Patients with an adnexal mass should be placed on the operating table in the dorsal lithotomy position. A thorough examination under anesthesia is performed prior to opening the abdomen. The bladder should be emptied with a catheter. The surgeon should not be surprised to see a patient who has been referred for ovarian cyst who actually has a problem with urinary retention.

The abdomen, perineum, and vagina are surgically prepared. Although hysterectomy is rarely required, a malignancy can occasionally be encountered that will necessitate removal of the uterus. For this reason, it is best to have previously prepared the vagina with an aseptic soap solution.

The patient can be changed to the supine position or to the modified dorsal lithotomy position.

In general, a patient of menopausal age or above should have a lower midline incision for adnexal masses. The incidence of malignant disease is such that a lower midline incision will be required in the course of surgery, and this overrides the cosmetic advantages of a transverse incision. It is extremely difficult to adequately explore the abdomen for a malignant ovarian process through a Pfannenstiel or transverse incision. For younger patients in whom the chance of a malignant disease is quite low, a transverse incision or Pfannenstiel incision is acceptable. If a malignant disease is encountered in this younger age group, the transverse or Pfannenstiel incision can be closed and a midline incision can be made.

A lower midline incision is made.

The peritoneum is opened. The abdomen is thoroughly explored. Any suspicious tissue in the upper abdomen or along the aortic lymph nodes should be sent for a frozen section pathologic analysis.

A uterine elevator or a suture is placed in the fundus of the uterus to retract it anteriorly. Bilateral cysts are shown here: the one on the left appears to be more polypoid; the one on the right appears to be involved with significant amount of ovarian tissue.

The ovary is anchored by placing Babcock clamps on the suspensory ligament of the ovary. A scalpel is used to incise the ovarian capsule near the base of the cyst.

After incising the ovarian capsule with a scalpel, the surgeon uses delicate tissue forceps to elevate the capsule and small Metzenbaum scissors to dissect the alveolar tissue between the cyst and the ovarian capsule.

The margins of the ovarian capsule are held with Allis clamps. An adhesion on the cyst can be used to provide retraction, and the remaining cyst can be dissected out of the ovary with Metzenbaum scissors.

The ovarian capsule and base of the ovary are shown after the cyst has been removed. Hemostasis within the bed of the ovary can be controlled by clamping and electrocoagulating small bleeders.

The hemostatic running mattress suture is placed with a 3-0 synthetic absorbable suture starting at the upper pole where the suture is tied.

The mattress suture of the ovary has been completed.

When the lower pole of the ovary has been reached, the same suture is used to suture the edges of the ovary in a running Connell inverting suture.

The completed operation is shown.

Both ovarian cysts have been removed with the ovaries intact. The abdomen is closed in layers.