For children with an ovarian mass that requires surgery, the pediatric general surgery team at Johns Hopkins All Children’s in St. Petersburg, Florida, provides expert care.

Ovarian cysts and solid ovarian tumors occur in children as well as adults. The ovaries can enlarge and form cysts, which are fluid filled, or masses, which are solid, for several reasons, and can include simple ovarian or hemorrhagic cysts, benign masses like endometriomas, or other types of growths known as neoplasms.

In very young infants ovarian cysts can form because of the influence of maternal hormones. In adolescent girls (as in adults) cysts can form as a result of the normal monthly hormone cycle. Solid tumors, both benign and malignant, also occur in children. The most common ovarian masses are usually benign, either a teratoma or a dermoid cyst.

Large cysts and solid masses are usually removed surgically because:

• Pain and risk of infection associated with ovarian torsion 
• Cysts may leak, with the leaked fluid causing pain, so large cysts with demonstrable leaked fluid in the abdomen may require surgery
• Solid masses are never normal and require surgical exploration

How We Diagnose Ovarian Masses

Pelvic imaging is necessary to confirm a diagnosis of an abnormal ovary. A pelvic ultrasound is typically the first test performed. If the characteristics of the mass or tumor are unclear, a pelvic CT or MRI may also be recommended.

Based on the size and appearance of the mass, blood tests may be ordered before surgery to help assess whether the growth is more likely benign or malignant. This preoperative risk assessment helps guide selection of the most appropriate surgical approach.

Ovarian neoplasms typically continue to grow and usually require surgical treatment. When preoperative evaluation suggests a low risk of cancer, an ovarian-sparing procedure can be performed to remove only the mass while preserving the healthy ovary.

If imaging or tumor markers raise concern for malignancy, removal of the entire ovary may be recommended.

Our Approach to Treatment

Surgery to remove an ovarian mass can be done either open or laparoscopically. Open surgery is usually done through a “bikini” incision low in the abdomen, splitting rather than cutting the abdominal muscles. Laparoscopic surgery is done through small incisions in the umbilicus and lower abdomen. After placing ports in these incisions, a viewing scope and operating instruments are inserted.

Some ovarian cysts can be removed while leaving the rest of the ovary intact, but other cysts may require removing the entire ovary and fallopian tube on the affected side. In all cases surgeons take great care to inspect the opposite ovary and protect it from torsion in the future. Incisions are usually closed with absorbable sutures, and skin sutures are buried so stitches do not need to be removed.

Treatment for Ovarian Torsion

A large ovarian mass will pull on pelvic ligaments and make it likely that the ovary will become twisted (called "torsion"), which is very painful and compromises blood flow. This can lead to ovarian ischemia and necrosis if not treated promptly. 

Symptoms of ovarian torsion include sudden severe lower abdominal or pelvic pain (it can be intermittent or constant and may radiate to the flank, back or groin), nausea and vomiting, and tenderness in the lower abdominal region. A pelvic ultrasound is used to diagnose ovarian torsion.

The treatment for ovarian torsion is an emergency laparoscopic surgical operation. The surgeon will untwist the ovary (called detorsion), remove the ovarian cyst (called a cystectomy), and if needed suture the ligaments of the ovary to the pelvic sidewall to help prevent re-twisting (called oophoropexy).

The ovary may need to be removed. Surgeons make every effort to leave an ovary that has the chance of recovery rather than removing it. Sometimes a follow up ultrasound will show a mass that needs to be removed at a second operation. If the ovary is clearly nonviable and suspected to be malignant, removal may be necessary (this is called oophorectomy).

What to Expect

Our team is here to guide you and your child through each step of the process. This includes your child’s pre-operative consultation, anything you need to do to prepare for your child’s surgery, and what to expect the day of. Learn more about what happens before and on the day of your child’s surgery.

We also offer a number of other resources and support services for families. Learn more about some of the resources available to your family.

Treatment of an ovarian cyst or mass depends on the diagnosis and the patient’s symptoms. Many ovarian cysts are small, resolve on their own, and do not require surgery. If surgery is recommended, we will thoroughly explain the procedure to you and answer any questions you may have.

Recovery from ovarian surgery is usually rapid. Most patients are discharged the day following surgery. Patients are usually allowed fluids and food as soon as they recover from anesthesia and are switched from IV to oral pain medicine. Physical activity is restricted for a few weeks after surgery, but patients may return to school within a few days, once the pain subsides.

Other than the normal process of recovering from surgery, removing a cyst while leaving the ovary intact should cause no noticeable effect. Removing one ovary will not affect the normal function of the other ovary, so hormone effects (such as pubertal change and menstruation) and reproductive capacity of the other ovary should be unaffected.