Journal of Pediatric Surgery (2008) 43, 1353–1357
www.elsevier.com/locate/jpedsurg
Is the stripping technique a tissue-sparing procedure in
large simple ovarian cysts in children?
Francesco Arena a , Carmelo Romeo a,⁎, Marco Castagnetti b , GianFranco Scalfari a ,
Marcello Cimador b , Pietro Impellizzeri a , Daniela Villari c ,
Fabrizio Zimbaro d , Enrico DeGrazia b
a
Department of Medical and Surgical Pediatric Sciences–Unit of Minimally Invasive Pediatric Surgery,
University of Messina, 98125 Messina, Italy
b
Department of Pediatric Surgery–Istituto Materno Infantile, University of Palermo, Palermo, Italy
c
Department of Human Pathology–Unti of Histopathological Diagnosis, University of Messina, 98125 Messina, Italy
d
Department of Radiological Sciences University of Messina, 98125 Messina, Italy
Received 28 June 2007; revised 7 November 2007; accepted 9 November 2007
Key words:
Ovary;
Conservative surgery;
Stripping technique
Abstract
Background: Stripping of the cystic wall is performed by gynecologists to treat large ovarian cysts.
Information in the pediatric population is poor. We prospectively evaluated the pathologic specimens of
large ovarian cyst to determine whether the stripping technique is a tissue-sparing procedure even in
this age.
Methods: We evaluated 5 patients. Samples were taken from the intermediate part of the cystic wall and
from the layer covering the cyst during excision. The presence of ovarian tissue adjacent to the cyst wall,
and the morphological features of the surrounding tissue were both evaluated. Pelvic ultrasound followup was also performed.
Results: Patients' mean age was 4.5 years (7 days to 12 years). All cysts were removed because all were
symptomatic. The mean diameter was 86.6 mm (74-100 mm). Cysts were follicular in 2 cases, serous in
other two, and endometriotic in 1 case. Adjacent ovarian tissue was present in 1 of 5 specimens and was
approximately 1 to 2 mm in thickness. The layer adjacent to the cystic wall always appeared as normal
ovarian tissue. Ultrasound scans at follow-up revealed presence of ovarian tissue.
Conclusion: The stripping procedure for large ovarian cyst excision allows to spare the adjacent normal
ovarian tissue even in pediatric age because ovarian tissue is rarely excised with the cyst wall during
the procedure.
© 2008 Elsevier Inc. All rights reserved.
⁎ Corresponding author. Department of Medical and Surgical Pediatric
Sciences, Unit of Minimally Invasive Pediatric Surgery, Policlinico
Universitario, Via C. Valeria Pad. NI, 98125 Messina, Italy.
E-mail address: [email protected] (C. Romeo).
0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2007.11.014
Management of large ovarian cysts in children is
controversial and complicated by a poorly understood natural
history [1,2]. Surgery should be undertaken in the presence of
symptoms, of tendency of the cyst to increase in size, or of
failure of the cyst to resolve or shrink off spontaneously [3].
1354
Table 1
F. Arena et al.
Age at operation of the patients studied, cyst size and location, indications for surgery, and histological classification
Case
Age at surgery
Cyst size (mm)
Side
Symptoms
Histology
1
2
3
4
5
7d
3y
3 y 6 mo
4y
12 y
84
74
85
100
90
R
R
L
R
R
Respiratory distress
Abdominal pain
Abdominal pain
Abdominal pain
Persistent after 1 year F-U
Follicular cyst
Follicular cyst
Serous cyst
Serous cyst
Endometriotic cyst
× 80
× 68
× 56
× 80
× 80
R indicates right; L, left, F-U, follow-up.
Operative treatment has also been suggested to be appropriate
in asymptomatic patients with ovarian cysts larger than 5 cm
in diameter or greater than 13 mL in volume [4] to reduce the
risk for serious complication and rescue ovarian tissue [5].
Ovarian cysts selected for treatment can be aspirated
percutaneously or laparoscopically, unroofed or resected
laparoscopically, aspirated, and then resected via a minimally
invasive laparotomy or treated with an open procedure [6].
In any case, aim of the procedure should be to spare as much
ovarian tissue as possible while minimizing the risk for
cyst recurrence.
Stripping of the cystic wall is a technique used by
gynecologists for the treatment of large benign ovarian cysts
[7]. The procedure can be performed via either an open [8] or
laparoscopic approach [7] and even if ovarian tissue is not
macroscopically evident. Evidence shows that this is a tissuesparing procedure.
To our knowledge, such a technique has not been reported
in children yet.
We report our experience with surgical stripping of large
benign ovarian cysts in 5 patients. The study also includes
a histologic analysis of the excised cystic tissue to investigate
its morphology and verify whether ovarian tissue is
inadvertently excised together with the cystic wall. We finally
report the ultrasound scan (US) follow-up of the residual
ovarian tissue left behind after the stripping of the cyst.
After excision of the entire cyst wall, a 2 × 2-cm sample was
taken from the intermediate part of the specimen. This was
midway between the point where the stripping was started and
finished, usually at the site of ovarian adhesion to the ovarian
fossa and the ovarian hilus, respectively. The latter portions
were excluded because these are the points where the cyst wall
and the ovarian parenchyma are most tightly adherent, possibly
yielding noncomparable specimens.
The institutional review board approved the study, and
all biopsies were undertaken always after informed consent
was obtained.
The same pathologist blinded to the clinical and surgical
history of the patient evaluated both ovarian and cyst
samples. The remaining part of the cyst wall was sent for
routine histologic examination. Presence of ovarian tissue
adjacent to the cyst wall was evaluated, and if present, the
morphologic characteristics of the tissue were graded on a
semiquantitative scale from 0 to 4 (0, complete absence of
follicles; 1, primordial follicles only; 2, primordial and
primary follicles; 3, some secondary follicles; 4, pattern of
primary and secondary follicles as seen in normal ovary) [9].
All patients underwent a follow-up pelvic US 6, 12, and
18 months after surgery.
1. Materials and methods
Between January 2004 and December 2005, 5 patients,
7 days to 12 years old, underwent excision of large ovarian
simple cysts (Table 1). Preoperatively, all patients underwent
a plain abdominal x-ray, US, computed tomographic scan,
and evaluation of β human chorionic gonadotropin (β-HCG)
and α fetoprotein (α-FP) levels.
In all cases, a laparotomy was performed via a
Pfannenstiel incision. The cyst wall was stripped off the
remaining ovarian parenchyma through traction exerted in
opposite directions by using 2 atraumatic grasping forceps.
When necessary, hemostasis was achieved applying the
bipolar forceps on the ovarian parenchyma after excision of
the cystic wall. A 2 × 2-mm biopsy specimen was harvested
from the ovarian cortex for histologic examination. The
cortex was then reconstructed with absorbable sutures.
Fig. 1 Full thickness specimen from a serous cyst wall. Section of
a surface epithelial cyst wall, consisting of a single layered cuboidal
epithelium. Follicular structures are absent in the pericystic stroma
(Hematoxylin and eosin, original magnification × 80).
Stripping technique in ovarian cysts in children
1355
2. Results
Abdominal US revealed in all cases a simple anechoic
cyst, with an imperceptible wall, no solid components, and
no fluid debris levels; computed tomographic scan confirmed the US findings.
In case 1, the ovarian cyst was diagnosed at the 34th week
of gestation. The initial diameter was 46 mm but increased
progressively during pregnancy. After birth, the cyst
measured 84 mm appearing as simple cyst without
calcifications but symptomatic with respiratory distress.
Cases 2, 3, and 4 were admitted for severe abdominal pain
with episodes of bilious vomiting. On examination, an
abdominal mass arising from the pelvic fossa and reaching
the transverse umbilical line was evident. Case 5 underwent
surgical resection of a large ovarian cyst on the right side
because the asymptomatic cyst increased in size during
follow-up (Table 1).
In all the cases, tumor markers were within normal ranges.
At laparotomy, no ovarian tissue was macroscopically
evident in 4 of 5 cases. A thin rim of ovarian tissue rich in
small follicles was identified in case 4.
All procedures were accomplished successfully without
any intraoperative or postoperative complication.
Histologic classification of the cysts was as follows:
follicular cyst in 2 cases (cases 1 and 2, 40%), serous cyst in
Fig. 3 Full thickness specimen from the cyst wall of follicular
cyst, obtained by using the stripping technique at laparotomy. Three
primordial follicles are evident inside pericystic ovarian gonadal
stroma (Hematoxylin and eosin, × 80).
2 cases (cases 3 and 4, 40%), and endometriotic cyst in one
case (case 5, 20%). Routine histologic examinations of the
entire specimen confirmed the blinded histologic diagnosis
in all cases.
Adjacent ovarian tissue was present in 1 of 5 specimens
(case 2). This ovarian tissue was approximately 1 to 2 mm
in thickness. No ovarian tissue was found in 4 specimens
(Figs. 1 and 2). With regard to morphologic characteristics,
the ovarian tissue excised with the cyst wall was graded
as 0 in 4 of 5 specimens and 1 in the remaining specimen
(case 2) (Fig. 3).
The small biopsy specimens from the ovarian tissue
cortex always highlighted ovarian parenchyma with regular
features for age.
Six months after surgery, the US revealed presence of
ovarian tissue on the operated side. The size of ovaries at
12-month follow-up is reported in Table 2. The operated
ovary always appeared to increase in size with respect to the
contralateral one, and in case 4, both ovaries appeared to be
Table 2
Case
Size of ovaries 12 months after operation
Size of right ovary
mm
Fig. 2 Endometrioid cyst of the ovary in a 12 years old girl. The
cyst wall is lined by secreting columnar cells, which lay on scanty
endometrial stroma. No evidence of follicles. (Hematoxylin and
eosin, × 160).
1
2
3
4
5
20 ×
24 ×
20 ×
18 ×
28 ×
Size of left ovary
cm
10 × 6.6
20 × 18
11 × 10
9 × 16
24 × 23
3
1.7
4.3
1.1
1.3
8
mm
cm3
10.9 × 5.6 × 5
24 × 17 × 5
25 × 13 × 10
11 × 14 × 8
24 × 24 × 16
0.3
1.2
1.7
0.7
5
1356
multifollicular. At 18 months from surgical excision, no
relapse has been documented.
3. Discussion
As with neonates, most cysts in prepubertal child are
follicular in origin and will resolve spontaneously [1]. The
distinction between a pathologic cyst and a physiologic
mature follicle is based on size alone, with cyst larger than
2 cm considered as pathologic [9]. In prepubertal age, it is
also possible to observe endometriotic cyst or serous cysts, as
confirmed by our experience. These types of cysts have a
different behavior from simple follicular cyst because they
tend to grow. The decision as to intervene has to be based on
cyst size, ultrasound characteristics, and clinical symptoms
[6]. Nussbaum et al [10] have developed ultrasound diagnostic criteria differentiating simple from complex ovarian
cysts. A simple cyst is anechoic, with an imperceptible wall,
no solid components, and no fluid debris levels. A
complicated cyst contains a fluid debris level, retracting
clot, septa, or is completely filled with echoes producing a
solid masslike appearance [10,11]. In general, simple
unilocular cysts have a very low risk for malignancy [12].
Moreover, it has been hypothesized that large simple cysts
are at higher risk of torsion, and surgery is meant to reduce
the potential for serious complications [5,6].
With large ovarian cysts, reported complications include
compression of the ureters [13], reduction of aortocaval
blood flow [14], and displacement [15] or perforation [16] of
the colon. Aspiration of large ovarian cysts during the
neonatal period has been reported to be successful, without
recurrence of the cyst [2,17].
If surgery is chosen, the laparoscopic approach is
nowadays generally favored even in infants [17]. Whether
a laparoscopic technique is chosen, simple cysts should
undergo fenestration [17].
When surgical treatment is performed, every attempt
should be made to rescue as much gonad tissue as possible.
Indeed, even if no ovary is macroscopically visible, ovarian
tissue may still be present, and surgery should be limited to
removal or unroofing of the cyst [1,18].
Gynecologists have introduced the stripping technique for
the enucleation of benign large ovarian cysts. This procedure
can be performed through an open or a laparoscopic
approach and even in the absence of macroscopic evidence
of any ovarian tissue. Such a technique allows to rescue at
maximum the existing ovarian tissue. Our experience shows
this technique to be feasible in children, too, irrespective of
age. Indeed, we accomplished the procedure successfully
and without intraoperative or postoperative complication in
neonates, infants, and prepubertal patients.
Nature of the ovarian cysts has been suggested to be a key
factor in the success of the procedure in adults. When the cyst
does not have a proper capsule, such as in the case of
F. Arena et al.
endometriomas, the risk to remove ovarian tissue together
with the cyst increases by 9 times [8].
As the primary goal of the stripping technique is to
preserve ovarian tissue, we performed a histologic analysis
of the cyst wall and the adjacent parenchyma. Only in one
patient, a thin rim of ovarian tissue, containing few follicles,
was found attached to the removed cyst. The ovarian
parenchyma that was left behind, instead, always displayed a
normal histologic finding and a normal appearance at followup USs.
Besides, many technical details may be of relevance to
spare ovarian tissue. For instance, careful use of electrosurgical coagulation on the residual tissue after excision of
the cyst seems to be key to avoid further damage to the
ovarian tissue. However, when appropriate technique is used,
small vessels may be identified and safely coagulated with
bipolar forceps. Similarly, use of microsurgical technique,
such as that available during the laparoscopic procedure
seems to allow better results.
We do not favor instead the practice of aspirating the cyst
to allow delivery via a minimally invasive approach for 2
reasons. To begin with, dissection of the cysts is easier as
long as it is full. Secondly, even despite normal tumor
markers, it is possible for the cysts to be malignant. Hence,
we stress the importance of a proper patient selection and
appropriate surgical technique consistent with the principles
of ontological surgery.
In conclusion, the stripping procedure for simple large
ovarian cyst excision appears to be an organ-preserving
procedure even in pediatric age because the ovarian tissue
was never inadvertently excised with the cyst wall.
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