Giant Ovarian Cysts Treated by Single-Port Laparoscopic Surgery: A Case Series

Giant Ovarian Cysts Treated by Single-Port Laparoscopic Surgery: A Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Giant Ovarian Cysts Treated by Single-Port Laparoscopic Surgery: A Case Series Lili Jiang, Kuiran Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-433441/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Dec, 2021 Read the published version in Frontiers in Oncology → Version 1 posted You are reading this latest preprint version Abstract Background: Ovarian cysts are very common diseases of female reproductive system. Giant ovarian cysts refer to the tumors with diameters greater than 10 cm. In recent years, due to the development of clinical diagnosis, imaging modalities and the improvement of patients' cognition of the diseases, the occurrence of giant ovarian cysts become rare. The purpose of this study was to show a new operation method of single-port laparoscopy to treat giant ovarian cysts. Methods: We report a case series of 5 patients with giant ovarian cysts who underwent single-port laparoscopic surgery in gynecology department, Shengjing Hospital of China Medical University between June 2020 and March 2021. The inclusion criteria were ovarian cysts at least 20 cm in diameters, and cases which the tumor might be malignant were excluded. Results: The patients' mean age was 26.2years. The most common clinical presentation was progressive abdominal distension. Median size of the cysts at imaging was 39.2 cm (range 21–63 cm). All patients underwent single-port laparoscopic surgery, and none of them converted to laparotomy. On final pathological reports, two cysts were serous cystadenomas, and three were mucinous cystadenomas. All patients recovered well and discharged on time. Conclusion: Giant ovarian cysts can be treated by single-port laparoscopic surgery. In addition to the well-known advantages of laparoscopic surgery (e.g., small pelvic interference, fast postoperative recovery), it can also play the role of perfect cosmetic results, which has more advantages for young women. Surgery Giant Ovarian cyst Single-port laparoscopic surgery Figures Figure 1 Figure 2 Figure 3 Background Female pelvic cysts mostly come from the ovary with asymptomatic when they are small. The symptoms appears when they reach enormous dimensions. Giant ovarian cysts (GOCs) are tumors larger than 10 cm in diameters or those cysts reaching above the umbilicus[ 1 ]. Progressive abdominal distension, nonspecific diffuse abdominal pain and organ compression (constipation, vomiting and frequent urination) are the main clinical symptoms of ovarian cysts[ 2 – 4 ]. Most giant ovarian cysts are treated by surgery. Surgical indications include a rapidly growing or symptomatic cyst, and when its malignant potential cannot be excluded[ 5 ]. In the past, exploratory laparotomy was the most common surgical method, which had the advantage of minimizing the risk of intraperitoneal implantation caused by cell overflow in case of unexpected malignant transformation of tumor. However, some giant ovarian cysts filled the abdominal cavity and superior reaching the xiphoid process. The abdominal incision as long as tens of centimeters caused great trouble to patients, especially young women. In recent years, minimally invasive surgery has been widely used in the field of gynecology. Laparoscopy is the choice for most benign ovarian cysts, but the size of the cysts may be a limiting factor. Giant ovarian cysts increase the complexity and difficulty of laparoscopic surgery. How to avoid the leakage of cyst fluid has become a challenge[ 6 ]. We report a case of giant ovarian cyst treated by single-port laparoscopy. This method tries to ensure the oncologic safety while treating the disease. The aim of this study is to introduce a new, minimally invasive and effective surgical approach for the treatment of giant ovarian cysts. Materials And Methods Four female patients with giant ovarian cyst who underwent single-port laparoscopic surgery between June 2020 and March 2021 were included from gynecology department, Shengjing Hospital of China Medical University. The study was approved by the China Medical University Research Ethics Committee. The inclusion criteria: ①All patients were diagnosed as giant abdominal cysts by pelvic ultrasound, MRI or CT-scan before operation(Fig. 1 A-D). ②The patients had signed the informed consent.③The umbilicus was normal. Exclusion criteria: ①Conversion to open surgery or other surgical methods.②Malignant transformation of cysts.③Severe medical system diseases which could not endure laparoscopic surgery. Four patients were confirmed by preoperative imaging (ultrasound, MRI or CT-scan) with giant abdominal masses at least 20 cm, mainly cystic, without obvious solid components, showing no sign of malignancy. Blood tumor markers (CA125, HE4, CA199 and CEA) were detected for each patient. The patients with complications were consulted in relevant departments to exclude surgical contraindications. The operations were performed by experienced gynecologists. Data was collected with operative time, intra- and post-operative complications, intracystic liquid volume, conversion to laparotomy and the length of postoperative stay. 30 days after operation, the satisfaction of patients with abdominal scar was recorded. Surgical procedure The patients received standardized preoperative nursing preparation and general anesthesia. Single-port laparoscopic surgery was performed using the following techniques. After partial eversion of the umbilicus, a 2-3cm longitudinal incision was made at the umbilicus(Figure 2 A). The umbilical incision was lifted, the skin and subcutaneous tissue were incised layer by layer, and the peritoneum was incised after confirming that there was no intestinal adhesion below the incision. The disposable incision protection sleeve (Lookmed, Jiangsu, China) was placed in the incision, the inner ring was placed in the abdominal cavity, and the outer ring was left to the abdominal wall to form a single-port laparoscopic approach platform༈Figure 2 B༉. A giant cyst appeared under the incision and was liquid in the visual field. In order to prevent the adverse effects of sudden drop of abdominal pressure on patients, we used a syringe needle connected with a suction device to suck out the liquid in the cyst slowly༈Figure 2 C༉. If the cyst divided into several septums, we suck out the liquid in one septum and then used the instruments to lift the wall of the cyst to prevent the leakage of the liquid in the cyst. We changed another septum and continued to suck out the liquid to reduce the pressure of the cyst. When the liquid was sucked out completely, we used silk thread to ligate the incision and returned the cyst to the abdominal cavity༈Figure 2 D༉. A sterile glove was connected with the outer ring. The thumb of the glove was cut, and 10mm trocar (Dike, Guangzhou, China) was placed as the access of a scope and laparoscopic instruments. In order to prevent air leakage and loosening at the joint, No. 7 silk thread was used to fix and tie tightly, and the 5mm (Dike, Guangzhou, China) trocars were inserted into the other two fingers as the instrument port. This is a self-made simple laparoscopic single-port (Fig. 3 A). The advantage is that it can save the cost for the patients without affecting the operation. Carbon dioxide was injected at a pressure of 13 mm Hg and a rigid 30° 5-mm laparoscope was inserted (Karl Storz, tutlingen, Germany). 30° laparoscope is a better choice because it provides a wide field of vision. Then the standard laparoscopic surgery was performed. Giant ovarian cysts were removed from the umbilicus using endopouch specimen retrieval bag (Wellead, Guangzhou, China) (Fig. 3 B, C). Results The study consisted of 4 female patients and data are shown in Table 1 . The mean age of the operated patients was 26.2 years (range, 19–34 years). The most common symptom was progressive abdominal distension(patients 1,2,4 and 5),several of which were accompanied by abdominal pain(patients 1,2 and 5). No obvious abdominal distension occurred in patient 3, mainly due to palpation of abdominal mass. All patients were diagnosed by imaging, ultrasound, MRI or CT-scans. Median size of the cyst at imaging was 39.2 cm (range 21–63 cm), while the maximum was 63.0 cm with the superiors reach the sword (patients 2). In particular, there were many comorbidities in patient 2. Hypertension occurred 17 years ago. Now oral antihypertensive drugs are used to control blood pressure, and the blood pressure is controlled at 130 / 80mmHg.In 2014, she suffered from cerebral thrombosis. The specific location is unknown. She felt numb on the right side of the body at the time of onset, which was improved after conservative treatment and now she is hemiplegic at the right limb. We consulted the anesthesiology department, cardiology department and neurology department before operation to evaluate the safety of operation and eliminate the operation contraindications. Based on the patient’s age and personal will, we decided to perform single-port laparoscopic exploration after discussion. Table 1 Patient’s data. Patient Age Cyst size(cm) Operative time(min) Fluid volume in cyst(ml) Intra-op. blood loss(ml) Post-op. stay (d) Conversion to laparotomy Histology Post-op. complications Satisfactin with abdominal scar 1 23 32 100 7000 20 5 No Serous cystadenoma No Yes 2 34 63 75 16000 20 5 No Mucinous cystadenoma No Yes 3 19 21 37 3500 10 5 No Mucinous cystadenoma No Yes 4 25 23 82 4000 50 4 No Serous cystadenoma No Yes 5 30 57 132 13000 30 6 No Mucinous cystadenoma No Yes Mean 26.2 39.2 85.2 8700 26 5 - - - - Four of the five patients presented with a normal blood tumor markers. One patient presented with an elevated CA125 of 70.78 (normal range 0–35mIU/ml) and CA-724 of 8.94(normal range 0–6.9 mIU/ml) (patient 3). In the postoperative reexamination, the blood tumor markers returned to normal gradually. All patients underwent single-port laparoscopic surgery, no one converted to laparotomy. Intraoperative suction of intracapsular fluid range 3500-16000ml (Fig. 3 D). Four patients underwent unilateral adnexectomy, and one patient an ovarian cystectomy(Fig. 3 E). We had a cosmetic suture of the single-port laparoscopic incision in patients’ navel (Fig. 3 F). The average operative time was 85.2min (range 37–132min). There was no extravasation of cyst fluid and no decompression syndrome happened due to gradual reduction of cyst pressure. Mean blood loss was 26ml (range 10–50ml). The average hospitalization time after operation was 5days, such operative method did not increase the Post-operative stay. All patients recovered well, and no complications related to the operation occurred. On final pathological reports, two cysts were serous cystadenomas, and three were mucinous cystadenomas. There was no borderline tumor or epithelial ovarian cancer in any of the ovarian cysts operated, but one case reported active cell proliferation, which should be reexamined. All the patients were satisfied with the abdominal scar after 30 days after operation. Discussion Female pelvic cysts are very common gynecological diseases in women, most of which come from ovary. The clinical manifestations appear when the cysts reach enormous dimensions. Giant ovarian cysts (GOCs) are tumors larger than 10 cm in diameters[ 1 ]. Due to improved imaging techniques, giant abdominal cyst has become increasingly rare. The patients can present with rare complications such as torsion, intestine obstruction, hydronephrosis in addition to causing non-specific abdominal distension, pain, nausea and vomiting and changes in defecation habits[ 7 – 10 ]. As the nonspecific clinical manifestations of giant ovarian cysts, the differential diagnoses include the giant cysts from other intra-abdominal organs (e.g. gastrointestinal, urological, or lymphatic)[ 11 ]. The treatment of ovarian cysts depends on the patient's age, the size of the cyst, and its histopathological feature. Excision of the intact cysts for histology is the gold standard[ 12 ].Most giant ovarian cysts are benign and are treated by surgical excision generally either by cystectomy or salpingo-oophorectomy [ 13 ]. It is utmost important to exclude any possibility of malignant tumor before operation[ 14 ].In the past, resection of the cystic mass by exploratory laparotomy is the preferred management strategy[ 8 ]. But for laparotomy of benign giant cysts, the huge incision caused trouble to the patients (especially young patients). A study shows that with the development of advanced technology, it is feasible to use laparoscopic surgery to remove giant ovarian cysts on the basis of selecting suitable patients and laparoscopic experts[ 15 ]. Recently, laparoscopic-assisted excision of these giant cystic masses has been reported in several literatures[ 6 , 16 , 17 ]. How to avoid the leakage of cyst fluid has become a challenge in laparoscopic surgery for treating giant ovarian cysts. In recent years, single-port laparoscopic surgery has become a hot spot as it uses the natural pores of the navel to hide the surgical incision and has the characteristics of perfect cosmetic results and fast postoperative recovery. In our study,we used single-port laparoscope to perform surgery on a slightly larger incision at the umbilicus, which exposed the visual field better and avoided the exudation of liquid in the giant cysts. In order to avoid the impact of sudden drop of intraperitoneal pressure on patients, we used the method previously described to slowly reduce the fluid in the giant cyst. Facts had proved that this method is effective, these patients did not appear related discomfort symptoms. We use the wound protector-retractor to protect the incision and reduce the risk of cell spillage. The endopouch specimen retrieval bag was used to take out the specimen after resection of the diseased tissue, which reduced the potential risks of the leakage of cells and residual cystic fluid. These measures ensured the safety of the operation. Although giant ovarian cysts are larger than 10 cm in diameter, we still selected cysts larger than 20 cm in diameter for study, which are more rare in clinic. We analyzed the general information and surgical outcomes of these patients and found that single-port laparoscopic surgery did not increase the adverse prognosis of patients. On the contrary, minimally invasive surgery and perfect cosmetic results accelerated the recovery and satisfaction of patients. Despite the advantages of single-port laparoscopic surgery, not all giant ovarian cysts are suitable for this type of surgery. We need to evaluate the patient's condition before operation rigorously, and it is very important to exclude any possible malignant tumors before operation. Single-port laparoscopic surgery is difficult to form an operation triangle as its limited operation space, relatively concentrated instruments and mutual interference which places high demands on the surgeon. It is necessary for us to improve the safety of surgery through more research. Conclusion In the treatment of giant ovarian cysts, it is safe and feasible to perform single-port laparoscopic surgery through screening of suitable patients strictly. This operation method has the same advantages of traditional laparoscopy, it ensures the safety of operation as most as possible and improves the cosmetic results perfectly, which are particularly important for young women. Abbreviations GOCs Giant ovarian cysts MRI Magnetic Resonance Imaging CT Computerized Tomography CA125 Carbohydrate antigen-125 HE4 Human Epididymis Protein 4 CA199 Carbohydrate antigen-199 CEA Carcinoembryonic antigen Declarations ACKNOWLEDGMENTS The authors thank the support of the funding “Scientific research funding project of Liaoning Provincial Department of Science and Technology (No.2020JH2/10300050)” to this article. AUTHOR CONTRIBUTIONS Jiang LL conducted a thorough literature review and was the major contributor in writing the manuscript; Liu KR was responsible for reviewing and revising the article. FUNDING This research received the support from “Scientific research funding project of Liaoning Provincial Department of Science and Technology（No.2020JH2/10300050）”. AVAILABILITY OF DATA AND MATERIALS The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. ETHICS APPROVAL AND CONSENT TO PARTICIPATE The study was approved by the China Medical University Research Ethics Committee. CONSENT FOR PUBLICATION Each author agrees to the publication of the present study. COMPETING INTERESTS The authors declare that they have no competing interests. References de Lima SH, Dos Santos VM, Darós AC, Campos VP, Modesto FR. A 57-year-old Brazilian woman with a giant mucinous cystadenocarcinoma of the ovary: a case report. Journal of medical case reports. 2014;8:82. doi: 10.1186/1752-1947-8-82 . Cîrstoiu MM, Sajin M, Secară DC, Munteanu O, Cîrstoiu FC. Giant ovarian mucinous cystadenoma with borderline areas: a case report. Romanian journal of morphology embryology = Revue roumaine de morphologie et embryologie. 2014;55(4):1443–7. PMID: 25611279. Mehboob M, Naz S, Zubair M, Kasi MA. Giant ovarian cyst–an unusual finding. Journal of Ayub Medical College Abbottabad: JAMC. 2014;26(2):244–5. PMID: 25603687. Abu Sulb A, Abu El Haija M, Muthukumar A. Incidental finding of a huge ovarian serous cystadenoma in an adolescent female with menorrhagia. SAGE open medical case reports 2016, 4:2050313x16645755. doi: 10.1177/2050313X16645755 . Leite C, Barbosa B, Santos N, Oliveira A, Casimiro C. Giant abdominal cyst in a young female patient: A case report. International journal of surgery case reports 2020, 72:549–555. doi: 10.1016/j.ijscr.2020.06.085 . Dubuisson J, Heersche S, Petignat P, Undurraga M. Laparoscopic Management of Giant Ovarian Cysts Using the Alexis Laparoscopic System®: A Case Series. Frontiers in surgery 2020, 7:24. doi: 10.3389/fsurg.2020.00024 . Bolukbas FF, Bolukbas C, Furuncuoglu Y, Tabandeh B, Saglam FY, Iyigun G, Orug T, Ozcan A, Yapicier O. Large abdominal cystic masses: Report of seven cases. JPMA The Journal of the Pakistan Medical Association. 2016;66(2):226–8. PMID: 26819176. Yeika EV, Efie DT, Tolefac PN, Fomengia JN. Giant ovarian cyst masquerading as a massive ascites: a case report. BMC Res Notes. 2017;10(1):749. doi: 10.1186/s13104-017-3093-8 . Kim HY, Cho MK, Bae EH, Kim SW, Ma SK. Hydronephrosis caused by a giant ovarian cyst. Int Braz J Urol. 2016;42(4):848–9. doi: 10.1590/S1677-5538.IBJU.2015.0354 . Kim TJ, Yeh YT, Zobair K. Impending abdominal compartment syndrome from a giant ovarian cyst torsion. ANZ J Surg. 2019;89(4):E164–5. doi: 10.1111/ans.14147 . Epub 2017 Sep 18. Vecchio R, Leanza V, Genovese F, Accardi M, Gelardi V, Intagliata E. Conservative laparoscopic treatment of a benign giant ovarian cyst in a young woman. Journal of laparoendoscopic advanced surgical techniques Part A. 2009;19(5):647–8. doi: 10.1089/lap.2009.0138 . American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstetrics gynecology. 2016;128(5):e210–26. doi: 10.1097/AOG.0000000000001768 . Katke RD. Giant mucinous cystadenocarcinoma of ovary: A case report and review of literature. Journal of mid-life health 2016, 7(1):41–44. doi: 10.4103/0976-7800.179167 . Ou CS, Liu YH, Zabriskie V, Rowbotham R. Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter. Journal of laparoendoscopic advanced surgical techniques Part A. 2001;11(3):125–32. doi: 10.1089/10926420152389251 . Alobaid A, Memon A, Alobaid S, Aldakhil L. Laparoscopic management of huge ovarian cysts. Obstetrics and gynecology international 2013, 2013:380854. doi: 10.1155/2013/380854 . Epub 2013 May 8. Uyanikoglu H, Dusak A. A Huge Ovarian Dermoid Cyst: Successful Laparoscopic Total Excision. Journal of clinical and diagnostic research: JCDR 2017, 11(8):Qd03-qd05. doi: 10.7860/JCDR/2017/29262.10436 . Epub 2017 Aug 1. Baradwan S, Sendy F, Sendy S. Complete Laparoscopic Extirpation of a Giant Ovarian Cyst in an Adolescent. Case reports in obstetrics and gynecology 2017, 2017:7632989. doi: 10.1155/2017/7632989 . Epub 2017 Aug 3. Cite Share Download PDF Status: Published Journal Publication published 09 Dec, 2021 Read the published version in Frontiers in Oncology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-433441","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":24534738,"identity":"a91de2e1-3f6e-41e2-b6f2-f0c188e1aef1","order_by":0,"name":"Lili Jiang","email":"","orcid":"https://orcid.org/0000-0003-1628-7248","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lili","middleName":"","lastName":"Jiang","suffix":""},{"id":24534739,"identity":"982ea70c-a550-46de-b7a1-d39562c8d078","order_by":1,"name":"Kuiran Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIie3QMQuCQBTA8ScPzuWo1TDqK1wctFWfRQ6aGoSWghAlcG0Nir5E0FwITrX3MQobGhx6V1GbOgbdf3io+DvvBDCZfrAaAgJMaDj6VtCTMsKe5PghAlgpAXrbiunqSaAKsbmU001ggztPMt/P2wwwvd4KN8ald9olCM106C6F6MTA1KpZQg7Rbo+D86iLXAjaJJfolJJ1QMcfyYzIoBLxohA1ES4RTxPrUkjYuBOmdBZnqM8iVYxMYYGAej3ZNsJZoMBR9MfyVm9hzxPrXmTeKT1ei9NEXoH0v4Sq9BWTyWT6mx5tTDZj6N0PKAAAAABJRU5ErkJggg==","orcid":"","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kuiran","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2021-04-17 13:38:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-433441/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-433441/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3389/fonc.2021.796330","type":"published","date":"2021-12-09T07:23:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":8932117,"identity":"10c99651-be9f-47c3-91c5-14c26f5a785f","added_by":"auto","created_at":"2021-05-07 19:25:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":881224,"visible":true,"origin":"","legend":"A and B）Transvaginal ultrasound imaging. A: A giant cyst in the abdominal and pelvic cavity (63.0cm x 44.0cm x 13.4 cm); B: The blood flow signal detected at the separation; (C and D) Abdomen enhanced CT imaging. C: A giant cyst with septums; D: The uterus was pushed to the back of the pelvis by a giant cyst.","description":"","filename":"Figure1..png","url":"https://assets-eu.researchsquare.com/files/rs-433441/v1/6004ca481606210dc52b9d5f.png"},{"id":8931859,"identity":"5ed1c20b-63ed-4cf6-8cda-28ec174b11ba","added_by":"auto","created_at":"2021-05-07 19:22:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2812592,"visible":true,"origin":"","legend":"(A) The 2-3cm longitudinal incision was made at the umbilicus. (B) Single-port laparoscopic approach connection instrument. (C) A syringe needle connected with a suction device to suck out the liquid in the cyst. (D) Ligate the incision in order to avoid the leakage of cyst fluid.","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-433441/v1/d7e0a0210529cb9ce82d3d2e.png"},{"id":8932118,"identity":"141f8eaa-76c6-4171-b1fc-344a5d123519","added_by":"auto","created_at":"2021-05-07 19:25:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5447138,"visible":true,"origin":"","legend":"(A) The instruments enter the abdominal cavity through single-port laparoscopic access.（B）The excised tissue was put into endopouch specimen retrieval bag under laparoscope.(C) The wall of a giant cyst removed through the navel.(D) Intraoperative suction of intracapsular fluid.(E) Unilateral salpingo-oophorectomy by laparoscope.(F) A cosmetic suture of the single-port laparoscopic incision in patients’ navel.","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-433441/v1/56dabfbcb4fe68bdba235114.png"},{"id":16304595,"identity":"f47ca865-9292-4a63-90dc-80c59375a642","added_by":"auto","created_at":"2021-12-09 07:23:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4778619,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-433441/v1/59450d57-6ecc-426e-8e5a-139c887a3790.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eGiant Ovarian Cysts Treated by Single-Port Laparoscopic Surgery: A Case Series\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eFemale pelvic cysts mostly come from the ovary with asymptomatic when they are small. The symptoms appears when they reach enormous dimensions. Giant ovarian cysts (GOCs) are tumors larger than 10 cm in diameters or those cysts reaching above the umbilicus[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Progressive abdominal distension, nonspecific diffuse abdominal pain and organ compression (constipation, vomiting and frequent urination) are the main clinical symptoms of ovarian cysts[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most giant ovarian cysts are treated by surgery. Surgical indications include a rapidly growing or symptomatic cyst, and when its malignant potential cannot be excluded[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the past, exploratory laparotomy was the most common surgical method, which had the advantage of minimizing the risk of intraperitoneal implantation caused by cell overflow in case of unexpected malignant transformation of tumor. However, some giant ovarian cysts filled the abdominal cavity and superior reaching the xiphoid process. The abdominal incision as long as tens of centimeters caused great trouble to patients, especially young women. In recent years, minimally invasive surgery has been widely used in the field of gynecology. Laparoscopy is the choice for most benign ovarian cysts, but the size of the cysts may be a limiting factor. Giant ovarian cysts increase the complexity and difficulty of laparoscopic surgery. How to avoid the leakage of cyst fluid has become a challenge[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. We report a case of giant ovarian cyst treated by single-port laparoscopy. This method tries to ensure the oncologic safety while treating the disease. The aim of this study is to introduce a new, minimally invasive and effective surgical approach for the treatment of giant ovarian cysts.\u003c/p\u003e "},{"header":"Materials And Methods","content":" \u003cp\u003eFour female patients with giant ovarian cyst who underwent single-port laparoscopic surgery between June 2020 and March 2021 were included from gynecology department, Shengjing Hospital of China Medical University. The study was approved by the China Medical University Research Ethics Committee. The inclusion criteria: ①All patients were diagnosed as giant abdominal cysts by pelvic ultrasound, MRI or CT-scan before operation(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-D). ②The patients had signed the informed consent.③The umbilicus was normal. Exclusion criteria: ①Conversion to open surgery or other surgical methods.②Malignant transformation of cysts.③Severe medical system diseases which could not endure laparoscopic surgery. Four patients were confirmed by preoperative imaging (ultrasound, MRI or CT-scan) with giant abdominal masses at least 20 cm, mainly cystic, without obvious solid components, showing no sign of malignancy. Blood tumor markers (CA125, HE4, CA199 and CEA) were detected for each patient. The patients with complications were consulted in relevant departments to exclude surgical contraindications. The operations were performed by experienced gynecologists. Data was collected with operative time, intra- and post-operative complications, intracystic liquid volume, conversion to laparotomy and the length of postoperative stay. 30 days after operation, the satisfaction of patients with abdominal scar was recorded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eThe patients received standardized preoperative nursing preparation and general anesthesia. Single-port laparoscopic surgery was performed using the following techniques. After partial eversion of the umbilicus, a 2-3cm longitudinal incision was made at the umbilicus(Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The umbilical incision was lifted, the skin and subcutaneous tissue were incised layer by layer, and the peritoneum was incised after confirming that there was no intestinal adhesion below the incision. The disposable incision protection sleeve (Lookmed, Jiangsu, China) was placed in the incision, the inner ring was placed in the abdominal cavity, and the outer ring was left to the abdominal wall to form a single-port laparoscopic approach platform༈Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB༉. A giant cyst appeared under the incision and was liquid in the visual field. In order to prevent the adverse effects of sudden drop of abdominal pressure on patients, we used a syringe needle connected with a suction device to suck out the liquid in the cyst slowly༈Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC༉. If the cyst divided into several septums, we suck out the liquid in one septum and then used the instruments to lift the wall of the cyst to prevent the leakage of the liquid in the cyst. We changed another septum and continued to suck out the liquid to reduce the pressure of the cyst. When the liquid was sucked out completely, we used silk thread to ligate the incision and returned the cyst to the abdominal cavity༈Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD༉.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA sterile glove was connected with the outer ring. The thumb of the glove was cut, and 10mm trocar (Dike, Guangzhou, China) was placed as the access of a scope and laparoscopic instruments. In order to prevent air leakage and loosening at the joint, No. 7 silk thread was used to fix and tie tightly, and the 5mm (Dike, Guangzhou, China) trocars were inserted into the other two fingers as the instrument port. This is a self-made simple laparoscopic single-port (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The advantage is that it can save the cost for the patients without affecting the operation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCarbon dioxide was injected at a pressure of 13 mm Hg and a rigid 30\u0026deg; 5-mm laparoscope was inserted (Karl Storz, tutlingen, Germany). 30\u0026deg; laparoscope is a better choice because it provides a wide field of vision. Then the standard laparoscopic surgery was performed. Giant ovarian cysts were removed from the umbilicus using endopouch specimen retrieval bag (Wellead, Guangzhou, China) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB, C).\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eThe study consisted of 4 female patients and data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the operated patients was 26.2 years (range, 19\u0026ndash;34 years). The most common symptom was progressive abdominal distension(patients 1,2,4 and 5),several of which were accompanied by abdominal pain(patients 1,2 and 5). No obvious abdominal distension occurred in patient 3, mainly due to palpation of abdominal mass. All patients were diagnosed by imaging, ultrasound, MRI or CT-scans. Median size of the cyst at imaging was 39.2 cm (range 21\u0026ndash;63 cm), while the maximum was 63.0 cm with the superiors reach the sword (patients 2). In particular, there were many comorbidities in patient 2. Hypertension occurred 17 years ago. Now oral antihypertensive drugs are used to control blood pressure, and the blood pressure is controlled at 130 / 80mmHg.In 2014, she suffered from cerebral thrombosis. The specific location is unknown. She felt numb on the right side of the body at the time of onset, which was improved after conservative treatment and now she is hemiplegic at the right limb. We consulted the anesthesiology department, cardiology department and neurology department before operation to evaluate the safety of operation and eliminate the operation contraindications. Based on the patient\u0026rsquo;s age and personal will, we decided to perform single-port laparoscopic exploration after discussion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient\u0026rsquo;s data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCyst size(cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOperative time(min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFluid volume in cyst(ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntra-op. blood loss(ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePost-op.\u003c/p\u003e \u003cp\u003estay (d)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eConversion to\u003c/p\u003e \u003cp\u003elaparotomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePost-op.\u003c/p\u003e \u003cp\u003ecomplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSatisfactin with\u003c/p\u003e \u003cp\u003eabdominal scar\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSerous cystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMucinous\u003c/p\u003e \u003cp\u003ecystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMucinous\u003c/p\u003e \u003cp\u003ecystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSerous cystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMucinous\u003c/p\u003e \u003cp\u003ecystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFour of the five patients presented with a normal blood tumor markers. One patient presented with an elevated CA125 of 70.78 (normal range 0\u0026ndash;35mIU/ml) and CA-724 of 8.94(normal range 0\u0026ndash;6.9 mIU/ml) (patient 3). In the postoperative reexamination, the blood tumor markers returned to normal gradually. All patients underwent single-port laparoscopic surgery, no one converted to laparotomy. Intraoperative suction of intracapsular fluid range 3500-16000ml (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). Four patients underwent unilateral adnexectomy, and one patient an ovarian cystectomy(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE). We had a cosmetic suture of the single-port laparoscopic incision in patients\u0026rsquo; navel (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eF). The average operative time was 85.2min (range 37\u0026ndash;132min). There was no extravasation of cyst fluid and no decompression syndrome happened due to gradual reduction of cyst pressure. Mean blood loss was 26ml (range 10\u0026ndash;50ml). The average hospitalization time after operation was 5days, such operative method did not increase the Post-operative stay. All patients recovered well, and no complications related to the operation occurred. On final pathological reports, two cysts were serous cystadenomas, and three were mucinous cystadenomas. There was no borderline tumor or epithelial ovarian cancer in any of the ovarian cysts operated, but one case reported active cell proliferation, which should be reexamined. All the patients were satisfied with the abdominal scar after 30 days after operation.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eFemale pelvic cysts are very common gynecological diseases in women, most of which come from ovary. The clinical manifestations appear when the cysts reach enormous dimensions. Giant ovarian cysts (GOCs) are tumors larger than 10 cm in diameters[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to improved imaging techniques, giant abdominal cyst has become increasingly rare. The patients can present with rare complications such as torsion, intestine obstruction, hydronephrosis in addition to causing non-specific abdominal distension, pain, nausea and vomiting and changes in defecation habits[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As the nonspecific clinical manifestations of giant ovarian cysts, the differential diagnoses include the giant cysts from other intra-abdominal organs (e.g. gastrointestinal, urological, or lymphatic)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe treatment of ovarian cysts depends on the patient's age, the size of the cyst, and its histopathological feature. Excision of the intact cysts for histology is the gold standard[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].Most giant ovarian cysts are benign and are treated by surgical excision generally either by cystectomy or salpingo-oophorectomy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is utmost important to exclude any possibility of malignant tumor before operation[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].In the past, resection of the cystic mass by exploratory laparotomy is the preferred management strategy[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. But for laparotomy of benign giant cysts, the huge incision caused trouble to the patients (especially young patients). A study shows that with the development of advanced technology, it is feasible to use laparoscopic surgery to remove giant ovarian cysts on the basis of selecting suitable patients and laparoscopic experts[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Recently, laparoscopic-assisted excision of these giant cystic masses has been reported in several literatures[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. How to avoid the leakage of cyst fluid has become a challenge in laparoscopic surgery for treating giant ovarian cysts.\u003c/p\u003e \u003cp\u003eIn recent years, single-port laparoscopic surgery has become a hot spot as it uses the natural pores of the navel to hide the surgical incision and has the characteristics of perfect cosmetic results and fast postoperative recovery. In our study,we used single-port laparoscope to perform surgery on a slightly larger incision at the umbilicus, which exposed the visual field better and avoided the exudation of liquid in the giant cysts. In order to avoid the impact of sudden drop of intraperitoneal pressure on patients, we used the method previously described to slowly reduce the fluid in the giant cyst. Facts had proved that this method is effective, these patients did not appear related discomfort symptoms. We use the wound protector-retractor to protect the incision and reduce the risk of cell spillage. The endopouch specimen retrieval bag was used to take out the specimen after resection of the diseased tissue, which reduced the potential risks of the leakage of cells and residual cystic fluid. These measures ensured the safety of the operation. Although giant ovarian cysts are larger than 10 cm in diameter, we still selected cysts larger than 20 cm in diameter for study, which are more rare in clinic. We analyzed the general information and surgical outcomes of these patients and found that single-port laparoscopic surgery did not increase the adverse prognosis of patients. On the contrary, minimally invasive surgery and perfect cosmetic results accelerated the recovery and satisfaction of patients.\u003c/p\u003e \u003cp\u003eDespite the advantages of single-port laparoscopic surgery, not all giant ovarian cysts are suitable for this type of surgery. We need to evaluate the patient's condition before operation rigorously, and it is very important to exclude any possible malignant tumors before operation. Single-port laparoscopic surgery is difficult to form an operation triangle as its limited operation space, relatively concentrated instruments and mutual interference which places high demands on the surgeon. It is necessary for us to improve the safety of surgery through more research.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eIn the treatment of giant ovarian cysts, it is safe and feasible to perform single-port laparoscopic surgery through screening of suitable patients strictly. This operation method has the same advantages of traditional laparoscopy, it ensures the safety of operation as most as possible and improves the cosmetic results perfectly, which are particularly important for young women.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGOCs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGiant ovarian cysts\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputerized Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCA125\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarbohydrate antigen-125\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHE4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Epididymis Protein 4\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCA199\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarbohydrate antigen-199\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarcinoembryonic antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the support of the funding \u0026ldquo;Scientific research funding project of Liaoning Provincial Department of Science and Technology (No.2020JH2/10300050)\u0026rdquo; to this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiang LL conducted a thorough literature review and was the major contributor in writing the manuscript; Liu KR was responsible for reviewing and revising the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received the support from \u0026ldquo;Scientific research funding project of Liaoning Provincial Department of Science and Technology（No.2020JH2/10300050）\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the China Medical University Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach author agrees to the publication of the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ede Lima SH, Dos Santos VM, Dar\u0026oacute;s AC, Campos VP, Modesto FR. 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Epub 2013 May 8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUyanikoglu H, Dusak A. A Huge Ovarian Dermoid Cyst: Successful Laparoscopic Total Excision. Journal of clinical and diagnostic research: JCDR 2017, 11(8):Qd03-qd05. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7860/JCDR/2017/29262.10436\u003c/span\u003e\u003c/span\u003e. Epub 2017 Aug 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaradwan S, Sendy F, Sendy S. Complete Laparoscopic Extirpation of a Giant Ovarian Cyst in an Adolescent. Case reports in obstetrics and gynecology 2017, 2017:7632989. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2017/7632989\u003c/span\u003e\u003c/span\u003e. Epub 2017 Aug 3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Giant, Ovarian cyst, Single-port laparoscopic surgery","lastPublishedDoi":"10.21203/rs.3.rs-433441/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-433441/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eOvarian cysts are very common diseases of female reproductive system. Giant ovarian cysts refer to the tumors with diameters greater than 10 cm. In recent years, due to the development of clinical diagnosis, imaging modalities and the improvement of patients' cognition of the diseases, the occurrence of giant ovarian cysts become rare. The purpose of this study was to show a new operation method of single-port laparoscopy to treat giant ovarian cysts.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe report a case series of 5 patients with giant ovarian cysts who underwent single-port laparoscopic surgery in gynecology department, Shengjing Hospital of China Medical University between June 2020 and March 2021. The inclusion criteria were ovarian cysts at least 20 cm in diameters, and cases which the tumor might be malignant were excluded.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe patients' mean age was 26.2years. The most common clinical presentation was progressive abdominal distension. Median size of the cysts at imaging was 39.2 cm (range 21\u0026ndash;63 cm). All patients underwent single-port laparoscopic surgery, and none of them converted to laparotomy. On final pathological reports, two cysts were serous cystadenomas, and three were mucinous cystadenomas. All patients recovered well and discharged on time.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eGiant ovarian cysts can be treated by single-port laparoscopic surgery. In addition to the well-known advantages of laparoscopic surgery (e.g., small pelvic interference, fast postoperative recovery), it can also play the role of perfect cosmetic results, which has more advantages for young women.\u003c/p\u003e","manuscriptTitle":"Giant Ovarian Cysts Treated by Single-Port Laparoscopic Surgery: A Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-05-07 19:22:36","doi":"10.21203/rs.3.rs-433441/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"35a9aa88-5762-46cf-b4eb-12dba9991186","owner":[],"postedDate":"May 7th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":4152185,"name":"Surgery"}],"tags":[],"updatedAt":"2021-12-09T07:23:47+00:00","versionOfRecord":{"articleIdentity":"rs-433441","link":"https://doi.org/10.3389/fonc.2021.796330","journal":{"identity":"frontiers-in-oncology","isVorOnly":true,"title":"Frontiers in Oncology"},"publishedOn":"2021-12-09 07:23:47","publishedOnDateReadable":"December 9th, 2021"},"versionCreatedAt":"2021-05-07 19:22:36","video":"","vorDoi":"10.3389/fonc.2021.796330","vorDoiUrl":"https://doi.org/10.3389/fonc.2021.796330","workflowStages":[]},"version":"v1","identity":"rs-433441","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-433441","identity":"rs-433441","version":["v1"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}