Giant ovarian cysts superior to 20 cm are rare and pose several problems in terms of surgical strategy. Because of the difficulty to achieve safely a pneumoperitoneum, and in order to extirpate the cyst without spilling the content (which would expose to a contamination of the abdominal wall and the peritoneal cavity), a large midline laparotomy is usually the classic proposed route. Nevertheless, when the cyst is presumed benign, the laparoscopic route offers several advantages: patient’s comfort and quicker recovery, cosmetic prejudice reduced, complete exploration of the abdominal cavity from the pouch of Douglas to the diaphragm.

This digital communication presents 2 observations:

A 40 –year- old G0P0 lady presenting with a left adnexal cyst measuring 25 x 20 x 12 cm, and a 62-year-old G2P2 lady, with a background of vaginal hysterectomy, and previous laparotomy for cholecystectomy with a biliary tract stone, referred with a suspected left ovarian cyst (25 x 14 x 23 cm).

In each case the cyst had thin wall, no granulations, and there was no ascites. In both cases, the tumour markers were normal, and the malignancy risk index was low.

In the first case, the patient was managed purely laparoscopically (Hasson entry, peritoneal exploration, aspiration of the content under visual control without any spillage, closure of the hole with a PDS endoloop*, left salpingooophorectomy with a Ligasure*). The final histology was mucinous cystadenoma with borderline contingent.

In the second case, the patient was managed with a combination of a 5 cm mini laparotomy and laparoscopy. The use of an Alexis* retractor allowed the access to the cyst and the clean aspiration of the content with a suction cannula after confection of a purse string. The obturator cap of the Alexis* allows a tight pneumoperitoneum without gas leak, and a laparoscopy was then performed. The protocol was similar to the first case (peritoneal exploration, bilateral salpingooophorectomy with a Ligasure*). Frozen section confirmed a mucinous cystadenoma.

In this digital communication, we will present operative pictures, and discuss the advantages and flaws of each strategy.

Even though non consensual, the management of large ovarian cysts with isolated liquid content can certainly be performed safely via laparoscopy. A recent refinement of the technique is the use of the small Alexis Laparoscopic System with Kii Fios which retracts a 2.5 - 6cm incision and gives good access to the cyst for the initial approach.