Bartholinische cyste Ziektebeelden

Niet incideren indien niet fluctuerend. In dit geval: retour 2 dagen. Advies twee keer per dag biotex badje, PCM en diclofenac 50mg 3dd.
Indien pijn in tussentijd onhoudbaar of indien patiente koorts ontwikkelt neemt patiente eerder contact op.

Incisie en drainage met achterlating Word-catheter

Protocol WoMan trial^[1]
Lokatie: polikliniek. Anaesthesie: lokaal of geen anaesthesie.
Benodigdheden:
- Word catheter, 5cc spuitje en no.11 mesje ( samen in pakketje word catheter te vinden in studie koffer)
- Jodium
- Xylocaine 10% of coolspray
- NaCl 0.9%
- Pincet
- Steriele doek
- Steriele handschoenen
- Eventueel gazen

Stappenplan:
1. Jodeer omgeving cyste/abces.
2. Palpeer de cyste/abces.
3. Breng xylocaine 10% spray of coolspray aan.
4. Pak de cystewand vast met een pincet.
5. Plaats met een no.11 mes een incisie van 0,5cm, in de introïtus, buiten de hymenaalring.
6. Draineer de cyste/abces.
7. Spoel de holte tweemaal met NaCl 0,9%.
8. Plaats de Word catheter.
9. Spuit het ballonnetje op met 5cc NaCl 0,9% (de catheter is erg dun, kijk uit dat je niet met de naald door de catheter steekt waardoor het water niet in het ballonnetje maar in de vagina loopt).
10. Plaats vrije eind van de catheter in de vagina.
11. Laat de catheter maximaal 6 weken in situ. Valt vaak al eerder uit. Kans op recidief ca 12%.

Incisie en marsupialisatie

Bartholin Cyst Marsupialization^[2]

1. Place the patient in the dorsal lithotomy position. Block the incision site with local anesthetic with 2% lidocaine with epinephrine or use a pudendal block with 2% lidocaine without epinephrine. Some patients may prefer spinal or general anesthesia, but this requires that the procedure be done in a same-day surgery center.
2. Clean the perineum with povidone-iodine solution (if the patient is not allergic).
   
   
3. Inspect the external genitalia to determine the extent of the duct cyst. Retract the labium laterally to identify the incision site, internal to the hymenal ring. Make the incision longitudinal with respect to the vagina (Fig. 118.3). Incisions can also be done vertically, following the circumferential folds of the vaginal mucosa, but these will lack the natural tension of the mucosa and could lead to premature closure and incomplete marsupialization. Generally a fusiform incision 1 or 2 cm in width at the center is needed to allow for removal of a substantial portion of the Bartholin cyst wall. Avoid excising any portion of the external skin (vs. mucosa). Excise the mucosal fusiform segment first, and if the cyst wall is still intact, excise a fusiform section of the exposed cyst wall in the same manner.
   
   
4. During excision of the mucosal fusiform segment, the cyst wall will usually be entered, the contents will spill, and the cyst wall will collapse. Therefore the mucosa over the cyst should be excised first, so it can be clearly defined. Next, the exposed cyst wall should be grasped with two small hemostats before the cyst wall fusiform segment is removed. Explore the remaining cyst with small hemostats and remove any attached loculations. Patients above 40 years of age are at higher risk for cancer in the Bartholin gland, so look for any signs of neoplastic appearing epithelium on the cyst wall being removed and the remaining cyst wall (Fig. 118.4). The removed tissue should be sent for pathology.
   
   
5. Thoroughly irrigate the cyst cavity with normal saline.
   
   
6. When the Bartholin cyst wall is being sutured, approximate the cut edge of the cyst wall to the adjacent edge of the vaginal mucosa. This allows for more rapid transformation of the Bartholin cyst wall into a normal mucosal lining that will blend into the vaginal mucosa. Interrupted sutures will be placed around the excisional margins using 4-0 Vicryl.
   
   
7. Place an anchoring stitch with long tags proximally to grasp and stabilize the tissue. Pass the interrupted stitches from the inside through just the Bartholin cyst wall. Bring the needle to the surface between the cyst wall and the submucosal layer. Now insert the needle under the vaginal epithelium and pull it to the surface of the vaginal wall. This effectively imbricates the two layers (cyst wall and vaginal mucosa) over the submucosal tissue, which allows them to heal together (Fig. 118.5). The intent is to suture the cyst cavity open.
   
   
8. After the entire site has been sutured open, irrigate the wound and inspect it for bleeding. There should be a gap of at least 1 cm across the open marsupialization. Normally no dressing is needed. A pad is placed to allow for the collection of blood or drainage from the wound. Pressure, silver nitrate, or electrocautery can be used to deal with any bleeding. For persistent bleeding, the entire incision can be closed with suture for 20 to 30 minutes, if necessary, for hemostasis. After 20 to 30 minutes, the suture can be removed and any persistent bleeding treated with pressure, silver nitrate, or electrocautery.
   
   
9. Instruct the patient to perform sitz baths daily for 3 or 4 days and to return for follow-up in about a week (see the postoperative patient handout available at www.expertconsult.com). At that time, the cavity will be probed for patency. Use of prophylactic antibiotics is unnecessary in most cases; the need for this should be assessed individually. Excessive induration in the local tissue or risk factors for infection, such as pregnancy or diabetes, may prompt the need for antibiotic therapy. The sutures will be absorbed without further intervention.