Bartholin’s

Cyst
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Noureen P M

Roll No 44
 Bartholin’s
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Gland

 The gland lies posterolaterally in relation to the

vaginal orifice,deep to bulbospongiosus muscle and
superficial to outer layer of the triangular ligament.

 It’s embedded in the erectile tissue of the vestibular

bulb at its posterior extremity.

 Normally impalpable but readily palpable between

finger and thumb when enlarged by inflammation

 Its vascular bed accounts for the brisk bleeding

which always accompanies it’s removal
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 The duct passes forward and inwards to open, external to

hymen, on the inner side of labium minus

 Gland measures 10 mm in diameter, lies near the junction of

middle and posterior thirds of the labium majus

 Duct of gland is about 25 mm long and thin mucous secretion

can be expressed from it by pressure upon the gland

 The Bartholin’s gland and duct infected in acute gonorrhoea

where the reddened mouth of duct easily distinguished
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 The Bartholin’s gland is a compound
racemose gland and its acini are lined
by low columnar epithelium

 The epithelium of the duct is cubical

near the acini, but becomes transitional
and finally squamous near the mouth of
the duct

 Function of gland is to secrete

lubricating mucous during coitus

 The labia majora join at the posterior

commissure and merge imperceptibly
into the perineum
 Bartholin’s Cyst
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Bartholin’s cyst is formed when it’s duct is blocked either by

inflammation or by inspissated secretion
Cause maybe trauma, infection, wrongly directed
episiotomy(duct) infection further leading to abscess
formation.
It appears as a swelling on the inner side of the junction of
the anterior two-thirds with the posterior one-third of the
labium majus
A smaller cyst remains asymptomatic but larger one bulges
across the vaginal introitus and causes dyspareunia,
discomfort – it may get infected, thus needing excision or
marsupialization
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 Management
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 Analgesia

 Antibiotics

 Surgical drainage by
marsupialisation

Is recomended
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 Marsupialisation : It is easy to perform, causes less bleeding and

retains the gland function.

 An incision is made over the inner aspect of the cyst to involve the
labium minora and the cyst wall, thereby releasing the cyst contents.

 The opening is enlarged to make it elliptical

 Then the edges of the vagina and the epithelial lining of the cyst are
sutured using interrupted sutures.

 Thus the final opening is circular and the cyst is left open thereby
preventing accumulation of secretions and recurrence
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 Marsupialisation is easy to perform, causes less bleeding and

retains the function of the gland

 The incision runs along the long axis of the labia majora away
from the introitus to avoid a painful scar and dyspareunia

 The cavity is scraped, hemostasis secured and the edge

sutured to the skin

 The cavity shrinks and heals by granulation tissue

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 The advantages of this procedure are

 Its simplicity

 Prevention of recurrence

 Maintanence of gland function ( lubrication)

 A part of cyst wall must be sent for histopathological

examination.
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Treatment of Bartholin Cyst

 Cyst Excision :

The incision is placed along the long axis of the labium majus so
that there is no risk of dyspareunia when healed

The cyst is slowly enucleated using sharp dissection

The gland duct is resected and the entire cyst removed after
clamping and ligating the vascular supply to the cyst
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 The cavity must be obliterated completely to remove all dead

space as otherwise a haematoma may form resulting in
infection.

 The wound edges are then approximated with interrupted

sutures

 A drain may be kept if thought necessary

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 In women above 40, the edges of the cyst must be sent for
histopathological examination to exclude malignancy

 Cyst excision is indicated in the case of recurrent cysts following

marsupialisation
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Myomectomy
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 Myomectomy is enucleation of myomata from uterus leaving behind

a potentially functioning organ capable of future reproduction.

 Victor Bonney – pioneering surgeon in myomectomy

 Atlee brothers – 1st performed Myomectomy in 1844


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 Restoring anatomy and function of uterus, tubes ovaries

following myomectomy are important not only for future
reproductive function but also to avoid future hazards

 Final decision as to whether to perform myomectomy or

hysterectomy is to be taken following laparotomy.

 Pre-treatment with GnRH help reduce size and vascularity of

Uterus.
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 Myomectomy refers to the removal of fibroids, leaving

the uterus behind.

 Myoma implies benign tumours that arise from

smooth muscle cells of uterus but contain varying
amounts of fibrous tissue.

 20-50% women in perimenopausal age cases of

fibroid. It is slow growing.

 It is indicated in an infertile woman or a woman

desirous of childbearing and wishing to retain the
uterus.
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Myomectomy – preoperative requisites

 lts important to counsel the woman on risk of recurrence following a

myomectomy, the probability being 50% in 5 years

 The risk is less when the woman has given birth following myomectomy and in
case of solitary fibroid.

 Autotransfusion arranged a few days before surgery is preferred to donor

transfusion at surgery to avoid transmission risk of HIV, malaria and hepatitis B

 In infertility, other causes of infertility should be excluded.

 Signature for hysterectomy is required in difficult unforeseen circumstances like

cases of high risk of intraoperative bleeding.
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 Plenty of cross matched blood should be available

 Myomectomy should be performed in the preovulatory

menstrual cycle to reduce blood loss during surgery

 Endometrial cancer to be ruled out by D&C

 Bowel preparation avoids bowel injury

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 Vasopressin installation – About 20 units diluted in

200 ml of saline is instilled into the serosa and
myometrium over the myoma

 Bonney’s clamp must be released at 20 min

intervals because there can be accumulation of
histamine like substances which if suddenly
released at the end of postoperative shock.

 Tourniquet : Soft plastic tube passed through a

small hole one on either side made in an avascular
part of the broad ligament at the level of uterine
isthmus. This tourniquet tightened before making
incision for myomectomy.
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Technique of Myomectomy – Open Type
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 Opening the abdominal cavity by
Pfannenstiel incision is possible if
the uterus is less than 16-20 weeks
size and is mobile.If difficulty is
anticipated as with large uterus,
fixed uterus with adhesions,
associated PID and endometriosis,
a vertical paramedian incision is
safer

 Care taken not to injure the bladder

while incising the parietal
peritoneum, as the bladder maybe
elevated in cervical and low-lying
anterior wall fibroids
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 The pelvic organs should be carefully inspected

and the feasibility of myomectomy confirmed

 An incision over the anterior uterine wall is

preferred whenever possible and as many fibroids
removed through minimal tunneling incisions

 Haemorrhage controlled with the myomectomy

clamp which is applied from the pubic end of the
abdominal wound and the round ligaments which
will include uterine vessels be gripped The ovarian
vessels temporarily occluded with sponge forceps,
Rubber tourniquet applied for cervical fibroids
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 The capsule should be incised and the fibroid

enucleated. This will minimise bleeding as well as avoid
trauma to the bladder and ureter. Myomectomy screws
help during enucleation

 Following enucleation, the haemostasis is secured and

the cavity obliterated with several catgut sutures. This
will avoid scar rupture during subsequent pregnancy
and labour.

 The clamp should be released and hemostasis

confirmed.

 Submucous fibroid (TVS) – Cavity should be opened

 Important not to injure cornua and tubes in case of

cornual fibroids
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 The raw visceral area should be

well-peritonized to prevent post
operative adhesions.
Hydrofloatation also reduces
adhesions. The uterus remains
bulky following myomectomy and
requires to be anteverted by
plicating the round ligaments with
non- absorbable sutures.
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Results

 Pregnancy rate of 40-50% has been reported following

myomectomy and pregnancy loss reduced.

 However 10-15% continue to suffer from menorrhagia.

 Recurrence of fibroids in 5-10% cases is due to overlooking

seedling fibroids at the time of surgery.
 Complications
z  They include

 Primary, reactionary and secondary haemorrhage

 Trauma to the bladder, ureter (in broad ligament and cervical

fibroids) and bowel during surgery

 Conversion to hysterectomy

 Febrile morbidity or myoma fever ( tissue reaction)

 Relaparotomy

 Infection

 Adhesions ( Btwn uterus and rectosigmoid) and intestinal

obstruction

 Recurrence of fibroids (50% in 5 years) and persistence of

menorrhagia (10%)
Vaginal
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myomectomy

 Indicates in submucous
fibroid polyps.

 Vaginal myomectomy is
possible in cervical
fibroids and
pedunculated fibroid
polypus and if more than
50% submucous fibroids
project into the cavity
 Hysteroscopic
z myomectomy

 Has become possible for submucous fibroids not removable by the simple
vaginal route.

 Limited to myomas less than 5 cm in size and where more than 50% is
projecting into the cavity.

 Preoperative TVS and sonohysterography ideal to assess whether

hysteroscopic removal is feasible.

 Pre-treatment with GnRH in larger fibroids is useful

 The fibroid is excised either by cautery, laser or resectoscope.

 It is best done under laparoscopic guidance to avoid uterine perforation.

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Hysteroscopic myomectomy -
Complications
 Cervical trauma, uterine perforation

 Thermal injury

 Bleeding – Foley catheter can be used as tamponade to stop

bleeding

 Infection

 Failure

 Uterine adhesions

 Complications of distending media

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Laparoscopic myomectomy is feasible in
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 A pedunculated fibroid

 Useful to remove subserous and intramural fibroids

 Subserous fibroid not exceeding 10 cm in size and not

more than four in number. Multiple fibroids of any size
should be approached by laparotomy. Unipolar, bipolar
cautery and laser have been employed to remove the
fibroma and obtain haemostasis. The fibroma is retrieved
through posterior colpotomy, minilaporatomy or by
morcellation. Myolysis a technique of destruction of myoma
tissue by laser or cautery, is a sophisticated technology
practised by endoscopists

 LAVH enables vaginal hysterectomy to be completed from

below in the presence of pelvic pathology.
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 Laparoscopic
myomectomy is made
easier and faster by
newer instruments,
morcellator, newer
energy sources and
newer suture materials.
The bleeding is
controlled by infiltration
of myoma with
vasoconstrictors and
bilateral uterine artery
ligation before
myomectomy
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Disadvantages of Laparoscopic
Myomectomy
 Although a minimal invasive surgery, and without an abdominal scar,
laparoscopic myomectomy can cause more bleeding because of no
applicability of a hemostatic clamp, and being an adhesiogenic
procedure, it takes longer to perform. Post operative adhesions can
increase the infertility rate. Scar rupture is also reported in late
pregnancy and during labour. Some use intercede (oxidised regenerated
cellulose) to prevent or reduce adhesions. The major complication is
rupture of the myomectomy scar during pregnancy or labour due to
imperfect or inadequate suturing of the myomectomy wound.
Laparoscopic myomectomy may therefore not be safe in an infertile
woman except for small fibroids. Recurrence rate is higher than that in
laparotomy.
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