Anaesthetic management in removal of a huge ovarian cyst.SH Pandya, R Divekar, L Tuteja
Dept of Anaesthesia, KEM Hospital, Parel, Bombay, Maharashtra.
A patient with a huge ovarian cyst weighing 38 kg was operated successfully with utmost care to avoid all possible intra and postoperative complications. The same has been presented and the salient features of management have been discussed.
Keywords: Anesthesia, Inhalation, instrumentation,methods,Case Report, Cystadenoma, pathology,surgery,Female, Human, Intraoperative Care, Middle Age, Ovarian Neoplasms, pathology,surgery,Postoperative Care, Preoperative Care,
Giant ovarian tumours have become uncommon in contemporary medical practice, since patients now present earlier for medical care. Management of such cases is associated with appreciable mortality e.g. in two of eight reports death of the patient has been reported. The survivors encountered serious cardiovascular complications,. The potential problems associated with removal of a huge ovarian cyst are summarised in [Table - 1]. We describe here our management for a case of large ovarian cyst.
A 50 year old emaciated female presented with progressive abdominal distension of three years duration. She also had marked difficulty in walking because of her huge abdomen. Her weight was 73.5 kg and abdominal girth 145 cm. She was not dyspnoeic, despite marked flaring of the rib cage. No cardiovascular abnormality was noted. An ultrasound examination confirmed the presence of a massive cystic abdominal mass, arising from the pelvis. Haematological and biochemical investigations demonstrated a mild hypochromic microcytic anaemia (Hb 9.9 gm%); PCV of 30; BUN, blood sugar, serum electrolytes, liver function test, ECG and arterial blood gases were within normal limits. Her chest x-ray showed marked upward diaphragmatic displacement.
As preoperative management, it was decided to drain the cyst gradually over a period of 14 days; 12.5 litres were tapped by repeated paracentesis at 2-3 days interval, removing about 3 litres per day over a period of 6-12 hours. As a result, her preoperative abdominal girth decreased to 121 cm and weight became 63 kg.
Prior to surgery, 4 units of blood, fresh frozen plasma, and platelets availability were confirmed. No sedative premedication was prescribed. Injection atropine 0.5 mg was given intramuscularly. 30? left lateral tilt was considered most suitable for anaesthesia and surgery. One central venous and one peripheral intravenous line were inserted for fluid replacement.
After preoxygenation for 3 minutes with 100% oxygen, anaesthesia was induced with thiopentone (125 mg) and suxamethonium (75 mg) intravenously. Cricoid pressure was applied just before induction. The patient was intubated with No.7 oral Rusch cuffed endotracheal tube. The patient was maintained on controlled ventilation with 70% nitrous oxide and 30% oxygen. Muscle relaxation was provided with inj. pancuronium 4mg. A nasogastric tube was passed. Pentazocine (10 mg) and diazepam (2.5 mg) were given intravenously.
Continuous monitoring of pulse rate, blood pressure, CVP, urine output and blood loss was done.
A multilocular mucinous cystadenoma was removed which contained 22.5 lit of greenish, viscous fluid. Intraoperatively the patient was given 3 units of blood and 2 litres of crystalloids. Central venous pressure (CVP) was maintained between 3-5 cm of H20 and urine output at the end of surgery was 1,200 ml. The patient was reversed with atropine (1 mg) and prostigmine (2.5 mg) intravenously. She was breathing well and was extubated on table.
The patient was then returned to the intensive therapy unit after surgery. During the first 24 hours the patient was stabilised with a pulse rate 88 beats/min, blood pressure 110/70 mm of Hg, respiratory rate 16-18 per minute IV fluid for 48 hours. On the 3rd postoperative day, the patient was allowed oral liquid diet. Tightening of abdominal binder and provision of analgesia resulted in adequate expectoration. She was trained to do deep breathing exercises and encouraged to cough in the postoperative period. Her postoperative weight was 35 kg.
Patients with a huge ovarian cyst present rarely and it is unlikely that clinicians will have previous experience. We discuss here the salient features of management.
In the preoperative period, the psychological and nutritional aspects are of importance. These patients are known to have low plasma albumin and iron deficiency. A longer period of preoperative enteral hyperalimentation has been advised.
Alongwith routine haematological and biochemical investigations, ventilatory function was clinically found adequate and the arterial blood gas report was also within normal limits; therefore, a pulmonary function test was not done. Measurement of pulmonary artery wedge pressure has been suggested in the presence of pulmonary oedema.
There has been considerable debate over the merits of preoperative drainage of the cyst. The potential hazards of drainage are the possibility of intraperitoneal spillage and seeding of ovarian carcinomata and increased risk of intra abdominal infection, haemorrhage and adhesions. The main advantage of drainage is shrinkage of the cyst to a more manageable size and subsequent ease of operation.
The patient received general anaesthesia with controlled ventilation for resection of the cyst. Acid aspiration syndrome was prevented by cricoid, pressure in this case. However, oral administration of antacids prior to induction has been suggested []. It is important to ensure that intravenous cannulae are adequate to cope with the expected rate of transfusion. In our case blood pressure was maintained throughout surgery.
The postoperative course was relatively uncomplicated in our patient. In our case coagulation abnormalities were not seen.
Six of eight reported cases encountered post-operative ventilatory difficulty,,,. Postoperative pain may contribute to ventilatory disability and was managed satisfactorily with pentazocine in our case. Pulmonary oedema has been descibed following cyst drainage and in the postoperative period,.
Postoperative hypothermia may largely be avoided by prevention of intraoperative heat loss. Intestinal ileus has been reported in several cases. Gaseous distension of the abdomen has also been described and has led to death in one case. The risk of both is thought to be reduced by the use of an abdominal binder. However, in our case an ileus did not develop and oral feeding was started on the third postoperative day and the patient was discharged on the twelfth postoperative day.
These patients are at risk from deep venous thrombosis and pulmonary embolism. Intravenous dextran 70, and rapid mobilisation were the prophylactic approaches in our patient.
[Table - 1]