BENIGN GYNECOLOGIC LESIONS SCRIPT

For our disposition and future plans, we should advise our patient to avoid strenuous
activity or exercises for at least a week or until she is comfortable enough. Since our patient
is 17 years old, according to the ACOG Committee Opinion number 783 on Adnexal Torsions
in Adolescents… Adolescents generally recover well from surgery and resume activities
quickly and usually they do self-limiting activities because of the discomfort from the
procedure.

Analgesics may also be taken if the patient experiences pain. So in a systemic review of post-
operative pain regimens including acetaminophen, codeine, and hydrocodone, with no
consensus on a professed regimen. Post-operative pain control is achieved with scheduled
NSAIDs in combination with a short course (3 days or less) of opiates.

INSERT MEDICATIONS:

1. Cefazolin 1g IV 30mins- 1hour of skin incision.

a. 1st generation cephalosporin- to prevent SSI
2. Percocet (Oxycodone hydrochloride + Acetaminophen) 5mg/325mg/ tab 1 tablet
every 6 hours as needed for pain (total daily dose should not excess 4 grams)
a. Oxycodone- semisynthetic opioid analgesic. Relatively selective for mu and
kappa opioid receptors. Inhibits ascending pain pathways, which causes
alteration in response to pain. Produces analgesia, respiratory depression,
and sedation.
b. Acetaminophen- non-opiate, non- salicylate analgesic and antipyretic. Work
peripherally to block pain impulse generation. Acts on hypothalamus to
produce antipyresis.
3. Simethicone 100-250 mg 3-4x/day as required
a. Silicone compound that functions as a non- systemic surfactant, decreasing
the surface tension of gas bubbles in the GI tract. This results in the
coalescence and dispersion of the gas bubbles allowing removal from the GI
tract thru flatulence of belching.
4. Ibuprofen 200-400mg/ cap 1 cap every 4-6 hours as needed for pain
a. NSAID, with analgesic, anti-inflammatory, and anti- pyretic properties.
Inhibits COX 1 and 2 thereby also inhibiting prostaglandin synthesis.
5. Ondansetron 16mg single dose 1 hour prior to induction of anesthesia, or, 8 mg 1
hour prior to anesthesia followed by 2 further doses at 8mg at 8 hourly intervals
a. For post-operative nausea and vomiting
b. Selective antagonist of 5HT3 receptor on both peripherally on vagal nerve
terminals and centrally in the chemoreceptor trigger zone.
6. Docusate Sodium 50-300 mg daily in divided doses (max: 500mg)
a. For constipation. Surfactant decrease in surface tension of oil and water in
stool.
7. Tramadol IM/IV 50-100 mg 4-6 hours over 2-3 mins/ Oral 50-100 mg 4-6 hours.
a. For mod-sev pain
 b. Inihibits reuptake of norepinephrine, serotonin and enhances serotonin
release. It alters perception and response to pain by binding to mu- opiate
receptors in the CNS.

We should also advice proper wound care to make sure adequate healing is achieved. We
should discuss with the patient to clean the incision by gently washing it with soap and
water, but to be careful to not scrub or soak the wound. To not use rubbing alcohol,
hydrogen peroxide, which can harm the tissue and slow wound healing. The incision should
be dry before changing the dressings. We should also advise the patient to look out for signs
of infection in the incision like a yellow or green discharge, change in odour, change in size
of the incision, fever, increasing pain, excessive bleeding. And of course to come back for
suture removal after 10-14 days.

Perineal care should also be advised. Patient should thoroughly wash the external genitalia,
washing in the direction of perinium to rectum and to dry the area thoroughly.

Since our patient is still underage, we should discuss this together with her parents. Ovarian
function and future fertility and risks of recurrence and monitoring. If Oophorocystectomy is
done, contrary to appearances, the remaining cortical tissue after cystectomy contains
numerous viable follicles which can serve for future hormonal production and oocytes for
reproduction. It was noted that even cysts larger than 8cm, an average of 3.7 cm3 of
functioning ovarian tissue was seen on follow up transvaginal ultrasound. In the case of
oophorectomy, according to the ACOG’s practice bulletin no. 174 on the Evaluation and
Management of Adnexal Masses, it was noted that unilateral oophorectomy has not been
shown to impair menstrual regularity or spontaneous pregnancy rates and, although
possibly associated with lower follicular response to controlled ovarian stimulation,
pregnancy and live birth rates are not decreased.

In adults, there is a reported incidence of 3-4% of recurrent MCT following cystectomy.

However, given the slow growth of teratomas, small rate of recurrence and rare risk of
malignancy, the most appropriate method of surveillance is an area of great debate. Given
the sensitivity of ultrasound in detection of this masses, annual imaging in pre-pubertal and
young adolescents has been advocated. However, it has also been argued that regular
surveillance is not required and young women should have regular follow-up with a
physician and no additional imaging/ testing unless symptomatic.

Of course, the specimen will be sent to pathology for biopsy and so our patient is advised to
follow up once with the biopsy results or anytime if with problem.