Ovarian cysts are among the most common gynecological conditions encountered in women of reproductive age. While most small cysts are functional and resolve spontaneously, large ovarian cysts—especially those exceeding 8–10 cm—often require surgical intervention. Traditionally, laparotomy was the preferred approach for managing large cysts due to concerns about rupture, spillage, and technical difficulty. However, with advancements in minimally invasive surgery, laparoscopic ovarian cystectomy has become a safe and effective option even for large ovarian cysts, offering women reduced morbidity and faster recovery without compromising surgical outcomes.

Understanding Large Ovarian Cysts

Large ovarian cysts may be simple (serous or mucinous cystadenomas), dermoid cysts, endometriomas, or even borderline tumors. They often present with abdominal pain, bloating, pressure symptoms on the bladder or bowel, or are discovered incidentally during imaging. In some cases, large cysts may undergo complications such as torsion, rupture, or hemorrhage, requiring urgent management.

The goal of treatment is to excise the cyst while preserving as much normal ovarian tissue as possible, particularly in young women desiring fertility.

Indications for Laparoscopic Management

Laparoscopic ovarian cystectomy for large cysts is indicated in:

Symptomatic large cysts not resolving spontaneously

Benign-appearing cysts on ultrasound and tumor markers

Cysts causing infertility or menstrual irregularities

Complicated cysts (torsion or rupture)

Cosmetic concerns due to abdominal distension

Malignancy must be reasonably excluded preoperatively through ultrasound features, Doppler, and CA-125 or other tumor markers.

Surgical Technique

Anesthesia and Positioning
The procedure is performed under general anesthesia with the patient in lithotomy position and slight Trendelenburg tilt.

Port Placement
A 10-mm umbilical port for the laparoscope and two or three 5-mm ancillary ports are placed under direct vision. In very large cysts occupying the abdomen, an open (Hasson) entry or supraumbilical entry may be preferred to avoid cyst puncture.

Cyst Decompression
For very large cysts, controlled decompression is performed. A suction needle or trocar is inserted into the cyst under laparoscopic guidance, and the fluid is aspirated into a closed system. This reduces cyst size, creating working space for dissection. Care is taken to prevent spillage, especially in dermoid cysts and mucinous cystadenomas.

Cyst Enucleation
A small incision is made on the ovarian surface, and traction–countertraction technique is applied to peel the cyst wall from normal ovarian tissue. Blunt and sharp dissection methods are used with minimal electrocautery to avoid damage to ovarian reserve.

Specimen Retrieval
The cyst wall is placed in an endoscopic retrieval bag and extracted through the umbilical port. For large specimens, the bag may be withdrawn after morcellation or piecemeal removal within the bag to avoid spillage.

Ovarian Reconstruction
Hemostasis is achieved with bipolar cautery or fine sutures. The ovarian edges are approximated using intracorporeal suturing, restoring ovarian anatomy.

Closure
Ports are removed, and incisions closed. The patient is awakened from anesthesia and shifted to recovery.

Advantages of Laparoscopic Approach

Minimally invasive – Smaller incisions, less pain, and faster recovery

Fertility preservation – Healthy ovarian tissue conserved

Cosmetic benefit – Avoids large abdominal scars

Shorter hospital stay – Most patients discharged within 24–48 hours

Lower risk of adhesions – Compared to open surgery

Improved magnification – Facilitates precise dissection even in large cysts

Challenges in Large Cyst Management

While laparoscopy is advantageous, large cysts present unique challenges:

Risk of intraoperative rupture and spillage

Limited working space in the abdomen prior to decompression

Difficulty in specimen retrieval

Need for advanced laparoscopic suturing skills for ovarian reconstruction

Careful preoperative planning, use of retrieval bags, and meticulous surgical technique minimize these challenges.

Postoperative Care and Recovery

Recovery after laparoscopic cystectomy is rapid. Patients usually mobilize within hours, resume diet the same day, and are discharged within 1–2 days. Postoperative pain is minimal, managed with oral analgesics. Follow-up includes monitoring ovarian function, menstrual cycles, and fertility outcomes. Women are advised to avoid strenuous activities for 2–3 weeks.

Outcomes and Prognosis

Studies show that laparoscopic cystectomy for large ovarian cysts is associated with excellent outcomes, low recurrence rates, and preservation of ovarian function. Fertility rates improve significantly in women who previously had anovulation or mechanical infertility due to cysts. Complication rates are low when performed by experienced laparoscopic surgeons.

Conclusion

Laparoscopic ovarian cystectomy for large ovarian cysts is a safe, effective, and fertility-preserving technique that has replaced laparotomy in most cases of benign cysts. With careful patient selection, appropriate preoperative evaluation, and expert surgical skills, even very large ovarian cysts can be successfully managed laparoscopically. This approach not only provides excellent clinical outcomes but also ensures faster recovery, minimal scarring, and better quality of life for women.