt digital dissection to assist in mobilizing the subcutaneous fat. Incise the anterior rectus fascia vertically through the full length of the cleared area. Retract the rectus muscles from the midline to expose the underlying transversalis fascia and the peritoneum. Control small bleeding points with the Bovie device. Enter the peritoneum either digitally or with scissors above the bladder dome and extend the peritoneal incision to the full length of the fascial incision.
FIGURE 3 Self-retaining retractor
The retractor consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve.
FIGURE 4360° retraction force
Squeeze the inner ring of the soft, sleeve-type, self-retaining retractor into the peritoneal cavity through the cruciate abdominal incision and allow it to spring open against the parietal peritoneum. Make a digital assessment to ensure that viscera is not trapped between the inner ring and the abdominal wall. Place the entire sleeve on traction by lifting the outer ring. Then roll the outer ring onto the sleeve, collecting excess length, until it sits firmly against the skin. The atraumatic retraction provided by the sleeve-type retractor maximizes exposure of the pelvis. Note how a portion of the large cyst is clearly seen through the atraumatic, circular area of retraction.
Cyst assessment
Visually and digitally inspect the cyst and carefully evaluate the uterus, pelvis, and contralateral adnexa. Determine the extent of adhesions and any unexpected pelvic pathology. When needed, use traditional small retractors or gentle packing to gain additional exposure. If the cystic mass appears suspicious (internal and external excrescences on the cyst, ovaries, or peritoneal surfaces, or ascites), obtain pelvic washings with a suction-irrigation cannula, send the fluid for cytologic examination, and convert the minilaparotomy to a standard exploratory laparotomy. Extensive adhesions to the bowel, broad ligament, or pelvic sidewall and unexpected extensive endometriosis may also require a conversion to standard laparotomy.
Reduce cyst size by decompression
Simple aspiration is inadvisable. To remove a large ovarian cyst using the Pelosi minilaparotomy, reduce the size of the cyst to permit safe and effective mobilization and resection through the small abdominal incision. Simple aspiration of the cyst, with its potential for spilling the contents, is not a wise strategy for several reasons. First, many ovarian cysts contain functional epithelium with a high recurrence rate (8% to 67%). Second, studies show that 10% to 66% of ovarian cyst fluid aspirates initially diagnosed as benign actually are malignant. Further, relying on negative cytology from the aspirate of an ovarian cyst without tissue biopsy may delay appropriate surgery, and the puncture of an unexpected malignant cyst may seed the peritoneal cavity and possibly worsen the patient’s prognosis.11,12