What is the appropriate management of a simple ovarian cyst discovered during an appendectomy in a 12-year-old female, given that it can be efficiently treated without increasing operation time?

From the Guidelines

The correct approach in this scenario is to leave the simple ovarian cyst and adhere to the consent obtained for appendectomy only (option A). When discovering an incidental finding during surgery, especially in a pediatric patient, it is ethically and legally required to respect the boundaries of the original consent. Simple ovarian cysts in adolescents are often functional and resolve spontaneously, so immediate intervention is rarely necessary.

Key Considerations

• The risk of malignancy in simple ovarian cysts is extremely low, especially in premenopausal women, as demonstrated by studies such as 1 and 1.
• Proceeding with ovarian surgery without specific consent would constitute battery and violate patient autonomy.
• The proper course of action would be to complete the appendectomy, document the incidental finding, and then discuss the ovarian cyst with the patient's parents postoperatively, arranging appropriate follow-up with a gynecologist if needed.

Supporting Evidence

• A recent meta-analysis by Parazzini et al 1 demonstrated that in 987 unilocular cysts removed surgically in premenopausal women, the risk of malignancy was 0.6%.
• The American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology, has recommended that “Simple cysts up to 10 cm in diameter on transvaginal ultrasonography performed by experienced ultrasonographers are likely to be benign and may be safely monitored using repeat imaging without surgical intervention, even in postmenopausal patients” 1.

Clinical Implications

• This approach respects patient rights while ensuring proper medical care for both the primary condition and the incidental finding.
• It also avoids unnecessary surgical intervention and potential complications, prioritizing the patient's quality of life and minimizing morbidity and mortality.

From the Research

Management of Simple Ovarian Cyst During Appendectomy

• The discovery of a simple ovarian cyst during an appendectomy in a 12-year-old female raises questions about the best course of action to prevent future surgery.
• According to the available evidence, the management of ovarian cysts depends on various factors, including the size of the cyst, the presence of symptoms, and the patient's overall health 2, 3.
• In this scenario, since the cyst is simple and can be efficiently removed without increasing the operation time, the best option would be to remove the cyst while preserving the ovary, as this approach can help prevent future complications and reduce the risk of recurrence 4.

Considerations for Ovarian Cyst Management

• The decision to remove the cyst should be based on the principle of doing what is best for the patient, taking into account the potential risks and benefits of the procedure 2, 3.
• It is essential to note that the patient's age and the fact that she is undergoing an appendectomy already may influence the decision-making process.
• However, the available evidence suggests that removing the cyst and preserving the ovary is a viable option that can help prevent future surgery and reduce the risk of complications 4.

Preventing Future Surgery

• Removing the cyst and preserving the ovary can help prevent future surgery by reducing the risk of recurrence and minimizing the potential for future complications 4.
• Additionally, this approach can help avoid the need for future laparotomies, which can be associated with increased risks and complications 2, 3.
• By taking a proactive approach to managing the ovarian cyst, the surgeon can help ensure the best possible outcome for the patient and reduce the risk of future surgical interventions 4.