1. Introduction

Recurrenceof theBartholin’scystandscarringof the vaginal wallfollowingvariousconventional surgical proceduressuch asdrainageof anabscessor marsupia-lization, etc.causean unpleasant situation for thepatient and thecouple[1].Infectionof theBartholin’sgland cyst andformationof theabscesscausessevere vulval pain and dyspareunia.Theexcisionof theBartholin’s glandcyst orabscesswith layer closurecausesscarring of the vaginal wall andsubsequentdyspareunia. To avoid scarring of the vaginal wall andrecurrence followingthe surgical treatment [2, 3],we demonst-ratedthe below described operative procedure to excise theBartholin’s cystorabscess with thegland, and studieditsfeasibility.

2. Materials and Methods

In a retrospectivestudyin our private hospital from December 2017 through November 2020westudied consecutive caseswho hadundergonesurgical treatment of the Bartholin’s gland cyst orabscessfor benign indications. Weexcludedexcisionof other cysts of the vagina or vulva from thestudy. Each patient signed informed consent beforeoperation.Purohit general hospital ethics committee approved thestudy on dt. 2.6.20 (Referenceno-04/2020/PGHIEC).We wanted to know the feasibility of the excision of the Bartholin’s cyst or abscess by the following described procedure.

2.1 Procedure

Fourdropsof injection adrenaline(1:1000)weremixed with 40 ml of normal saline [4].Thesolutionwas infilt-rated subcutaneously into the loosetissuesaround the cyst orabscessto facilitate thedevelopmentof the tissue dissection plane and toreduce intraoperative bleeding.Medial to the hymen fold, a linear incision of 2.5–3.0 cm wasmadeby a surgical knife to incise the vaginal skin.The incision margins weregrasped andstretched byAlli’sforceps tomake asplit.The cleavage between the vaginal skin and the cyst wall was established by artery forceps orscissors using the open and close technique of dissection to expose the cyst wall.

The exposedcystwallwasgraspedby another Alli’s forcepsandpulled gentlyin the medially down-ward direction.Then,the tipof the index finger wasinsertedinto thecleavagebetween the vaginal margin and thecystwall (Figure 1),and thetensecyst was gradually dissected above downwards out of the loose subcutaneous andparavaginalfasciausingthe tactile feel.No sharpdissectionwasused. Vessels and tough cords of the tissue encountered on the way during the blunt dissection were coagulated using bipolar forceps coagulation(40-45 W)and separated from the cyst wall using scissors(Figure2)to cause bloodless enucleation.Medially downward traction of thecystand bluntdissection byfingergradually easedcomplete sca-ling of thecystwiththe glandout of the loose parava-ginalbedoftissues.The labial or vaginal skin was not excised at any stage of the operation.No mops wereused toclean blood duringdissection.Normal saline spray by a syringe of 20 ml with suction aspiration was used to keep the operation site clean.

In the case of an open cyst or an open abscess, normal saline lavage with suction aspiration was done to clear the contents.The tip of an artery forceps was used to grasp the cyst wall margin and pulled in the medially downward direction in a similar fashion as described before for the intact cyst.The tip of the surgeon’s left index finger was placed inside the lumen of the cyst or abscess (Figure3) to define the outer limit of the cyst wall and then, the blunt dissection procedures were carried out bythe right index finger in a similar aforementioned fashion for an intact cyst.

After removal of thecyst, incision margins were retracted byAlli’s forcepstoexposebleeder, if any inside thewoundbed and were cauterized using bipolarforcepscoagulation (40-45 W)toachieve complete hemostasis. Suturing of the wound cavity in layers or closure of the wound margins was not done.No gauze packing was used inside the wound to cause hemostasis, but a betadine lotion-soaked ribbon gauze pack was placed in the vagina(outside the wound)for approximately 4–6 h tokeepboth incision margins inpositionand tokeepthe woundcompressed. Postope-ratively, thepatientwas givenbroad-spectrum antibio-tics. She was examined vaginally by one finger 24 h after the operation to find hematoma if any and before sending her to the home.She was further advised to have sitz baths and the local application of betadine ointment for 2 weeks at home.They were followed up after 6weeksand 6months.

Figure 1: Shows Bartholin's cyst (C) dissection by index finger (F) from above downwards. V- vaginal wall.

Figure 2: Shows an intact Bartholin's cyst (C) following excision.

Figure 3: Shows the excision in a case of an open cyst using bipolar forceps haemostasis (B). F-Index finger tip inside an open cyst.

3. Results

Thetotalnumber ofcaseswas28. All patients were between 22 and 40 years of age, and were married.
Sevencasesof 28 hadundergoneincision and drain-ageof theBartholin’sabscessas an emergency measure toprovidereliefof severe vulvar pain. 21 cases of 28 underwent excision of Bartholin’s cyst or abscess owing to vulval swelling, pain, and dyspareunia.Of them, fourcaseshadahistoryof spontaneous rupture of theabscess within 24hoursbefore theoperation, and twocasesunderwentBartholin’sabscessexcisiondur-ing thepregnancy.

AllcasesunderwentunilateralBartholin’s cyst gland excisionby the described procedure.No other surgical proceduresuch asmarsupialization or Word catheter wasperformedin anycase.Therewasno major intra-operative complication.None of the caseshad severe intraoperativebleeding. Fivecasesdeveloped postop-erative pyrexia, whichsubsidedafter 48hoursof broad-spectrum antibiotic administration.Allcases experi-encedless postoperative pain.None of cases had burn ulcer of skin. Spontaneous apposition of the vaginal wound margins wasseen24hours afteroperationin allcases.None of the cases developeda postoperative hematoma, injury to the rectum, severe cellulitis, or abscess of operation site requiring readmission. None of the cases developed severe postoperative scarring at the operation site and subsequent dyspareunia.After 6 weeks following theoperation, no difference between the leftand the right vaginal wall was observed except a light scar mark on the site of the incision.

Histopathological study of the excised gland did not show malignancy in any of the cases.None of the cases complained of difficulty in sexual function subsequently after 6 weeks.The median operation timewas17min (13–23min).Hospital stay ranged from 1 to 2days. None of the 21 cases reported recurrence after excision of the cyst or abscess. Allthose sevencaseswho receivedincision anddrainageofBartholin’s abscess developedrecurrenceof the cyst orabscess.

4. Discussion

Infiltrationof the normal saline mixed solution with injection adrenaline(1:1000)around the Bartholin’s cystcausedtemporary hemostasis and helped to developa bloodless soft tissue dissection plane. Thehydrodissectionalsoassistedthe progress of blunt dissection byfingerusing tactile feel to enucleate through theskinsplitthe firm Bartholin’s gland mass(cyst orabscess)entirely from the loose para-vaginalfascia.Bipolar forceps coagulation hemostasis avoided the use of sutures to ligate bleeder if any, and thus, avoided the development of subsequent suture-induced scarring of the vaginal wall.

Incontrastto conventional surgical methods ofexcision, no layer closure wasneededin thisstudyas both incision margins fall on each other afterremovalof the space-occupyingsubcutaneouscyst. Non-recurrence of Bartholin’s cyst after the excision indicated complete excision by the present procedure. Methods of fistulization of Bartholin’s cyst such as marsu-pialization, Word catheter, and incision and drainage, though are simple have the disadvantages of frequent recurrence, scarring, dyspareunia, persistent drainage, and hemorrhage [1, 5, 8, 9].

Similar tofindingsby anotherstudy [6, 7],the present one-time initial surgicalexcisiontreatment of the Bartholin’s glandin eithercystor abscess stage can bedone.The excision avoided the botherations of recurrence in this study - finding similar to other studies [2, 3, 8,9]. Exci-sion usingbipolar hemostasis avoided layer closure by sutures and theformationof excessive scarring of the vaginal wall andsubsequent dyspareunia. Similar to theearlierstudy, theexcisionmethod did not hamper thesexualfunction ofwomenof thisstudy [9].

Contribution to Authorship

All authors qualified for authorship.

Disclosure of Interests

All authors have nothing disclosure of interest to declare.

Funding

No external funding was received for the study.

Acknowledgements

The authors would like to thank Vijay Babar for statistical assistance in the planning of the study.

References

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