From the Guidelines
The correct answer is a. Don’t do it. When performing an appendectomy and discovering an incidental finding like a simple ovarian cyst, you should not proceed with removing the cyst without obtaining specific consent, and considering the low risk of malignancy in simple cysts, as suggested by the American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology 1, it is reasonable to monitor these cysts without surgical intervention. The original consent was only for an appendectomy, not for ovarian surgery, and extending the operation beyond what was agreed upon constitutes unauthorized treatment.
Key Considerations
- The risk of malignancy in simple ovarian cysts is low, especially in premenopausal women, with studies suggesting a risk of approximately 0.5% 1.
- The American College of Obstetricians and Gynecologists recommends that simple cysts up to 10 cm in diameter may be safely monitored using repeat imaging without surgical intervention, even in postmenopausal patients 1.
- Surgical consent is procedure-specific, and obtaining new consent for an additional procedure respects patient autonomy and follows ethical and legal requirements for informed consent.
Clinical Decision
Given the low risk of malignancy and the recommendation for monitoring simple cysts, the best course of action is not to remove the cyst during the appendectomy without new consent. However, considering the context of the question, which implies the procedure could be done without complication, the primary concern is the principle of obtaining consent for any additional surgical procedure beyond what was originally agreed upon. But, prioritizing the patient's safety and the low risk associated with simple cysts, the most appropriate action is to not remove the cyst during the appendectomy, unless there are exceptional circumstances that would necessitate immediate action, which is not indicated for simple ovarian cysts.
From the Research
Management of Incidental Ovarian Cyst During Appendectomy
- The presence of a simple ovarian cyst during an appendectomy can be managed without complications, as seen in a case report where a 13-year-old female underwent concomitant laparoendoscopic single-site ovarian cystectomy and appendectomy without any complications 2.
- The American College of Obstetricians and Gynecologists (ACOG) states that simple cysts found on ultrasound may be safely followed without intervention, even in postmenopausal women, suggesting that incidental ovarian cysts can be managed conservatively 3.
- However, it is essential to consider the patient's overall condition and the potential risks and benefits of managing the ovarian cyst during the appendectomy.
Considerations for Managing Incidental Ovarian Cyst
- The decision to manage an incidental ovarian cyst during an appendectomy should be based on the patient's individual circumstances and the surgeon's professional judgment.
- In the absence of any complications or concerns, it may be possible to manage the ovarian cyst without obtaining a new consent, as the primary goal is to complete the appendectomy safely and effectively.
- However, it is crucial to prioritize the patient's safety and well-being, and if there are any concerns or uncertainties, it may be necessary to seek additional guidance or consultation.
Available Options
- The available options for managing an incidental ovarian cyst during an appendectomy include:
- Proceeding with the management of the ovarian cyst without obtaining a new consent, if it can be done safely and without complications.
- Obtaining a new consent from the patient or their representative, if necessary.
- Seeking additional guidance or consultation from a colleague or specialist, if unsure about the best course of action.
- Documenting the incidental finding and the decision-making process in the patient's medical record, to ensure transparency and accountability.