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 (from the 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 in a duct, canal, or Gartner duct;
• pancreatic cysts , as well as pseudocysts against the background of pancreatic necrosis;
• simple cystic formation of the kidney or liver.

The marsupialization technique can also be used for:

• pilonidal cyst -  coccyx cyst ;
• odontogenic cyst  of the jaw; [1]
• sublingual cyst of the salivary gland (ranula); [2], [3]
• a large intranasal cyst with congenital dacryocele - accumulation of fluid or mucin in the lacrimal sac or its inflammation (dacryocystitis);
• cyst of lacrimal canals (tear ducts);
• nasopharyngeal (nasopharyngeal) Thornwaldt's cyst;
• vocal fold cyst.

Preparation

As with any surgical intervention, preparation for this operation requires an ECG and a complete blood count, coagulogram, RW; a general urine test is given. Before marsupialization of a Bartholin's gland cyst or Gartner's ducts, a blood test is taken for infections that cause STDs, and the microflora of the vagina is examined (by taking a smear).

Also, preoperative studies conducted by specialized specialists include: ultrasound, computed tomography scanning or magnetic resonance imaging of the corresponding organ.

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

Technique of the marsupialization

In general terms, the marsupialization technique consists in opening the cyst (a section of its wall) and removing its contents (a sample of which is sent to the laboratory for microbiological examination). Then the edges of the incision in the wall of the opened cyst are sutured to the edges of the surgical wound or nearby tissues to form an open artificial "pouch" or "bag" (the cyst shell remains in the depths of its open cavity). The healing process of the "pouch" goes through 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 incision in the abdominal wall - with a purulent complication of acute pancreatitis and infected necrotizing pancreatitis, with inflammation of pancreatic false cysts (which are formed in chronic pancreatitis). During abdominal intervention, the omental sac is opened, fixed with a gastrocolic ligament, and drained, clearing the parapancreatic region. [5]

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

Marsupialization of the Bartholin gland cyst (located at the base of the labia minora - on the eve of the vagina) is carried out with unsuccessful attempts to get rid of it in other ways (for example, by puncture) and the presence of large suppuration - a secondary abscess.

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

As clinical practice shows, both the healing rate and the recurrence rate are the same with marsupialization, fistulization and sclerotherapy (using ethanol or silver nitrate).

Marsupialization of a cyst of the Gartner duct - a rare cavity formation in the walls of the vagina in the area of the embryological remnant of the mesonephric duct - is carried out only in the presence of symptoms: pain or pressure in the pelvis, dysuria, dyspareunia, tissue protrusion. And if the cyst is large enough, then it is removed to avoid obstetric complications.  [6]

Marsupialization of cysts of the pancreas, kidney, liver

Marsupialization of a pancreatic cyst 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 gastrocolic ligament is dissected and, for access to the gland, the omental sac is opened; 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 edges of the wound.

This operation is inappropriate if the cyst has thinned walls or does not have formed walls, as well as if there is a communication between the cystic formation and the pancreatic ducts.

Laparoscopic intrarenal marsupialization of a renal cyst, along with transdermal puncture and aspiration or subsequent sclerosis, is an alternative to open surgical methods for the treatment of a simple cyst associated with renal failure, pain, hematuria, and infection. [7]

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

Contraindications to the procedure

The clinical use of marsupialization is limited to fluid cystic lesions and cannot be used for most dermoid and teratoid cysts. This method is unacceptable in cases of parasitic cysts, for example, echinococcal.

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, oncological diseases.

Consequences after the procedure

Such general consequences after the 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 a fever) and its suppuration.

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

A distant complication, which is the result of an unsuccessful operation, experts also consider the recurrence of the cyst.

Care after the procedure

The basic principle of proper postoperative care and successful rehabilitation is to follow the rules of antiseptics and follow all the recommendations of doctors. Patients are taken to measure the temperature, an increase in which allows you to determine the inflammatory process in time, to suppress which antibiotics are prescribed without fail  after surgery .

Specific recommendations depend on the location of the surgical intervention. So, after marsupialization of a cyst of the Bartholin gland or a cyst of the Gartner passage, the genitals should be treated with antiseptic solutions; keep them clean and dry; for two weeks to give up any physical activity and taking baths (only showers), and at least for a month - from sexual intercourse.

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