What is the step‑by‑step surgical technique for excising a benign, non‑infected vaginal cyst (e.g., Bartholin, Gartner, or inclusion cyst) in an adult female, including pre‑operative preparation, intra‑operative steps, and postoperative care?

Surgical Excision of Vaginal Cyst: Step-by-Step Procedure

Complete transvaginal surgical excision is the definitive management for symptomatic vaginal cysts, with excellent anatomical outcomes and high patient satisfaction. 1

Pre-Operative Preparation

Patient Assessment and Imaging

• Perform perineal ultrasonography with an empty bladder to differentiate the cyst from adjacent structures (bladder, urethra) and confirm no communication with the lower urinary tract 2
• Transvaginal ultrasound or MRI may be used when the diagnosis is uncertain or to better characterize large or complex lesions 3
• Cystoscopy should be performed if there is any concern about urethral or bladder involvement to rule out urethral diverticulum or bladder pathology 2

Special Considerations

• Pay particular attention to cysts in women older than 40 years, or those that are fixed, associated with pain, or bleeding, as these features warrant heightened vigilance 3
• Obtain informed consent discussing risks including bleeding, infection, recurrence, and potential injury to adjacent structures (bladder, urethra, rectum depending on location) 1, 3

Anesthesia

• Spinal or general anesthesia is typically used for complete excision 2
• Local anesthesia may be considered for smaller, superficial cysts in select cases 3

Intra-Operative Surgical Technique

Positioning and Exposure

• Position the patient in dorsal lithotomy with adequate lighting and exposure 1
• Insert a weighted speculum or retractors to visualize the vaginal wall and identify the cyst 1

Incision and Dissection

• Make a longitudinal or transverse incision directly over the most prominent portion of the cyst through the vaginal mucosa 1, 2
• Carefully dissect the vaginal epithelium away from the cyst wall using sharp and blunt dissection 2
• Identify the plane between the cyst wall and surrounding vaginal tissue, taking care to keep the dissection close to the cyst to avoid injury to the bladder (for anterior wall cysts) or rectum (for posterior wall cysts) 1, 2

Cyst Removal

• Excise the entire cyst intact when possible to prevent recurrence and allow complete histopathological examination 1, 3
• If the cyst ruptures during dissection, evacuate the contents and excise the entire cyst wall 3
• Ensure complete removal of the cyst wall, as incomplete excision may lead to recurrence 1

Closure

• Close the vaginal mucosa in a single or double layer using absorbable sutures (e.g., 2-0 or 3-0 polyglactin) 1
• Ensure hemostasis throughout the procedure 1
• A vaginal pack may be placed for 12-24 hours if there is concern about bleeding 3

Histopathological Examination

• Send all excised tissue for histopathological examination to confirm the diagnosis (Bartholin, Gartner, Müllerian, or inclusion cyst) and rule out malignancy 4, 5, 2

Post-Operative Care

Immediate Post-Operative Period

• Monitor for bleeding, urinary retention, and signs of infection 1
• Prescribe analgesics for pain control 3
• Prophylactic antibiotics may be considered based on institutional protocols 3

Activity and Hygiene

• Advise pelvic rest (no intercourse, tampons, or douching) for 4-6 weeks 3
• Encourage sitz baths for comfort and hygiene 3

Follow-Up Schedule

• Schedule follow-up at 6 weeks post-operatively to assess wound healing and symptom resolution 1
• Perform a second follow-up at 6 months to evaluate for recurrence 1
• Recurrence rates are low with complete excision 1, 3

Common Pitfalls and How to Avoid Them

• Do not mistake large vaginal cysts for cystocele or rectocele—perineal ultrasound with an empty bladder will differentiate these entities 2
• Avoid incomplete excision, which is the primary cause of recurrence; ensure the entire cyst wall is removed 1, 3
• Be aware that Bartholin cysts can occur in atypical locations (e.g., posterior vaginal wall), so do not rely solely on location for diagnosis 4
• Do not assume all vaginal cysts are benign—histopathological examination is mandatory, especially in women over 40 years 3