What operative technique is recommended to achieve hemostasis of the ovarian bed after an ovarian‑sparing cystectomy performed during a post‑cesarean delivery while preserving ovarian function?

Operative Technique for Hemostasis After Ovarian-Sparing Cystectomy During Post-Cesarean Delivery

Suturing is the recommended hemostatic technique for the ovarian bed after ovarian-sparing cystectomy to preserve ovarian function, as it causes significantly less damage to ovarian reserve compared to bipolar electrocoagulation or other energy-based methods.

Primary Hemostatic Approach

Use suturing as the first-line hemostatic technique for the ovarian bed after cystectomy. 1, 2, 3, 4

• Suturing demonstrates superior preservation of ovarian reserve compared to bipolar coagulation, with significantly higher anti-Müllerian hormone (AMH) levels at 12 months post-surgery (weighted mean difference: -1.10,95% CI: -1.83 to -0.38) 2
• The decline rate of AMH is significantly lower with suturing (24.6%) compared to bipolar coagulation (42.2%) at 3 months post-operatively 3
• Suturing preserves antral follicle count, peak systolic velocity, and ovarian volume better than energy-based methods 4

Suturing Technique Specifics

• Use barbed suture for hemostasis of the ovarian bed, as it facilitates efficient closure without requiring knot-tying during laparoscopic or open procedures 5
• Apply continuous suturing to reapproximate the ovarian edges after cyst removal 1, 4
• This technique avoids thermal damage to surrounding ovarian tissue that occurs with electrocoagulation 3, 4

Alternative Hemostatic Agents (Second-Line)

If suturing alone is insufficient or technically challenging, hemostatic sealants are preferred over bipolar coagulation. 2

• Hemostatic sealants show less decline in ovarian reserve compared to bipolar coagulation (decline rate difference: -17.02%, 95% CI: -22.81 to -11.23) 2
• Hemostatic agents are easier to apply and may be particularly useful when complete hemostasis cannot be achieved with suturing alone 5
• Common agents include fibrin sealants and oxidized regenerated cellulose 1, 2

Bipolar Electrocoagulation (Last Resort Only)

Reserve bipolar electrocoagulation only for persistent bleeding after suturing and hemostatic agents have been attempted. 5, 3

• Bipolar coagulation causes the most significant reduction in ovarian reserve among all hemostatic methods 1, 2, 3, 4
• If bipolar must be used, apply minimal energy at the lowest effective setting and for the shortest duration possible 3
• Avoid extensive coagulation of the ovarian cortex, as this destroys primordial follicles 4

Ultrasonic Energy

Avoid ultrasonic energy devices, as they provide no advantage over bipolar coagulation in preserving ovarian function. 1

• Ultrasonic energy was not superior to bipolar energy in preserving AMH levels or antral follicle count 1
• Both energy modalities cause thermal damage to ovarian tissue 4

Integration with Cesarean Delivery Technique

When performing ovarian cystectomy during cesarean delivery, apply the same hemostatic principles while incorporating cesarean-specific recommendations:

• Use blunt expansion rather than sharp extension of the uterine hysterotomy to minimize overall surgical blood loss 6
• Administer tranexamic acid 1g IV over 10 minutes prior to skin incision to reduce bleeding risk, particularly important given the dual surgical procedures 6
• Maintain perioperative euvolemia to optimize uterine and ovarian perfusion 6
• Have cell salvage equipment immediately available given the increased bleeding risk with combined procedures 6

Critical Pitfalls to Avoid

• Do not default to bipolar coagulation for convenience – the long-term impact on ovarian reserve is substantial and may affect future fertility 3, 4
• Avoid excessive thermal energy application – even brief bipolar coagulation causes irreversible damage to primordial follicles in the ovarian cortex 4
• Do not rely on visual estimation of blood loss – use volumetric and gravimetric measurement techniques 6
• Monitor fibrinogen levels if bleeding exceeds 1000 mL, as hypofibrinogenemia occurs in 5% of cases at this threshold 6

Postoperative Considerations

• Remove urinary catheter immediately after surgery if strict urine output monitoring is not required, as this reduces infection risk (0.5% vs 5.7% with delayed removal) and promotes early mobilization 7, 8
• Apply sequential compression devices starting preoperatively and continue until fully ambulatory to prevent venous thromboembolism 7
• Encourage early mobilization as soon as regional anesthesia wears off 7