Adnexal surgery

What is adnexal surgery?

Adnexal surgery is an operation on your ovaries or fallopian tubes, the organs that sit on either side of your womb. Surgeons use it to remove cysts, treat blocked or damaged tubes, or take out growths that are causing you problems.

What conditions does it treat?

Most people who have this surgery have an ovarian cyst or another type of adnexal mass, a growth on or near the ovary. Around 1 in 10 women will develop one of these masses at some point in their life, and most turn out to be harmless.

Adnexal surgery can treat:

• ovarian cysts, including follicular and corpus luteum cysts, which can grow large enough to cause pain or twist the ovary
• dermoid cysts, non-cancerous growths that can contain tissue such as hair, skin or teeth
• endometriomas, sometimes called 'chocolate cysts', which form when tissue like the womb lining grows on the ovary
• hydrosalpinx, a fallopian tube that has become blocked and filled with fluid, often after infection, appendicitis or endometriosis
• ectopic pregnancy, where a fertilised egg implants outside the womb
• Rarely for anovulatory infertility related to Polycystic Ovary Syndrome (PCOS), utilising laparoscopic ovarian drilling (where medications have not helped)
• a small number of masses that turn out to be cancerous.

What are the benefits of having adnexal surgery?

Removing a cyst or mass can relieve pain and prevents the risk of it growing further or causing the ovary to twist on itself. It also allows the tissue to be checked properly to confirm whether it's cancerous.

If a damaged or blocked fallopian tube is affecting your chances of pregnancy, surgery to repair or remove it can improve your fertility, including your chances of success with IVF. Ectopic pregnancy surgery can also be life-saving, as this condition can be fatal if left untreated.

Are there different types of surgical approaches?

Most adnexal surgery is now done by keyhole surgery (laparoscopy), using a small telescope-like camera passed through a cut at your belly button, along with two or three further small cuts near your bikini line. This causes less pain, a lower chance of fever, and a shorter hospital stay than open surgery.

Open surgery uses one larger cut and tends to be used for very large cysts or when there's a chance the growth could be cancerous, since it gives the surgeon a clearer view. Occasionally, an operation that starts as keyhole surgery needs to be changed to open surgery partway through.

A specific technique called ovarian drilling, using a heated needle or laser to create small marks on the ovary, is sometimes used for polycystic ovary syndrome, but only when medicine hasn't worked or isn't suitable.

What happens before the operation?

Your doctor will examine you and arrange an ultrasound scan to look at the cyst or mass. Your age, family history and how the growth appears on scan all help decide whether you need surgery.

You may also have blood tests, sometimes including specific markers linked to ovarian cancer, and a pregnancy test to rule out an ectopic pregnancy. If cancer is a concern, a CT or MRI scan may be arranged too.

Many cysts don't need immediate surgery. Instead, 'watchful waiting' is often recommended, with a repeat scan after a few weeks or months to see if the cyst has gone; if you've had the menopause, you may have scans and blood tests every 4 months for a year because of a slightly higher risk of ovarian cancer. If surgery is recommended, it's worth telling your surgeon about your fertility plans beforehand, so they can discuss how much ovarian tissue can be preserved.

What happens during the procedure?

You'll be given a general anaesthetic, so you're asleep throughout. The steps then depend on whether you have keyhole or open surgery:

1. For keyhole surgery, the surgeon makes a small cut at your belly button, fills your abdomen with gas so they can see clearly, and passes a laparoscope through to view your ovaries and tubes.
2. Two or three further small cuts, usually near your bikini line, allow instruments to be passed in to complete the operation.
3. The surgeon removes the cyst, mass or affected tissue, aiming to leave as much healthy ovary in place as possible.
4. Any bleeding is controlled using heat, stitches, or products designed to help it stop.
5. The cuts are closed, usually with dissolvable stitches. For open surgery, a single larger cut is used instead, and the whole ovary may need to be removed if cancer is suspected.

What does recovery look like?

In hospital, most people having keyhole surgery go home the same day or the next day. Open surgery usually means staying in hospital for a few days.

At home, you'll likely have some tummy pain or referred pain (when you feel pain in one part of your body while the actual source of the problem or injury is located somewhere else) for the first few days, which should then improve. If any tissue was sent off for testing, results are usually back within a few weeks.

Contact your doctor if you notice heavy bleeding, severe pain or swelling in your abdomen, a high temperature, or dark or smelly vaginal discharge, as these can be signs of infection.

What are the risks and complications?

As with any surgery, there are risks to be aware of:

• pain, bleeding and infection at the site of surgery
• adhesions, or internal scar tissue, forming afterwards
• reduced ovarian function, since removing a cyst can affect the number of egg-containing follicles left, even though your surgeon will try to preserve healthy tissue
• rarely, damage to nearby structures such as the bladder, ureters or bowel
• occasionally, keyhole surgery needs to be converted to open surgery during the operation, for example if the findings are more complex than expected.