Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy

CHAPTER 1

My name is Brianna Emr. I'm a pediatric surgeon here at Penn State Health University. Today we're gonna be doing an open exploration and removal of an ovarian cyst for a young female who came to see me in the office. So we are going to be doing an open Pfannenstiel incision for a very large ovarian cyst. This is a patient, came in as a teenager with some vague symptoms for about a year of reflux and discomfort when she was eating and some abdominal distension. And on imaging, she was found to have a pretty good size 20-by-24-centimeter cyst, likely coming off one of her ovaries. She had some preoperative tumor markers drawn that were all normal, which is good and not concerning for a malignant cause. And after a review of the imaging and talking to the parents, we decided to perform an ovarian cystectomy in the operating room. The big steps for this operation are first deciding where you're gonna make your incision. We looked for a nice crease that was on her lower abdomen that was easy access point. Once you have access into the peritoneal cavity, we placed a self-retraining Alexis wound protector, which serves as a retractor. And then we did a controlled drainage of the cyst fluid by using a specimen bag and Dermabond in order to shrink the size of the cyst so that we could keep her incision small. And then after we exteriorized the cyst and the ovary, we were able to peel the cyst off of the ovarian tissue and preserve it.

CHAPTER 2

So this is our young lady with a very large simple cyst coming off of one of her ovaries is the most likely diagnosis. It's just this whole abdomen here is really the ovarian cyst. It's very, very large. And if I push down on the top of it, I can get it to come down to the pelvis. So I think a Pfannenstiel incision would be nice for her to get it out safely and with minimal scar. And she has this natural fold right here, which should be nice for cosmesis. We can use that. And then, Kayla, I'll probably have you come up here. Sure. Above Mark, when the time comes. And then I'll have you kind of push the cyst downward. That'll make it safer for us to get it out safely. The other option is to go through the umbilicus 'cause the cyst is so large that it's come all the way up really to her xiphoid is right here. So you could make a mini-laparotomy incision right through the umbilicus. You could evacuate the fluid that way and then take the cyst out. But I think this is nice for cosmesis. Yeah, so if you wanna inject some Marcaine. Injecting local. And before we started the case, we did place a Foley catheter to make sure that the bladder is out of the way for safety reasons. We'll take it out at the end of the case. Okay, needle down. I'll take the knife. Making incision. You want the full thing? Yeah, thanks. We're starting. Okay, Adsons.

CHAPTER 3

I'll take a mosquito. Just come through the dermis is the first layer here. If you see red blood cells, just zap them. Okay? Okay. Mm-hm. Turn the table up a little bit. Yep. Yep, that's good. Thank you. I'll come through some of the sub-q fatty tissue layer here and Scarpa's. Come this way. And then we'll look for the rectus sheath. I think that small Alexis wound protector will be good. Not the extra small, yeah. See if we can get some better light in here. We don't wanna skive too much down. Okay. I think we're almost to the fascia here. Let's just use this whole incision here. Mm-hm. Okay. If we push this down, are we able to kind of get a better...? Yep. Yeah. Yeah. Kayla, can you do that? You feel the top of the cyst there? There you go, perfect. I think we're just cleaning off the top of the rectus sheath here. And then once we get in, we'll put an Alexis wound retractor in here. Good. All right, so this looks like rectus sheath. So we just gotta find the midline. So this coming down this way, I think something like this. I'm just gonna score it. Yep. In the middle first. Yep. Yeah, I think we're just scratching it. We'll get there. Right here. Yep. Let me see a Metz, I'll take a DeBakey. I think this is the middle. I'm moving to my side. This looks like muscle here, so yeah. Or they're fused. It almost looks like this is the middle here. There's a tiny little band right here. Let's see. Let's just make sure. Umbilicus, pubis. Yeah. All right. So we're opening up the midline here between the two rectus muscles. And then we'll put it back together when we're done. Similar to a C-section incision, only much smaller. Want go through that? Yeah. Put it on some tension there. Yep. Good. Mm-hm. So I think this is my muscle. A DeBakey. And that should be your muscle. She's strong. So is this the middle here? It's kind of fused. Or is this the middle over here? Yeah, that could be. That looks promising. Mm-hm. Yep. Go down this way. Get that retractor again. Thank you. Mm-hm. Yeah, I agree. I agree, just stay on that side. Okay. And then once we get in, we should be able to extend that even easier. All right, so hold this upper one again. All right. All right, you have those Metz? I feel the cyst for sure. Just get one more layer. Let's open this one. Mm-hm. Let's see. Maybe we can go that way a little bit. And my way. Yeah, there we go. All right, so that's just peritoneum right there on top of cyst. Mm-hm. See that? So we should be able to bluntly. Okay. Yep. And we're making this a tiny incision for her. And when we decompress the cyst, we'll be able to exteriorize everything. So that'll make it easier to do the cystectomy. All right. She's got peritoneum for days. Mm-hm. Mm-hm. There we go. Nice. And in pediatric patients who are younger than this, their bladder can really extend very high. It can go all the way up to the level of their umbilicus in babies even. So, this is a risky place to do an incision, but in an older female, you can definitely make a Pfannenstiel incision work. So if this was a younger child, and I was really worried about their bladder, I would opt more to do the umbilical incision. All right, let me know if you get tired by the way. You're doing good. So this is a self-retaining retractor. Exactly.

CHAPTER 4

So here's the cyst. So again, we just wanna confirm. So relax for a second. And you can see down in here a little bit. We'll see better once the cyst is out, but this is probably her right ovary way down there. You have a body wall or, yeah. Lemme see this Richardson retractor. So way down there. This is most likely her right ovary. See that? Mm-hm. It seems kind of big, at least to me. And then I think this thing is actually coming off of her left ovary, but we'll be able to tell a lot more once we decompress the cyst. Over here, this is her colon probably. It's probably some sigmoid right here. So we wanna stay away from him today. And then way down there is gonna be bladder. That's a little hard to see, but if I stick my fingers down here, you can feel the the balloon of the Foley. So you can do that. So just reach all the way down toward the pubis. You have to go down and you'll feel the balloon or the Foley rolling under your fingers. Mm-hm. So that's helpful to know where the bladder is. And then you can see the cyst here. It's kind of on this broad pedicle. And most likely the entire left ovary, if that's where it's coming from, is completely splayed out. There's not gonna be like a discrete structure anymore. It's gonna be very flat and thin. We'll still try to save as much of it as we can on the mesentery side. All right, yeah, I think that is the right ovary over there. See what I'm saying? Yeah. Yeah, I agree. Yep. And then down here are her iliacs. Okay, good.

CHAPTER 5

So now we're gonna do drainage of the cyst. So, this is gonna be our little magic trick here. So you're gonna keep the cyst down into view. So we wanna make it as dry as possible. There you go, nice. So we don't wanna spill the cystic fluid if we can help it. We don't think that this is a malignant ovarian cyst 'cause she has normal tumor markers. She really doesn't have calcifications on her scans. It looks like a fairly simple cyst, but just in case, we wanna try to control the fluid drainage. If we thought this was malignant, then you wouldn't wanna be doing this drainage procedure. You'd do a bigger incision and try to get it out that way. But we don't wanna give her a huge incision for a benign cyst. So I'm trying to pack off the edges of it here. We'll see if this helps us or hurts us. And then you wanna make sure that the surface of the cyst is very, very dry. And then we're gonna use Dermabond. And we're gonna use Dermabond to glue... So there's one Ray-Tec inside the abdomen by the way. We're gonna glue the specimen bag to the cyst and then we're gonna cut into it and drain it with the suction. So we'll need the Poole sucker when the time comes for that. Let's keep that down here. All right. So we're gonna glue Dermabond on here and do the bag trick. All right, so go ahead, Mark. You can get a Dermabond stick. Okay. And then do you have a sponge stick? And just glue... Yeah, we're just gonna put Dermabond on the cyst wall. Can you make one? Or... Or sponge on a stick? Yeah, it's a Pfannenstiel. It's pretty impressive. Yeah, yeah. It goes all the way up here. Kayla, it's key that you don't move too much here. You're doing great, Kayla. Okay. No pressure. So this is gonna glue to the cyst. Oh, yeah. That's awesome. And we're just gonna use this to control any spillage once we open it. So it should go into the bag and not into the abdomen. So now we gotta let the Dermabond dry for a minute. Let's take a look. All right, that looks better. I just won't pull as hard. Okay, so let's get our suction. And our blade. Do you have an 11 blade? And then we're just gonna make a decent-size incision so that we can suction as much as we can. Yep, exactly. Any extra fluid will come out of here. Because if you did this through like an angiocatheter or something, that would take ages. Mm-hm. All right, you ready? Mm-hm. But that's the other option. So this is all clear. Benign-appearing fluid. It's not bloody. It's not white. Mm-hm. And eventually you should start feeling this deflate quite rapidly. Yep, you're doing great. That's right, kind of just squeeze it down for me. Good job. Good job, Kayla. You have a Kelly? How much fluid we got coming out so far? One liter. All right, one liter. Yep, and just like you're doing, don't agitate the bag too much. Good. Look at how much smaller she is. It's quite a feat, huh? And if you put your fingers right here, you can feel the pulse of her aorta. Yeah. Now you can actually feel it. All right, once it slows down, we'll take a look. So lemme see if I can grab onto the wall here. How much now? 23. 2300? Mm-hm. All right. We should have taken bets. Yeah. How much fluid can we get out here? All right, let's see. Can we see anything? There we go.

CHAPTER 6

All right, so now what we wanna do is get another Kelly. See if you can keep the bag kind of controlled on there and start pulling this out. And our Ray-Tec should come out as well. Yep. Good. Yeah, it's all gonna be splayed out. We'll have to take a look. See if we can get more. I might need to make our incision even a little bit bigger. But let's see, this Ray-Tec I think is hurting us at this point. Carefully come... This way. So we don't spill that. All right. Kelly. See if we can get the rest of this Ray-Tec out too. I think that'll help. There we go. All right, good. So we got to move the bag out now. All right. So let's see... What we wanna do is make sure that this doesn't start leaking 'cause the bag will eventually fall off. All right. So now we can take this Kelly off. Okay. Yeah, the bag is just gonna come right off. There's a Kelly in there. You can give her that Ray-Tec back if it'll come off. Okay, good. So, let's see. Sometimes these do get torsed from being so big. Uh-huh. You can see there's even still fluid in it. Mm-hm. There we go. That was the move. Good. So that's ovary here. And this is all cyst. You can see all these fun vessels. Let's open that handheld LigaSure that Susie brought in. We took out two liters and there's probably another, like, half or a third of the liter. Yeah. There is actually a nodular portion to it if you feel right there. Oh yeah. It's probably still benign, but... Another thing that causes very large ovarian masses in female patients is teratomas. And this, even like her sigmoid has decided to become a part of it.

CHAPTER 7

Yeah. Pickups, mosquito. So her sigmoid fat has kind of fused to part of the cyst wall here. Let's see if we can get our lights a little bit better too. Thank you. So the nice thing is she's still gonna have a small incision, and now we're not struggling to see, 'cause everything's on the outside. Mm-hm. A lot of times in these cysts, Kayla. Mm-hm. When you think about the cyst, if you think of an orange with its peel. You think the cyst is more as the actual orange or the peel itself, The relationship of the ovary and the cyst? What do you think is what? Sorry. I know it's a hard analogy, but it'll make sense once I explain it. Like, so what's the relationship of the cyst to the ovary? Like the cyst sits around the ovary. It's actually the other way around. The ovary sits around the cyst in a lot of cases. Yep, he is right. Sometimes we have to go through a little bit of ovary to get to the edge of the cyst. So it used to be that people would just take out and do an oophorectomy. So this is the actual true cyst wall here, and this is some of the cortex around it. And we'll just use our LigaSure if we need to. Can I see the LigaSure? It's just thinking. There's a nice vein that's feeding this cyst. Can I get the other tip on the suction? There we go. So yeah, years and years ago, we would just take out the ovary, the cyst, the whole thing would come with it. But then we learned that most of these are benign, and girls have a better chance of normal fertility if you can leave both ovaries intact so... Another DeBakey. There's always gonna be a little bit of a plane, whether you do this open or laparoscopic. I'll take a DeBakey also. Between the cyst and the ovarian cortex. And so if you can find that plane, which is what we're developing right here. And then you can use some sort of energy device. Bovie, this is a handheld LigaSure. And you can just separate the two and do an ovarian cystectomy instead of an oophorectomy. And we'll save as much ovary as we can, but we are primarily here, we wanna get the whole cyst out safely. And we already worked so hard to do a nice controlled drainage. Yeah, there's some there. Question is which way do we wanna go first? So why don't you come my way a little bit. So it'll take a little time, but you can see the plane there. Yep. Good. And then we wanna save the blood supply, which is coming right through here. Nice. So a lot of times if these are smaller, you know, if the cyst is five, 10 centimeters, I'll do a laparoscopic excision. You don't even have to drain the fluid if you can see around the whole thing. And so you can open the cortex and then you can make a plane. Yep, just take your time. And you can do this exact same thing. You can just take the cyst right outta the ovary. And then once you have it in a bag, you can drain the fluid then if you need to for getting it outta the abdomen. So that's a common scenario. A patient will come in with acute ovarian torsion, and they'll have a cyst or a little teratoma or a paratubal cyst. And so we'll do a diagnostic laparoscopy and a cystectomy after detorsing the ovary. Yep. Just gonna burn this guy. Yeah, that sounds good. But you can see it's pretty satisfying once you find that plane. Some of these little strings here I think will help us. Yep. Mm-hm. Good. And then every once in a while we'll just check where we're going. Mm-hm. Laparoscopically, it's very easy to get lost in these giant cysts as well. They just keep twisting and twisting and twisting, and you kind of can't see where you're headed. So it is nice to have it up in the field. And the cyst wall itself is fairly vascular, as you can see. And ovaries in general are very vascular. All right, let me come... Yep, after you get that, I'll take the LigaSure. Nice. All right, so here's where we've got some more ovary to fend with around. You kind of wanna come around it, yeah. That's why when we do this... Do it where it's easy. A little bit of ovary. Yeah, let's see if I can make a plane. Some parts are more fused than others. That's partially into it there. That's all right. I'll just find another spot. Can I got another DeBakey? Mm-hm. Thank you. There we go. This spot seems to be friendlier. You can tell there's a lot of tissue there 'cause it takes a while for the LigaSure to get through. There we go. Mm-hm. Now it's running. You can let go where you are. You want to put a Kelly on it here so it doesn't leak? Yeah. Can I get a Kelly? Okay, so now I'll hold this side. There we go. And then we're gonna have to kind of peel it off the ovary itself. Yeah, that looks a little bit friendlier. So her symptoms were going on for a long time. She kind of had a lot of reflux. That was her main presenting symptom. She didn't really notice that she had this big cyst in her abdomen. A lot of patients just think that they're gaining weight. And in retrospect it's just been this very slow-growing cyst. And the parents were very relieved when I saw them in the office and told them that we can take this out. So just to make sure you know what we're doing, we're kind of peeling the ovary. This is a very thinned-out wall of ovary from the cyst underneath. So that's where the the orange thing comes from. I know it was confusing in the beginning, but now we're like peeling an orange. Mm-hm. Makes sense. I like that. That's a good analogy. Mm-hm. And again, we're just remembering where the blood supply is coming from 'cause we don't wanna compromise the blood supply to the ovary that's left behind. All right, so now... We're almost all the way around. Yeah, so if you wanna connect these two suture lines, and then we have to peel it off of... I'll take these vessels with me. Yeah, I think you can stay above some of them. Maybe come up here where it's thin. Mm-hm. Most of these are just going to cyst. They're not going to ovary, but we'll save what we can. You are good on my side. We still have a little ways to go. And you can see that if we got into bleeding for some reason, we have this whole mass up in our field so we can easily take care of it. Nice, and those two might be sticky so just let's see if we can peel a little bit. Just do a little bit at a time. Mm-hm. I think something's a little oozy down here. Can you turn the Bovie up? What's it on? So now we've got the lining off, and then you can see all this blood supply down here and we're still gonna have to disconnect it from ovary. So there's a definitely a few places that looks stickier than others. So let's just do the less sticky stuff first. Yep, see that big vessel right there? I'm gonna go ahead and take it... Yep, I agree. I really don't want that to bleed. I like it. Okay Mm-hm. Good. And then we should stay over here more 'cause this is where we started our dissection. See this? Here, let me see the, it's hard to see around this corner. This is where our two dissection planes have to meet up. And of course, it's kind of sticky here. All right, well, let's take what's easy and then we can come back to that sticky spot. Okay. More blood vessels. I can see where it ends mostly. Mm-hm. All right, why don't you come that way? See the... Mm-hm. Thin plane here? Yep, mm-hm. There we go. Yeah, that's where it's super sticky. I don't know. Mm-hm. It's coming. Yep. So do you know what the steps would be if this was a cancer operation, Mark? No, I'm not sure actually. This is - it's just, it's peeling off here. There you go. All right, let's find another spot. This spot is still stuck. Let's see. Here's our ovary. Yep, pickups. Why don't you hold this toward you. This is all stuck here. Sometimes we can do a little bit of this tearing and then dealing with any kind of oozing afterwards. I'm just trying to make these two dissection planes meet. Do you have a mosquito? Mm-hm. Do you have another DeBakey? Yeah, this one would've been no fun to do laparoscopically, that's for sure. There's a better spot. Is that meeting up with anything? There. Yeah. Right there. Okay. Thank you. Mm-hm. Good. All right, so let's just keep peeling. I think I like that plane the most. Mm-hm. Which means we have to go through this stuff. Yeah, there's some more there. But will it keep peeling off this way is the question. See if you can get this free here first. See these little bands? Mosquito. I found one of the little vessels in here. Might be better from... Your side. My side. Mm-hm. Once we get it, the thing off, it'll be easier to see what we're dealing with. All right, so do we wanna keep on with this plane or keep over here? Let's see, mosquito. Yeah, I'm wondering if we can get those two to meet up. Probably like there. That way we're not doing multiple planes of dissection. There we go. All right, so you can get a few of those from your side. See right in here? I think you can get some of this. Come towards me. See that? Mm-hm. Good. Because that cyst going up that way. And then our previous cut line is somewhere over here. So yep, if that's free, you can take that. Mm-hm. That's it, closer to the cyst. Colon. Okay. And then maybe I wanna keep going this way a little bit more, back and forth. This is the stickiest part, right where it's coming from the ovary. Mm-hm. You mind wiping that off? Thanks. Almost there. Yep. A little bit of blunt. Okay, not much left. Get that corner. We can Bovie as we do that. Bleeders. Yeah, well, those are on the cyst. They're coming out. I just gotta disconnect this corner here. See that? Mm-hm. Find our omega. Whoop. Sorry. Mm-hm. Almost there. Doesn't wanna give up. Yep. Just do this. It doesn't wanna come out, but we'll win. So if this was a cancer operation, we wouldn't necessarily drain it, we would just... Correct. Get the blood supply, and do the oophorectomy as well? Mm-hm. Or we just still trying to do cystectomy. Yep, you do an oophorectomy, you test the peritoneal fluid for cytology, you take out any omental implants, peritoneal implants that you see. You have to inspect everything. You don't have to do an omentectomy, but if you see something, you biopsy it. And then you also check for lymph nodes in the iliacs, right? Mm-hm. And if you see anything, feel anything there, then you also biopsy those lymph nodes. All right. Why don't you finish it off? Actually, Kayla, do you wanna finish it off? Yeah. So you just squeeze really hard and wait for the beep. So when you squeeze it presses a button between your prongs, yep. Yep, squeeze hard. And hold. Squeeze, squeeze. Wait for the beep. And then there's a trigger that cuts it. Nice. You did it. Good job. You took out the cyst. All right, so this is a left ovarian cyst. Left ovarian cyst. Yep, for permanent. Mm-hm.

CHAPTER 8

So now we wanna make sure that we have good hemostasis. We wanna make sure that we put the ovary back in it's normal orientation, no torsion. And then we'll close. Yeah, something in there. As I said, ovaries are very vascular, so it's normal to have some bleeders that we have to take care of. Any red blood cells you see, we can give 'em a little zap. Mm-hm. And the ovary is very resilient, even if it's been torsed for hours and it looks purple when you get in there. We just detorse it, take out any pathology and then we bring 'em back to the clinic in like three to six months with a pelvic ultrasound and check the ovary. Most of the time it's still viable. It might be a little bit smaller, but that is the good news. All right, good. So this was our colon that was trying to get involved in the operation. Anything on there that you need to pick up and zap? Mm-hm. Pinch burn isn't working as well. There you go. Nice. Yeah, I think the tip of the Bovie is important. All right, good. All right, so let's put this in, and then we can kind of take a look around again, and see what we see. All right, so uterus. Let's see, a body wall retractor. That's a good idea. All right, thank you. And I'll take it a DeBakey, long, maybe. Long? Yeah. So uterus is right down here. That's this midline structure right there. And then here is our ovary friend that we just operated on. Yep. Right there. And you can see how everything is very stretched out. Like, I really could get that to reach all the way up to the umbilicus if we needed to, but we don't need to do that anymore. So we're just gonna put that back in and make sure that we're not twisted. That looks like the best orientation I would say. So something like so. That's another part of the ovary. This right here is probably rectum. Yep, it feels like rectum. And then we already looked on this side, but for good measure, this is our right side. This is the ovary here. See that? And then there's your vessels and your tube sitting in normal orientation right there. That's your tube coming around. And this is your ovary here. And she's already passed puberty and has menses. So she's got more adult size organs here. But in like the prepubertal patients, these ovaries and structures are much smaller. That's her iliac artery right there. Yep, right there is the iliac artery. Mm-hm. And if we struggle, we could probably find the ureter, but we don't need to through this little incision here. And there really wasn't any fluid that we needed to sample when we got in. Hold that this way. Yeah, this side all looks good. No bleeding. Uterus. Good. Okay, you wanna take a feel? You wanna feel her uterus? Feels muscular. Yeah, she's a new woman. Normal. That's great. Okay, good. So nothing is damaged here. Nothing is bleeding. All right. So now we can take out our Alexis. Is it okay if we pass off the specimen? Yeah, thank you. Ooh. Hello.

CHAPTER 9

Okay, so now we're gonna close up our rectus sheath. And down here we're below the arcuate line, so you don't really have to worry about, but we can close the peritoneum if you want to. What do you wanna do, doctor? Yeah, let's close it. All right, snap. Pull snap on this. Let me get the Vicryl. And... Yeah, hold this if you can, Kayla. There you go. So we'll close in layers. If you're higher up in the abdomen, you have a posterior rectus sheath that you need to close because we are way down here on the lower abdomen, we're below the arcuate line, so there's no posterior rectus sheath, right? Mm-hm. Just peritoneum. Do you want Erin to take a picture and have her text you with it, or do you not want a picture of it? Oh, yeah, probably the parents would like that. Okay. Good idea. Thanks, Erin. Scissor? Now just hold it. Yeah, you wanna run it? I'll hold that. Yeah, I got the scissors. Yeah, I think this is the - yeah, just take big bites. Mm-hm. It's already healed. Oh. Somewhere in there. You can get a little bit of this too. Mm-hm. Do we have one or two PDS? Can we get a second one? Another of the Vicryl? PDS. Oh, PDS. I have two PDS. You do? Okay, good. And another Vicryl too. Yes. Cool. Yep. All right, relax just a little bit, Kayla. Yep. Yeah, there you go. So it's nice to put all the layers back together and then we'll give her a bunch of local here. Now is this intraperitoneal? Let's put that back. Yep. And then, let me take this from you. See what happens. And, yep. Mm-hm. One more and then... Yep. So it's nice what we were able to do with this incision here. Okay, sir. And we got the Ray-Tec out? Yes. Great. Needle down. All right. So those are her two muscle bellies there. Take another snap. Or do you have a microline? Now we'll close the rectus sheath. Yep. Lemme see. If we need to come from the bottom, it's all right. Take nice hefty bites. Yep, good. Take this off for a second one. Scissor. Can leave a little tail on this one. Can either do like an interrupted closure with a bunch of figures of eight, or you can do running closure. All right, before you get too far, I gotta put some local in here. Can I get the local, can you hold this for a second? Thank you. And a DeBakey. So we can kind of do like a little bit of a rectus sheath block here, kind of. We'll take some more. Yep. Thank you. So we'll see how she feels. She could potentially go home this afternoon. I think I put her in for a 23-hour stay, or she can go home tomorrow. I'm sure this is going to hurt. Thank you. Okay, I'll put the rest in after this layer. Is it 2-0 PDS? Yes. Great. Questions? Do these, like, is there like a chance that it reoccurs, or...? Mm-hm. Depending on the pathology. Okay. Teratomas are definitely known to recur even if they're benign. So we'll see what the path shows. But usually we do get a few serial ultrasounds. Okay. Of the pelvis. Good question, in follow up, and we see if there's any recurrence of cystic masses. All right, let's do one from the bottom. Okay. You can relax here. Stitch. PDS. I'm gonna take that off, I think. Mm-hm. Mm-hm. Thank you. Pickups. Here's the real fascia right here. Yep, see if we can get one more in there. Can I have another Rich? Yeah. I'll be going. This one isn't super necessary anymore. There you go, Kayla. Good? Mm-hm. All right, scissor. Let me just cut this needle off for you. Needle back. Thank you. And then we can close Scarpa's and do some deep dermals. Can we get a 4-0 Vicryl also? And then we'll do a subcuticular closure for the skin. It's amazing how different she looks, huh? Good. Take some local, he'll take the Vicryl. Skin now. We're on, yeah, Scarpa's and then skin. Two more layers. We're getting there. =Scarpa's first. I'm just gonna do a few interrupteds in the Scarpa's. Yeah, that sounds good. I'm gonna do a knotless in this sub-q. Yeah, if it lines up nicely. If you do some deep dermals, I bet that would work really well. And then we'll do Dermabond also. I think that's it. Mm-hm. Try not to sabotage you there. So what do you think it's gonna be? Any guesses? It looked like a simple cyst. You think it was a teratoma. Nah. I think it's probably a serous or a mucinous cystadenoma. Something benign. That fluid looked nice and simple. Yeah. It looks very simple on the MRI. And her tumor markers were normal, so that's also promising. So if they stay like small enough and they're not having symptoms, would you watch it or would you still take it out? So if there's any concerning features on the imaging, definitely take it out. If it's growing, take it out. And then a lot of articles will say if it's bigger than five centimeters, the risk of torsion is pretty high. So that's a good indication to take it out as well. But there's other things like hemorrhagic cysts, follicular cysts, like other very benign things you don't have to take out, right? But this is - probably has a little more to it than just those ones, right? They shouldn't get to be 24 centimeters, last time I checked. 2650 of fluid, wow. Plus whatever is in there. Yeah, exactly. Almost three liters. Yeah, that's impressive, right? I have to ask her how she feels. Even if it's simple fluid, that's almost like six pounds. Yeah. You have another Vicryl? Maybe like a 4-0 or something. I'll take 4-0, yep. And an Adson please. All right, so let's line up some of this deep dermal tissue here. Do you have another one for him? Another 4-0? Yeah, you can use a 3-0. Just take some of the tension off our skin closure here. Mm-hm. Slide down. All the way down. Yep. Good. What kind of block was he talking about doing? Do you remember? Mm. No. 30 of Marcaine. Hopefully she's not in too much pain. We send these patients home on routine Tylenol and ibuprofen. We recommend they take it as a scheduled medication for a few days. If they're still in the hospital and need some PRN morphine, that's okay. But we do not send them home on opioids. What kind of block were you thinking about? I gave her a bunch of local, but I'm just curious. Either a TAP block or a QL block. Yeah, I injected all through the fascia and the incision's like yay big or so. Love it. Hopefully she'll be all right. Nice. All right, we'll take the Monocryl. Let's get that knot to get under the skin there. So we can do a knotless closure. A lot of times these Monocryl knots will surface their way through the skin and cause a lot of distress. It is a dissolvable suture, so eventually it'll go away. But it's kind of nice to minimize that option. But you have to take the tension off of your skin edges before you do a knotless closure. So that's what we did all those deep dermal Vicryl sutures for. Thank you. Yeah, Dermabond sounds good. And we'll take the Foley out. And I'll give her two weeks is out of gym, sports. No lifting more than 10 pounds, a week without tubs or swimming. But she can shower. And then she can follow up with me in about three months with an ultrasound. All right, scissors, snap, wet and dry. You can cut right here. Get all this stuff off, yeah. Mm-hm. Scissors.

CHAPTER 10

The procedure went well. We were able to remove the ovarian cyst en bloc without getting into it, except for in the controlled fashion. We were also able to preserve her ovary, which is important for future fertility. The incision stayed small, which is good for her recovery. There was one part where the ovarian cyst was fairly stuck to the ovarian tissue itself, which always is expected and takes a little extra time. But it ended up coming off just fine. So she should do well. I'll follow up with her in the office in about three months. We'll do a pelvic ultrasound and see how that ovary is looking.