Ovarian Cyst and Laparotomy

Had a laparotomy in early September to remove an ovarian cyst that turned out to be benign (thank God!). Here's what I learned from the experience.

Detection

Ovarian cysts can be discovered during a routine visit to the OB-GYN via a quick, fairly painless (though occasionally uncomfortable) ultrasound. Since the human ovary is roughly the size of a large olive, ovarian cysts that are more than a few cm in size are easily detected.

Diagnosis

Without looking at actual tissue samples, it's not possible to conclude with 100% certainty as to the nature of the cyst. However, there are a few outpatient tests that can be done that may help determine if the cysts are benign.

• CA-125 (Cancer Antigen 125). Done via simple blood test. Note that this figure is usually higher during the woman's period so wait until your period is over before taking this test.
  
• HE-4 (Human Epididymal Protein 4). Also done via simple blood test. On its own, this test is found to be a better predictor than CA-125.

The results of both blood tests above can be combined to obtain a ROMA (Risk of Ovarian Malignancy Algorithm) score that can classify an individual as either being at low risk or high risk for ovarian cancer. At least one study, however, found it more accurate with post-menopausal women.

Aside from the two blood tests above, a separate test can be done via ultrasound to assess the flow of blood to the cyst.

• Color Doppler Flow Imaging. Generally speaking, high resistance flows are good, low resistance flows are bad. Several measurements are taken which collectively determine the Sassone Score. The higher the score, the more likely it is that the cyst is malignant. A score of 8 or higher has a very high chance of malignancy.

Deciding What to Do

If the cyst is still fairly small and if the results of the three tests above point strongly to the cyst being benign, it may be possible to remove the cyst via a laparoscopic procedure. Your OB-GYN may have sufficient experience to perform this procedure.

However, if the cyst is large, or if there is a risk of malignancy, it can be more prudent to have a laparotomy done so that the cyst can be removed intact, and a frozen section can be done while the patient is still in the Operating Room. 

If the cyst is found to be malignant, the ovary itself as well as adjacent lymph nodes may have to be removed, and a laparotomy gives the surgeon a clear field with which to work. In such cases, you may be better off consulting a gyne-oncologist who has had experience doing this type of work.

Hospitalization

What follows below is my own experience. Your mileage may vary.

Day before surgery

• Arrived at hospital admission department at 3pm with the admitting orders from the surgeon. Signed admission paperwork, was escorted to hospital room (which had been reserved by the surgeon beforehand). Settled in.
• Blood drawn for routine blood test
• Interviewed extensively by nurse for my medical history (it helps if you've got that all info written down beforehand so you can just hand it to the nurse). 
• Tag with my name, patient number, and my doctor's name was attached to my left wrist for identification purposes.
• Was advised that I can eat whatever I want for dinner, but that I should not eat or drink anything after midnight. Surgery was scheduled for 11am the next day
• Given a Fleet Enema after dinner to empty the bowel since it may be a couple of days before I can comfortably go to the bathroom. Side note: these things work fast!
• Was visited by the anesthesiologist, who explained what the procedure will be like on the day of the surgery. If you routinely take any medication, now would be a good time to ask if you should continue taking them or not.
• Was visited by the surgeon, who talked us through the planned approach and obtained my consent for the course of action she would take if the frozen section came back malignant.
• Signed consent forms for the surgery. Signed "risks have been explained to me" waiver for the general anesthesia.

Day of Surgery

• Took a shower per the anesthesiologist's recommendation soon after waking
• Was given a sedative via intramuscular injection
• Given a pair of compression stockings to wear (these reduce the chances of blood clots forming in the legs)
• Asked to change into hospital gown
• IV line attached to back of left hand (they let me choose which hand)
• Additional tag was attached to my left ankle.
• Bronchodilators administered via inhalation to open up the airways so the anesthesiologist will have an easier time intubating
• Felt sleepy from the sedative within half an hour.
• Half an hour before the surgery, a gurney arrived to take me down to the OR
• Walked to the gurney with my IV line, got on, and was wheeled down with family. Said our goodbyes at the OR door.
• Was wheeled to the side of the OR reception where I was shown the consent forms I had signed and asked to confirm that the signature is mine. Was asked what procedure I was there for, and my answer was compared against the consent form. Tags on both left wrist and left ankle were checked twice, by two different people
• After all the checks, was wheeled into the actual operating theatre. Was transferred to the table. Got settled in when surgeon arrived. Anesthesiologist arrived soon after.
• Last thing I remember is the anesthesiologist injecting something into my IV line and my abdomen being swabbed.
  
• Woke up 2.5 hours later in the recovery room to find the anesthesiologist and my Dad hovering over me. They showed me the cyst that had been removed -- it was in a glass vial. Was told that frozen section came back benign. Fell asleep again.
  
• Woke up some time later as they wheeled me back into my hospital room. Following the anesthesiologist's advice from the night before, I didn't try to help the staff when they transferred me from the gurney to the bed -- just let myself be a dead weight. They tucked me in then left.
• Slept for most of the next 7 hours, waking only when the nurses came in every hour to check my oxygen saturation and my blood pressure. 
• Woke at 10pm and realized I didn't feel any pain at all if I didn't move. Learned that painkillers were being administered via the IV. Also realized they had attached a Foley catheter so I wouldn't have to get up to pee.
• Tag on my ankle had also been removed.

Post-Op Day 1

• Was visited by the surgeon and the anesthesiologist separately. Surgeon listened for bowel sounds and seemed pleased with what she heard. Also checked my urine output. Advised me to not try to get out of bed until the next day to give the anesthesia time to wear off completely.
• Did not experience any of the side effects that people warned I might have: no dizziness, no nausea, no sore throat. 
• Was given a sponge bath and a fresh hospital gown.
• Followed the anesthesiologist's advice and took a lot of deep breaths to get the lungs fully expanded again. Also followed his advice about raising my knees every now and then to keep the blood pumping through my legs. Turns out it's possible to do that without hurting the incision site at all.
• Not allowed to eat anything in the morning, but allowed a small sip of water together with a dose of Losec, which inhibits the production of stomach acids. I continued to take Losec twice a day until I was discharged from the hospital.
• Realized that my vision had become quite blurred -- a side effect of the anesthesia which apparently affects people who have astigmatism. Didn't panic since this was not unexpected and would correct itself once the anesthesia wore off completely.
• There was some concern about my low urine output despite the constant IV infusion from the day before, though it's not unusual due to post-operative SIADH (Syndrome of Inappropriate Anti-Diuretic Hormone). A dose of Lasix got the plumbing working and I managed to produce 900cc of output in two hours.
• Had clear chicken broth for lunch. Tolerated it well.
• By evening, it was clear that I could handle food so I was allowed to have chicken noodle soup for dinner.
• Before dinner, IV was removed since I could eat on my own now. Hep-lock was left on the back of my left hand just in case they need to administer anything intravenously at a later time.
• After dinner, was able to get up from bed (with assistance) and walked around for 20 minutes carrying my Foley bag with me. Felt tired soon after so returned to bed.
• Wore an abdominal binder before getting out of bed, and also before retiring for the night because it makes turning on my side a lot easier. 
• Abdomen felt distended / bloated, which was expected.
• Continued to be given bronchodilators via inhalation twice a day.
• Continued my breathing exercises. Continued my knee raises.
• By 10pm, I started passing gas -- a sign that the intestines are working again. Never thought I'd be so happy over something so silly. I really think walking around even for such a short time helped get things working again.

Post-op Day 2

• Woke up feeling quite good. Had toast, ham, and eggs for breakfast. 
• Painkillers (Voltaren) now administered twice a day via suppository since the IV is out. They feel icky but they work amazingly well, and allowed me to sit up in bed and get up without assistance.
• Was on my feet for a full two hours in the morning -- ate my breakfast standing up next to the Mayo table. Felt good to be on my feet again, even with the Foley bag still with me.
• Surgeon visited and showed us photos of the cysts that had been removed -- turns out there were two. Subsequent tests on the cysts confirmed the initial benign finding.
• Was advised to drink a lot more fluids and told I was progressing well enough that the "accessories" could be removed. So by mid-afternoon, the Hep-lock was out, as was the Foley. 
• Dressing on the incision was changed to a waterproof one so I could take a much needed shower, which I managed to do on my own.
• Saw the incision for the first time before they applied the waterproof dressing: roughly six inches long, running down the abdomen, supported by 16 staples.
• Compression stockings removed before shower and no longer needed.
• Vision back to normal.
• Hit the showers at last. Ah, bliss!
• Urine output continued to be monitored. 
• Abdomen continued to feel distended, which I had already known to expect from reading other accounts online. Made me glad I had bought really loose pajamas and pants with me, otherwise I would have had to resort to wearing a hospital gown again after the shower.
• Back to regular diet. 
• Received my last dose of painkillers before bedtime.

Post-Op Day 3

• Visited by surgeon and given approval to be discharged.
• Had scrambled eggs, ham, toast with strawberry jam for breakfast.
• Was given all the hospital paperwork (including copies of my tests prior to the surgery) by the nurse.
• Was given four more days supply of Losec, which I was to take twice a day for two more days, then take once a day for another two days.
• Was told to return for an outpatient visit with the surgeon on Post-Op Day 7 for the staples to be removed from my incision.
• Settled the bill. Got the hospital seal on paperwork that had to be filed to claim social security benefits.
• Nurse cut the patient tag on my wrist -- free at last!
• Was wheeled out of the hospital by a nurse who watched attentively to make sure I was okay getting in the car.
• Can feel a warm sensation along the incision and get an occasional sharp twinge when I move or flex the abdominal muscles, but it's pretty mild. 
• No twisting, bending, heavy lifting for the next four to six weeks

Post-Op Days 4 to 7

• Started walking a lot to build my stamina. 
• Walked 10 minutes every hour for three hours on Post-Op Day 4.
• Walked 10 minutes every hour for five hours on Post-Op Day 5.
• Walked 15 minutes every two hours for three hours on Post-Op Day 6. 
• Ate regular meals. 
• Stopped using the abdominal binder during my walks on Post-Op Day 5.
• Normal diet, but a lot less in quantity since the abdomen still felt bloated.

Post-Op Day 7

• Went to see surgeon for outpatient appointment.
• Waterproof dressing removed. Incision checked. No redness, no infection. Looks good.
• Staples were removed.
• Incision was cleaned, steri-strips were applied, new Tegaderm dressing applied.
• Advised to leave the dressing on until Post-Op Day 12. After that it can be removed permanently.

Post-Op Day 14

• The dressing is off, the incision is fully closed and healing well. 
• I hardly use the abdominal binder except when I ride in cars, and recovery is progressing smoothly. 
• There's some residual numbness around the incision, but it's expected. It will take a couple of months for the nerves to grow back enough for the numbness to dissipate, although it's apparently not unusual for some spots to be permanently numb.
• The left side of my abdomen continues to be bloated and I still have trouble fitting in the jeans that I wore to the hospital before the surgery. Again, that will take a few weeks to subside completely.

Overall, it's been a good experience and recovery was a lot easier than I thought it would be. Walking early and often has clearly been beneficial, as was my very good tolerance of the anesthesia.

Have been really amazed by the outpouring of support from friends and family the world over throughout the entire process. Makes me wish everyone can experience this kind of positive emotional buzz at least once in their life -- preferably without having to go through surgery. ;-P

Very thankful for all the people who prayed for a good result. And thankful that God graciously listened and answered these prayers.