What is marsupialization?

During surgical interventions, including laparoscopic ones, performed for the treatment of cystic formations of various organs, such a surgical method as marsupialization (Greek: marsyppion - pouch) is used.

Indications for the procedure

The main indications for marsupialization are the presence of:

• Bartholin gland cysts;
• large or inflamed cysts of Gartner's duct, canal, or passage;
• pancreatic cysts, as well as pseudocysts on the background of pancreonecrosis;
• a simple cystic mass of the kidney or liver.

The marsupialization technique can also be used for:

• pilonidal cyst - coccygeal cyst;
• odontogenic cyst of the jaw; [1]
• Sublingual salivary gland cysts (ranulae); [2], [3]
• a large intranasal cyst in congenital dacryocele, a collection of fluid or mucin in the lacrimal sac or its inflammation (dacryocystitis);
• Lacrimal cysts (lacrimal ducts);
• Thornwaldt's nasopharyngeal cyst;
• a vocal fold cyst.

Preparation

As with any surgical intervention, preparation for this operation requires an ECG and a general blood test, coagulogram, RW; a general urinalysis is taken. Before marsupialization of the cysts of the Bartholin gland or Gartner's ducts, a blood test for STD infections is taken and the vaginal microflora is examined (by taking a smear).

Also preoperative studies conducted by specialized specialists include: Ultrasound, computerized tomographic scanning or magnetic resonance imaging of the relevant organ.

The optimal method of anesthesia is chosen in advance: local or epidural anesthesia or general anesthesia. [4]

Technique of the marsupialization

In general terms, the technique of marsupialization consists in opening the cyst (incision of its wall) and removing its contents (a sample of which is sent to the laboratory for microbiological examination). Then the cut edges of the opened cyst wall are sewn to the edges of the surgical wound or nearby tissues to form an open artificial "pouch" or "bag" (the cyst shell remains in the depth of its open cavity). The healing process of the "pouch" proceeds by granulation with the formation of scar tissue in its place.

It should be borne in mind that marsupialization of the omental sac (bursa omentalis) is one of the stages of laparotomy operations - through an abdominal wall incision - in purulent complications of acute pancreatitis and infected necrotizing pancreatitis, in inflammation of false pancreatic cysts (which are formed in chronic pancreatitis). In the course of cavitary intervention, the omental pouch is opened, fixed by the gastric-obstric ligament and drained, clearing the parapancreatic area. [5]

In addition, specific surgical manipulations and techniques depend on the localization of the cystic mass.

Marsupialization of bartolin gland cysts (located at the base of the labia minora - in the vaginal vestibule) is performed when unsuccessful attempts to get rid of it by other means (for example, puncture) and the presence of a large suppuration - secondary abscess.

Therefore, at the same time under local anesthesia can be performed marsupialization of the abscess of the bartholin gland: the surgeon widely opens the wall of the abscess cavity (that is, the gland itself) and evacuates its contents. Then the abscess shell is attached laterally to the skin of the introitus and medially to the vaginal mucosa with resorbable sutures, and granulation and wound re-elithelialization occurs in this area over time.

As clinical practice shows, both healing rates and recurrence rates are similar for marsupialization, fistulization, and sclerotherapy (using ethanol or silver nitrate).

Marsupialization of Gartner's passage cyst, a rare cavity in the vaginal wall in the area of the embryological remnant of the mesonephric duct, is performed only in the presence of symptoms: pain or pressure in the pelvis, dysuria, dyspareunia, bulging tissue. And if the cyst is large enough, it is removed to avoid obstetric complications. [6]

Marsupialization of pancreatic, kidney, liver cysts

Marsupialization of pancreatic cysts is most often used if the cyst is false, formed in chronic pancreatitis, and removal of the cyst is technically impossible. During the operation, the gastric-obstetric ligament is dissected and the omental sac is opened for access to the gland; then the cyst is drained through a puncture of its capsule, after emptying the cavity, a part of the anterior wall of the capsule is opened, and its edges are sutured to the wound edges.

This operation is inappropriate if the cyst has thin walls or has no formed walls, as well as in the presence of communication between the cystic formation and the pancreatic ducts.

Laparoscopic intrarenal renal cyst marsupialization - along with transdermal puncture and aspiration or followed by sclerosing - is an alternative to open surgical techniques to treat a simple cyst associated with renal failure, pain, hematuria, and infection. [7]

As a rule, liver cyst behaves asymptomatically, and in the presence of symptoms is most often subjected to percutaneous aspiration of the contents under ultrasound guidance. However, in rare cases, laparoscopic or laparotomic marsupialization of liver cysts, including giant liver cysts, is used, which in many patients is complicated by rupture and bleeding.

Contraindications to the procedure

The clinical use of marsupialization is limited to cystic masses with liquid contents and cannot be used for most dermoid and teratoid cysts. This technique is not acceptable in cases of parasitic cysts such as echinococcal cysts.

In addition, marsupialization is contraindicated when attempts at conservative treatment have failed and if complete resection is necessary.

Also contraindications include: severe heart failure, exacerbation of existing diseases and acute infectious diseases, poor blood clotting, bleeding, cancer.

Consequences after the procedure

Such common consequences after marsupialization procedure are noted as pain, bleeding, tissue swelling, hematoma formation.

Complications after the procedure are associated with infection of the surgical wound (patients have fever) and its suppuration.

There may also be complications after surgery for pancreatic, kidney, and liver cysts. For example, bile leakage may occur after marsupialization of a liver cyst. During the procedure on a pancreatic cyst, the splenic artery may be injured, and patients with pancreatitis may have localized fluid accumulation in the left paracolic trough (requiring surgical drainage). Later, there is a risk of abdominal hernia and chronic duodenal fistula.

A distant complication, which is a consequence of failed surgery, experts also consider the recurrence of the cyst.

Care after the procedure

The main principle of proper postoperative care and successful rehabilitation - compliance with the rules of antisepsis and compliance with all recommendations of doctors. Patients are measured temperature, the increase in which allows you to timely identify the inflammatory process, to suppress which is necessarily prescribed antibiotics after surgery.

Specific recommendations depend on the localization of surgical intervention. For example, after marsupialization of bartholin gland cysts or Gartner's passage cysts, genitalia should be treated with antiseptic solutions; keep them clean and dry; refuse any physical activity and bathing (only shower) for two weeks, and at least a month - from sexual contacts.

In addition, to prevent complications during the recovery period, you should take prescribed medications, eat properly (especially after marsupialization of pancreatic, liver, or kidney cysts), and drink enough water.