Laparoscopic Excision of Recurrent Pelvic Lymphocyst Following Pelvic Lymph Node Dissection for Clear Cell Carcinoma of Ovary

STUDY OBJECTIVE: Demonstration of safe laparoscopic technique for definitive excision of recurrent pelvic lymphocyst developing following pelvic lymph node dissection for clear cell carcinoma of the ovary; overcoming the additional surgical challenges of close proximity to vital anatomical structures and dense post-operative adhesions. DESIGN: Surgical video detailing a systematic approach to laparoscopic excision of pelvic lymphocyst - describing individual surgical steps and highlighting relevant anatomy. SETTING: Surgery was undertaken by a gynae-oncology consultant with one surgical assistant. The patient was positioned in modified Lloyd-Davis – with table height and stack adjusted for optimal ergonomics. PATIENTS OR PARTICIPANTS: A 68 year old lady underwent total abdominal hysterectomy, bilateral salpingo-oophrectomy and omentectomy in April 2018 for stage 1A clear cell carcinoma of ovary; followed by completion laparoscopic pelvic and para-aortic lymphadenectomy. The patient subsequently developed a right pelvic lymphocyst, causing pain. Pre-operative imaging described a 3.9 × 3.3 × 3 centimetre right pelvic lymphocyst, with internal septations and thick wall. Two attempts at percutaneous drainage were unsuccessful due to difficulty penetrating the cyst capsule and loculated interior. INTERVENTIONS: Laparoscopic excision of pelvic lymphocyst was undertaken. Pneumoperitoneum was maintained at a pressure of 12mmHG throughout. The pelvic peritoneum overlying the lymphocyst was opened and plane developed using a combination of monopolar, bipolar and advanced energy devices. The ureter and iliac vessels were systematically identified to avoid inadvertent injury; and avascular pelvic spaces developed to aid cleavage of the capsule with minimal blood loss. MEASUREMENTS AND MAIN RESULTS: No intra or post-operative complications occurred. Histopathology confirmed a benign lymphocyst. At post-operative review, the patient reported resolution of pain and improved mobility. CONCLUSION: This video demonstrates a safe laparoscopic approach to excision of a densely adherent pelvic lymphocyst, abutting important pelvic structures – facilitated by the step-wise identification of pelvic anatomy and relevant pelvic spaces.