What are the steps for a Bartholin gland excision procedure?

Bartholin Gland Excision: Surgical Technique

Complete surgical excision of a Bartholin gland is rarely indicated and should be reserved for cases of suspected malignancy (particularly in women over 40), recurrent cysts/abscesses failing conservative management, or when adenocarcinoma cannot be excluded. 1 For the vast majority of Bartholin gland pathology, less invasive approaches such as Word catheter placement or marsupialization are preferred and should be attempted first. 2, 3, 4

Indications for Complete Excision

• Suspected malignancy: Any Bartholin gland mass in a woman over 40 years requires biopsy or excision to exclude adenocarcinoma, as this rare malignancy can arise from Bartholin gland tissue. 1
• Recurrent disease after multiple failed conservative treatments: When Word catheter placement, marsupialization, or other drainage procedures have failed repeatedly. 5, 4
• Solid mass rather than cystic lesion: Solid masses require tissue diagnosis to exclude malignancy. 1

Preoperative Preparation

• Anesthesia: General or regional anesthesia is required, as local anesthesia is inadequate for complete gland excision (unlike Word catheter placement which can be done under local). 3, 4
• Patient positioning: Dorsal lithotomy position with adequate exposure of the vulva. 1
• Antibiotic prophylaxis: Consider perioperative antibiotics given the proximity to the rectum and high bacterial colonization of the vulvar area. 1

Surgical Steps

1. Incision Placement

• Make a vertical incision over the medial aspect of the labium majus, directly over the cyst or gland, extending from the hymenal ring posteriorly for approximately 3-4 cm. 1
• The incision should be placed on the mucosal (inner) surface of the labium majus rather than the hair-bearing skin to minimize visible scarring. 1
• Avoid tunneling—the incision should be made as close to the pathology as possible to achieve optimal exposure. 1

2. Dissection and Gland Identification

• Carefully dissect through the subcutaneous tissue to identify the Bartholin gland, which lies deep in the posterolateral aspect of the vestibule. 1
• The gland is typically located at the 4 o'clock and 8 o'clock positions relative to the vaginal opening, deep to the bulbocavernosus muscle. 1
• Develop a plane between the gland/cyst and surrounding tissues using blunt and sharp dissection. 5
• Exercise extreme caution to avoid injury to the bulbocavernosus muscle, vestibular bulb (erectile tissue with significant vascularity), and rectum. 1

3. Hemostasis

• Meticulous hemostasis is critically important throughout the procedure, as hematoma formation in this highly vascular area can lead to significant postoperative complications including infection and prolonged healing. 1
• Use electrocautery judiciously and ligate any significant vessels with absorbable suture. 1
• The vestibular bulb is particularly prone to bleeding and must be handled carefully. 1

4. Complete Gland Removal

• Remove the entire gland and cyst in one piece to allow for complete pathologic examination and accurate margin assessment. 1
• Removal in multiple fragments should be avoided as this precludes accurate pathologic evaluation, particularly if malignancy is suspected. 1
• Ensure the duct is excised completely to prevent recurrence. 5

5. Wound Closure

• Do not place drains in the excision cavity, as drains increase infection risk and do not improve outcomes. 1
• Close the dead space with interrupted absorbable sutures (such as 3-0 or 4-0 polyglycolic acid) in the deeper layers. 1
• Close the mucosa with subcuticular absorbable sutures to optimize cosmetic results and minimize scarring. 1
• Allow the cavity to fill with serum rather than attempting to obliterate all dead space, as this produces better cosmetic results. 1

Postoperative Management

• Pain control: Prescribe adequate analgesia, as this procedure is significantly more painful than simple drainage procedures. 3, 4
• Sitz baths: Recommend warm sitz baths 2-3 times daily to promote healing and comfort. 4
• Activity restrictions: Avoid intercourse and tampon use for 4-6 weeks until complete healing. 3
• Pathologic examination: All excised tissue must be sent for histopathologic examination to exclude malignancy. 1

Critical Pitfalls to Avoid

• Never perform complete excision as first-line treatment for simple Bartholin cysts or abscesses—Word catheter placement has 97% success rate and is far less morbid. 3
• Avoid injury to the rectum: The posterior wall of the excision cavity is in close proximity to the rectum, and rectal injury can lead to rectovaginal fistula. 1
• Do not underestimate blood loss: The vestibular bulb and surrounding tissues are highly vascular, and significant hemorrhage can occur. 1
• Never tunnel from a distant incision: This increases tissue trauma, worsens cosmesis, and makes the procedure more difficult. 1
• Avoid excision in women under 40 with typical cystic disease: These patients should be managed with conservative drainage procedures unless there are specific indications for excision. 1, 5, 4