Bartholin cyst removal surgery

The Bartholin glands are a pair of glands located near the outer entrance of the vagina. It is responsible for secreting lubricating fluid for the vagina. When these glands get blocked, they form a cyst. The cyst later develops symptoms that interfere with activities of daily living. Hence the cyst needs to be treated.

When medical management is unsuccessful, surgery is needed. Depending on the size and symptoms of the cyst, one of the following procedures is performed:

• Incision and drainage: it is done if the cyst occurs for the first time and is small in size
• Marsupialisation (creating a kangaroo pouch): it is done in recurrent cysts
• Cystectomy: in case marsupialisation fails, this is procedure is employed

Bartholin cyst surgery is needed when the symptoms of the cyst can’t be controlled by medicines (antibiotics and warm compresses). These symptoms include:

• Swelling, which is associated with pain and tenderness and causes difficulty in sitting and walking
• Dyspareunia i.e., painful sexual intercourse
• The cyst becomes infected, i.e. it turns into an abscess (pus-filled swelling). Fever along with extreme tenderness is seen.
• Recurrence of the cysts

There are no relative contraindications for the surgery. However pre-existing conditions should be under control if present. For example, uncontrolled diabetes may prolong wound healing and increase chances of infection and hence should be brought to control first.

The OBG surgeon takes a detailed history of the patient. Depending on the presentation and symptoms of the cyst, the doctor will discuss with the patient the type of procedure that will be performed.

Medications for any pre-existing conditions taken by the patient may be stopped or altered as per surgical requirements. Investigations include:

• Routine blood investigations.
• STD panel tests: STDs are found to have a role in the formation of the cyst.
• A sample of the secretions of the cervix (pap smear) will be taken to rule out any abnormalities.
• In women above 40 years, a sample of the tissue may be taken from near the cyst (biopsy) to rule out vulvar cancer.

Since the patient will experience soreness at the site of surgery after the procedure, the patient is advised to arrange a ride for going home beforehand. The procedure is usually a day-care admission.

On the day of the procedure, the patient is admitted, changes into the hospital gown. The final review is done by the surgeon and the nurses to clear the patient for surgery and the patient is shifted to a minor operating theatre (OT).

The patient is made to lie down in the lithotomy position (the patient is lying on their back and the legs of the patient are spread wide when giving birth). A monitor is attached to keep track of the vitals (heart rate, blood pressure and oxygen saturation) of the patient. The affected area is cleaned and covered with sterile drapes. Depending on the procedure to be performed, local, regional or general anaesthesia can be given.

There are three approaches to surgical management. They are

1. Incision and drainage

This method is preferred if the cyst is small and has occurred for the first time. An incision is made with a scalpel (sharp sterile knife) and the fluid in the cyst is drained. A special balloon catheter (a small hollow tube with a tip that swells up) is placed inside the opening of the gland to allow continuous drainage of the fluid and maintain the natural opening of the gland. The procedure is usually done under local anaesthesia.

2. Marsupialisation

This approach is used if the cyst is large or infected and is recurrent. An incision is made on the cyst and the fluid is drained. The incised edges of the cyst are then sutured (stitched) with the surrounding skin thereby creating a free opening (kangaroo pouch) for the fluid to drain. The opening is packed with gauze to minimise bleeding. The procedure is done under local or regional (lower half of the body is made numb) anaesthesia.

3. Cystectomy

This is the last approach employed when cysts are recurrent and marsupialisation fails. Another indication is abnormal results of the biopsy. In this method, the entire gland is removed completely and the wound is sutured closed. The procedure is done under regional or general anaesthesia

The entire procedure takes about 15 minutes to one hour depending on the approach.

The risks associated with the procedure are minimal. However, the common complications include

• Excessive bleeding from the wound
• Infection of the wound
• Excessive pain and swelling
• Numbness due to damage to nerve endings during the procedure
• Scarring of the wound made lead to cosmetic issues or painful sexual activity
• Complications due to anaesthesia

After the procedure, the patient is shifted from the OT and kept under observation for a few hours. The area will be sore and painful and is managed by analgesics. A discharge summary is prepared by the doctor which contains relevant medications and advice on wound care. These typically include:

• Continuation of medication of pre-existing conditions, if any
• Antibiotics and analgesics to prevent infection and pain, respectively
• Sitz bath 1-2 times a day: a sitz bath is a special bath that involves soaking the perineum (area between the urinary organs and anus) in warm water for 15-20 minutes. The bath relieves pain and swelling and promotes wound healing.
• Proper hygiene is to be maintained around the area especially after using the toilet. The area is to be kept clean and dry to prevent infection
• Breathable thin undergarments are to be worn to avoid irritation to the area of the wound
• Strenuous activities and sexual activities are to be abstained for at least 2 weeks.
• Avoid using creams, powders or tampons till the wound is completely healed
• Indulge in safe sex practices by using condoms and treating the partner for STD infection (if diagnosed) to prevent a recurrence.

The wound takes two to four weeks to be completely healed. However, the doctor should be notified if there is

• Excessive bleeding
• Swelling and pain
• Pus discharge
• Fever

Sutures are removed usually after 2 weeks. Follow up is as instructed by the doctor.

Bartholin cyst surgery is recommended in female patients when symptoms interfere with activities of daily living and non-surgical management is unsuccessful. The procedure has minimal risk and is of short duration (day-care). Aftercare of the wound is important to prevent infection. It has a high success rate, however, the cysts can recur.