What is the recommended technique for performing an ovarian cystectomy during a cesarean delivery for a pregnant patient with a benign‑appearing adnexal mass?

Technique for Oophorocystectomy During Cesarean Section

When a benign-appearing adnexal mass ≥10 cm is discovered during cesarean delivery, proceed with concurrent surgical removal using ovary-sparing cystectomy to avoid a second surgery, obtain definitive histopathology, and eliminate postpartum torsion risk. 1

Indications for Concurrent Removal

• Remove any mass ≥10 cm immediately because torsion risk rises sharply at this threshold (mean torsed mass size ≈10 cm), and delayed removal increases technical difficulty 1
• Proceed with removal if the mass persisted throughout pregnancy, even when asymptomatic 1
• Any suspicious ultrasound features (irregular solid components, thick septa, ascites, papillary projections) mandate intra-operative excision 1
• Confirm adequate surgical expertise before proceeding 1

Concurrent removal during cesarean is safer than postponing: fetal loss occurs in 1% versus 5%, and preterm birth in 4% versus 12% for elective versus emergent procedures 1

Pre-Operative Preparation

• Ensure obstetrical anesthesiologist involvement with review of pregnancy-specific features and comorbidities 2
• Perform surgery at an institution with obstetrical, neonatal, and pediatric services 2
• Obtain informed consent that includes discussion of potential oophorectomy if ovarian preservation is not feasible 2
• Consider left lateral tilt positioning to maintain hemodynamic stability and placental perfusion, though right lateral tilt may be used if exposure is improved 2

Surgical Technique

Access and Exposure

• The cesarean incision provides direct access to the adnexa without need for additional ports 2
• After delivering the infant and placenta, inspect both adnexa systematically 2
• Mobilize the uterus to optimize visualization of the affected adnexa 2

Cystectomy Procedure

• Perform ovary-sparing cystectomy rather than oophorectomy whenever technically feasible to preserve ovarian function 1, 3
• Make a linear incision on the ovarian cortex over the most prominent portion of the cyst 3
• Develop the cleavage plane between cyst wall and normal ovarian tissue using blunt and sharp dissection 3
• If the cyst is large (>10 cm), perform controlled aspiration before removal to facilitate extraction through the cesarean incision 4

Protected Aspiration Technique (for large cysts)

• Thoroughly dry the cyst wall before aspiration 4
• Apply surgical glue to the cyst wall and cover with a protective membrane (sterile glove material) 4
• Place a purse-string suture through the membrane and superficial ovarian wall 4
• Incise the ovarian wall within the purse-string, insert aspiration cannula, and tighten the suture to create a closed system 4
• After complete aspiration, tighten and close the membrane to prevent spillage 4

Specimen Removal

• Place the intact cyst or aspirated cyst wall in an impermeable retrieval bag before removal to prevent chemical peritonitis, potential malignant cell dissemination, and port-site implantation 5, 4
• Remove the specimen through the cesarean incision 4

Hemostasis and Closure

• Achieve meticulous hemostasis of the ovarian bed using bipolar electrocautery 2
• Close the ovarian cortex with fine absorbable suture if needed, or allow secondary healing 3
• Irrigate the pelvis thoroughly and inspect for bleeding 3

Intra-Operative Monitoring

• Maintain maternal normocapnia through standard anesthetic monitoring 2
• Monitor for maternal hypotension, which reduces placental blood flow and causes fetal hypoxia 2
• Recognize that fetal distress can occur before maternal deterioration 2

Post-Operative Management

• Administer prophylactic antibiotics per standard cesarean protocol 2
• Provide adequate analgesia; most patients require minimal additional pain medication beyond standard post-cesarean analgesia 3
• Send all specimens for histopathologic examination to confirm benign diagnosis 1
• If final pathology reveals malignancy (≈2% risk), arrange urgent gynecologic oncology consultation 1

Critical Pitfalls to Avoid

• Do not delay removal of ≥10 cm masses for postpartum management—the risk of emergent torsion (3–12%) outweighs the minimal added surgical time 1
• Do not assume "benign-appearing" lesions are definitively benign—38–60% of torsed masses show normal Doppler flow, and ultrasound sensitivity for malignancy is only 62–92% 1
• Do not remove the cyst without using a retrieval bag—spillage of dermoid contents causes severe chemical peritonitis, and potential malignant cells may implant 5, 4
• Do not proceed if surgical expertise is inadequate—complex cases require experienced hands to preserve ovarian tissue and avoid complications 1
• Do not perform oophorectomy routinely—ovary-sparing cystectomy preserves fertility and hormonal function in reproductive-age women 3

Special Considerations by Cyst Type

• Dermoid cysts (≈32% of pregnancy-related masses): Use protected aspiration technique and retrieval bag to prevent lipoid peritonitis from sebaceous material 1, 4
• Cystadenomas (≈19% of masses): These are typically amenable to cystectomy with good cleavage planes 1
• Endometriomas: Excise the cyst wall completely rather than simple drainage to reduce recurrence 6