What is the best technique to achieve hemostasis of the ovarian bed after cyst removal during a post‑cesarean surgery while preserving ovarian function?

Hemostasis of the Ovarian Bed After Cyst Removal

Suturing is the superior technique for achieving hemostasis of the ovarian bed after cystectomy, as it preserves ovarian function significantly better than bipolar coagulation or other surgical energy devices. 1

Primary Hemostatic Technique: Suturing

Use absorbable sutures to achieve hemostasis of the ovarian bed rather than bipolar coagulation or ultrasonic energy. 1 A systematic review of 1,133 patients demonstrated that suturing provides superior preservation of ovarian function compared to surgical energy, with improvements in four of eight ovarian reserve markers including anti-Müllerian hormone levels, antral follicle count, peak systolic velocity, and ovarian volume. 1

Technical Approach to Suturing

• After stripping the cyst wall using the stripping technique, carefully inspect the ovarian stromal wound bed for bleeding points. 2
• Place interrupted or running absorbable sutures to reapproximate the ovarian tissue and achieve hemostasis. 1
• Ensure meticulous hemostasis before completing the procedure to minimize adhesion formation. 3

Alternative Hemostatic Agents

Gelatin-Thrombin Matrix Sealant (FloSeal)

Consider using gelatin-thrombin matrix sealant as an alternative to both suturing and bipolar coagulation when preservation of ovarian tissue is paramount. 2 This technique avoids additional ovarian tissue damage from heat or sutures, which is particularly important for reproductive function. 2

• Apply the gelatin-thrombin matrix directly to the bleeding ovarian stromal wound bed after cyst removal. 2
• This approach eliminates the need for bipolar coagulation or suturing entirely. 2
• The technique is especially valuable in women desiring future fertility, as it minimizes surgery-induced ovarian tissue damage. 2

Techniques to Avoid

Bipolar Coagulation

Minimize or avoid bipolar coagulation for hemostasis of the ovarian bed, as it causes thermal damage that impairs ovarian reserve. 1 While bipolar energy is commonly used, the systematic review evidence clearly demonstrates inferior preservation of ovarian function markers compared to suturing. 1

Ultrasonic Coagulation

Avoid ultrasonic coagulation for the same reasons as bipolar energy—it causes tissue damage that compromises ovarian function. 1

Adjunctive Measures for Adhesion Prevention

After achieving hemostasis, consider wrapping the treated ovary with Interceed absorbable adhesion barrier. 3 A randomized study of 17 patients demonstrated that 76% of Interceed-treated ovaries remained adhesion-free compared to only 35% of untreated control ovaries (P < 0.05). 3 The area of ovary involved with adhesions was reduced from 20% in controls to 6% with Interceed treatment. 3

Specific Considerations for Post-Cesarean Surgery

Blood Conservation During Concurrent Procedures

• Administer tranexamic acid 1g IV over 10 minutes prior to skin incision to minimize blood loss, particularly important when performing ovarian surgery concurrent with cesarean delivery. 4
• Maintain perioperative euvolemia to optimize uterine and ovarian perfusion. 4
• Have cell salvage equipment immediately available if abnormal bleeding occurs. 4

Monitoring During Combined Procedures

• Measure blood loss cumulatively using volumetric and gravimetric techniques rather than visual estimation. 4
• Monitor fibrinogen levels if bleeding exceeds 1000 mL, as hypofibrinogenemia occurs in 5% of hemorrhages at this threshold. 4

Common Pitfalls to Avoid

• Do not rely primarily on bipolar coagulation even though it is faster and more commonly used—the long-term impact on ovarian function is significant. 1
• Do not skip meticulous hemostasis before closure, as inadequate hemostasis increases adhesion formation risk. 3
• Do not use excessive thermal energy thinking it provides better hemostasis—suturing is both more effective and preserves function. 1
• Do not forget adhesion barrier placement after achieving hemostasis, as this significantly reduces postoperative adhesion formation. 3