Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy

Abstract

Ovarian cysts are a common gynecologic finding in adolescent females and are typically benign, often resolving without requiring intervention. However, larger cysts can cause significant symptoms and pose a risk for complications such as torsion. These cysts were traditionally removed with a full midline laparotomy. Surgery as a field has moved towards minimally invasive approaches to promote healing and aesthetics. With large benign cysts, this is achieved with controlled intentional decompression, allowing for extraction with a smaller incision. In this case, we present a 14-year-old female who presented with abdominal discomfort and was found to have a 24x20x9-cm left ovarian cyst. She underwent controlled cyst decompression into a specimen bag, minimizing peritoneal contamination prior to removal of the cyst. This was achieved in a 5-cm Pfannenstiel incision. The patient was discharged the same day without complications and demonstrated full recovery with no cyst recurrence at the 12-week follow up. This case highlights the safe, effective management of large benign ovarian cysts using controlled decompression and innovative containment strategies to enable minimally invasive surgical access. 

Keywords

Ovarian cyst; pediatric surgery; benign ovarian neoplasms; laparotomy; cyst decompression; cystectomy.

Case Overview

Background

Ovarian cysts are common gynecological findings, often occurring as part of the normal ovulatory cycle, particularly in women of reproductive age as stimulation of the ovaries increase after puberty.¹ These cysts are typically benign and asymptomatic, but in some cases, they can present with abdominal pain, menstrual irregularities, or acute symptoms due to complications such as rupture, hemorrhage, or torsion.² While many cysts resolve spontaneously, persistent or complex cysts may require further investigation to exclude malignancy. This is a case of a healthy 14-year-old female who was found to have a large ovarian cyst while undergoing evaluation for her gastrointestinal discomfort. She was referred to our pediatric surgery clinic and subsequently underwent an open left ovarian cystectomy through a 5-cm Pfannenstiel incision. She was discharged home on the same day of surgery in stable condition.

Focused History of the Patient

This is a 14-year-old female presenting with poor appetite and gastrointestinal discomfort for several months. Imaging revealed a large pelvic mass during her evaluation for abdominal symptoms, prompting referral to pediatric surgery for further assessment. The patient reports decreased food intake due to pain and acid reflux but is otherwise experiencing normal bowel movements and urination. She continues to have regular menstrual cycles.

Physical Exam

Physical exam revealed a well-nourished, healthy-appearing female in no apparent distress with normal vital signs. No abdominal tenderness on exam. A large mass was palpable in the center of the abdomen, extending from the subcostal region to the pubis. Studies have shown that 60–70% of patients with ovarian masses present with abdominal symptoms, commonly pain or bloating, as seen with this patient.³ While these masses can be asymptomatic, they may be detected during a physical exam as a palpable mass. If such mass is suspected or felt on exam, imaging should be performed for further evaluation.

Imaging

This patient underwent evaluation of her upper and lower gastrointestinal (GI) tract and hepatobiliary iminodiacetic acid (HIDA) scan as part of her workup for her gastrointestinal symptoms. An MRI of the abdomen showed a 24x20x9-cm, large thin-walled cystic lesion taking up most of the abdomen, most likely originating from the left ovary. For evaluating pediatric ovarian masses, the primary imaging options are ultrasound, MRI, and CT. Ultrasound is typically the first line, given its availability and lack of radiation exposure, especially in the pediatric population. MRI offers superior soft tissue contrast and detailed imaging, but is time-consuming, expensive, and may require sedation, while CT is useful in emergent situations, despite its radiation exposure.⁴ Certain traits can raise the suspicion for malignancy, such as papillary projections, solid components, irregularity, thick septations, evidence of ascites, or increased vascularity on color doppler.⁵ This patient’s mass did not raise such suspicions.

Treatment Options

Options for treatment include expectant management, as many are functional and regress without treatment, cyst puncture, treatment with a combined oral contraceptive pill, hormonal replacement therapy, and surgical excision. This decision is based on a variety of factors, including pubertal status, size of the cyst, and composition of the cyst when seen on imaging.⁶

Rationale for Surgical Treatment

Surgical intervention is indicated in cases of suspected ovarian torsion, malignancy, enlarging cysts, symptomatic cysts, or those exhibiting hormonal activity. In this patient’s case, the large mass posed a risk for future torsion and was likely contributing to her abdominal symptoms due to its size.⁷ As part of the preoperative evaluation, tumor markers were obtained to assess the risk of malignancy. The patient’s results were within normal limits: lactate dehydrogenase (LDH) 187 U/L, Inhibin A 6.8 pg/mL, inhibin B 114 pg/mL, alpha-fetoprotein (AFP) < 0.8 ng/mL, quantitative human chorionic gonadotropin (hCG) 5 mIU/mL, and cancer antigen 125 (CA-125) 14.2 U/mL. These findings were consistent with a benign etiology and further supported the decision to proceed with cystectomy via a minimally invasive approach.

Discussion

While conservative approach is preferred for ovarian cysts, larger cysts require resection due to associated symptoms and complications from the mass effect. Traditionally, this has been approached with a full midline laparotomy. Minimally invasive surgery has been used to treat large cysts, though there are only a limited number of documented cases. In each case, the approach involved decompressing the cyst to create operative space, ease handling of both the cyst and ovary, and reduce the risk of accidental rupture and fluid leakage.⁸  

Intra-abdominal rupture of benign ovarian cysts, accidental and intentional, has not been shown to compromise clinical outcomes when managed appropriately. For example, a retrospective pediatric series found no significant increase in recurrence rates associated with cyst rupture during benign ovarian tumor resection.⁹ Additional studies focusing on dermoid cysts report high rates of intraoperative spillage (up to 60%) without resulting in chemical peritonitis or negative effects on fertility or overall prognosis.^10,11

In this case, a 5-cm low transverse (Pfannenstiel) incision provided adequate pelvic exposure while minimizing postoperative pain and optimizing cosmetic outcomes. After entering the peritoneal cavity and identifying the large ovarian cyst, careful dissection and preparation were critical to minimize rupture risk. To protect the peritoneal surfaces from spillage, Ray-Tec sponges were placed circumferentially around the cyst. Controlled cyst decompression was performed by intentionally puncturing the cyst wall to drain over two liters of fluid. A novel aspect of this technique is the adhering of a specimen retrieval bag to the cyst wall using Dermabond. This maneuver effectively stabilized the bag to the cyst surface, allowing cyst contents to drain directly into the bag rather than into the peritoneal cavity. This approach facilitated safe containment of cyst fluid and may reduce the risk of intraperitoneal contamination.

The patient tolerated the procedure well, was discharged the same day in stable condition, and on 12-week follow-up ultrasound, showed no cyst recurrence and normal ovarian appearance. No adverse events or complications were observed, and the preservation of ovarian tissue was confirmed. Final histopathological evaluation revealed a serous cystadenofibroma, a benign epithelial tumor characterized by both cystic and fibrous stromal components.

In addition to surgical management, consideration of postoperative care is important. Current evidence does not support routine hormonal suppression following surgery for benign, non-functional ovarian cysts such as serous cystadenofibromas.^6,12,13 Hormonal therapy has not been shown to reduce recurrence rates, which remain low after complete excision. As a result, clinical guidelines recommend against routine use of hormonal treatment in these cases. Given the benign pathology and successful removal in this patient, hormonal therapy was not indicated in her postoperative care.

This case illustrates that intentional, controlled decompression and innovative containment strategies can allow safe surgical management of large benign ovarian cysts through a minimally invasive incision, avoiding the morbidity of a full laparotomy. Meticulous intraoperative technique combined with careful postoperative monitoring is essential to optimize outcomes in pediatric patients.

Equipment

In addition to the standard pediatric laparotomy tray, a specimen bag, an Alexis wound protector, and a handheld LigaSure were used. 

Disclosures

The authors have no conflicts of interest to disclose.

Statement of Consent

The patient’s mother has signed the informed consent form, granting permission for filming and online publication of information and images.