Bartholin's Gland Cyst

• Excision of the Bartholin's gland has

been called the "bloodiest little
operation in gynecology." It is indicated
for persistent and recurrent Bartholin's
gland abscess and cyst. The key to
Bartholin's successful excision is hemostatic
Gland Excision control of the copious blood supply to
the gland.
• The purpose of the operation is to
remove the entire Bartholin's gland.
Bartholin's Gland
Excision
• Physiologic Changes. Bilateral removal of
Bartholin's gland eliminates the secretion of
fluid from the gland that is useful as a vaginal
lubricant. In the well-estrogenized vagina,
however, this is generally not a clinical
problem.
• Points of Caution. Meticulous hemostasis is
essential. The branches of the pudendal artery
are frequently lacerated during excision of the
Bartholin's gland. They must be carefully
identified, clamped, and tied, or postoperative
vulvar hematoma will result.
Technique

• The patient is
placed in the
dorsal lithotomy
position, and the
perineum is
prepped and
draped.
• Careful
rectovaginal
examination is
performed to
outline the entire
Bartholin's gland
cyst or abscess.
• To control bleeding, it is essential
that the surgeon understand the
vascular supply to the labia and
vagina.
• The labia are retracted laterally with several
Allis clamps. For resection of the Bartholin's
gland, it is preferable to make the incision
over the vaginal mucosa, directly over the
meatus of the gland, rather than over the
labia majora. Healing in this area appears to
be faster and less painful for the patient
than does healing to an incision in the skin
of the labia.
• The vaginal mucosa is
retracted medially, and
the skin of the introitus is
retracted laterally to
expose the wall of the
gland. Its meatus may be
seen if not distorted by
old infection and scarring.
• A small Metzenbaum scissors is
used to lyse the filmy adhesions
between the wall of the abscess or
cyst and the overlying vaginal
mucosa and subcutaneous tissue
of the labia majora. Either forceps
or an Allis clamp is placed on the
wall of the cyst. The wall is
retracted to allow adequate
dissection and identification of the
blood supply to the gland from
branches of the pudendal artery.
• It is important to
excise the entire
gland. Incomplete
removal may lead
to a recurrence of
the cyst or abscess.
The last few filmy
adhesions to the
gland are incised
with Metzenbaum
scissors, and the
gland is removed.
• After removal of
the gland, there
is frequently
bleeding from
the wound.
• Care must be taken
that meticulous
hemostasis is carried
out throughout the
bed of the gland.
Hemostasis frequently
requires
electrocoagulation
and suture ligation.
• The bed of the
gland should be
closed with
interrupted 3-0
absorbable suture
to eliminate dead
space.
• A small closed suction
drain is inserted into
the wound and sutured
into place with
interrupted 5-0
absorbable suture. This
prevents the drain from
being prematurely
dislodged but allows for
easy removal.
• The closure of the vaginal mucosa to the skin of the introitus is
completed with interrupted 3-0 Dexon suture.
• The closed suction drain is removed on the third or fourth day
when there is no further drainage.
• Cultures of the abscess should be made. Frequently, gonococci,
streptococci, or other organisms are found; therefore, preoperative
antibiotics are used in most cases.
• On the third postoperative day, the patient is placed on a regimen
of hot sitz baths and is given a stool softener and laxative.
• Sexual intercourse can usually be resumed in 4 weeks.
 • Indicated when there is a large abscess
that makes surgical excision of the
gland difficult.
Marsupialization • The surgeon opens wide the wall of the
abscess and allows the purulent
of the exudate to drain.
Bartholin's • The membrane of the abscess is then
sutured to the vaginal mucosa and to
gland the skin of the introitus in order to
effect granulation and
reepithelialization of the wound from
the bottom of the abscess to the top.
 Marsupialization of the Bartholin's gland

• The operation is fast. Hemostasis is not difficult and can be performed under local
anesthesia.
• The purpose of marsupialization of the Bartholin's gland is to exteriorize the abscess in
such a fashion that it will become epithelialized from the base.
• Physiologic Changes. If marsupialization is successful, the epithelium within the gland will
be epithelialized with squamous epithelium.
• Points of Caution. The opening into the gland must be sufficient to promote adequate
drainage
Technique

• A thorough bimanual examination should be performed to

determine the extent of the abscess.
Technique
• The labia are retracted with interrupted 3-0 sutures, and
the introitus of the vagina is exposed. An incision is made
over the mucosa of the vagina at its junction with the
introitus down to the wall of the gland.
 Technique

• The wall of the gland is incised. The entire length of the superficial incision is shown.
Technique
• The contents of the abscess are evacuated.
Technique

• A culture is taken of the

abscess. The walls of the
abscess are grasped with Allis
clamps.
Technique
• The wall of the
abscess is sutured
with interrupted 3-0
synthetic absorbable
suture to the skin of
the introitus laterally
and to the vaginal
mucosa medially.
Technique
• The marsupialization is complete.
Generally, no packing or drain is
necessary. The patient is placed on a
regimen of hot sitz baths on the
second postoperative day. A laxative
and stool softener are given on the
third postoperative day. Antibiotic
therapy should be directed by the
results of the culture. Sexual
intercourse can usually be resumed in
4 weeks.