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  • 1. Inject Local Anesthetic
  • 2. Incision
  • 3. Dissection
  • 4. Draining of Cyst
  • 5. Removal of Cyst
  • 6. Closure
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Pediatric Excision of Ganglion Cyst from Right Wrist

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Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES
Philippine Children's Medical Center

Main Text

A ganglion cyst is a small, fluid-filled sac that forms over a tendon or joint. It presents as a lump underneath the skin, which contains a jelly-like material that is typically thick, sticky, clear, and odorless. These cysts most commonly develop on the tendons of the wrist or hand, but can also appear on the ankle or foot. The exact cause is unknown, but injured joints or tendons are more likely to form a ganglion cyst. Ganglion cysts are usually painless; however, if a cyst presses on a nerve, it can cause pain, tingling, numbness, or muscle weakness. Asymptomatic ganglion cysts do not require treatment, and about half disappear without intervention. But with larger or symptomatic cysts, treatment may be recommended. Fluid inside the cyst may be aspirated to relieve pressure and pain, but it does not eliminate the cyst, and is associated with a high level of recurrence. Excision of the cyst can also be performed. It is more invasive, but generally has a lower level of recurrence. Here, we present the case of a pediatric patient with a ganglion cyst on her right wrist. Excision of the cyst was elected over aspiration in order to decrease the chance of recurrence.

Benign tumors, connective tissue diseases, wrist 

Ganglion cysts are mucin-filled cysts that are most commonly found on the dorsum of wrists. They arise from trauma and/or mucoid degeneration of the periarticular structures that present as a firm, well circumscribed knot.1 Ganglion cysts are distinguished from synovial cyst due to the lack of communication with the joint cavity or the synovial membrane. The size of the cyst increases with activity and can impinge on local nerves, resulting in motor and/or sensory loss. Diagnoses of ganglionic cyst is usually clinical and can be determined with transillumination. First line treatment for most patients is observation as over fifty percent resolve gradually but aspiration and excision can relieve impingement on neurovascular structures, improve joint pain and decrease rate of recurrence.2 

This female pediatric patient arrived to the clinic with a firm, smooth, unilateral ganglion cyst on the dorsum of her right wrist. This patient chose excision over aspiration due to the lower chance of recurrence. There were no known allergies or contraindications for the procedure.

No imaging was necessary for excision of the ganglion cyst. 

Ganglion cysts are the most common soft tissue hand mass.1 They are thought to result from the mucoid degeneration causing herniation of connective tissue from the tendon sheaths, ligaments, joints capsules, bursae and menisci with no true overlying epithelial lining. This swelling contains a gelatinous fluid that overlies the joint and be found anywhere in the body.1 Though this patient has a dorsal ganglion, pediatric ganglions are more commonly found on the volar surface of the hand and wrist, whereas they are most commonly dorsal in the adult population.3 Recurrence of ganglion cyst is approximately 50% with aspiration and 10% with excision surgery.4

The patient was given the options for her treatment before her procedure took place. As she had a large cyst that was causing her pain and an unpleasant cosmetic presence, observation deferred. She ultimately chose excision over aspiration due to the lesser chance of recurrence. Observation is typically the first line treatment for ganglion cyst as 50% of the time they regress over time with no intervention.2 Aspiration and excision is often turned to when the cyst recurs after a period of observation and fails to regress. Aspiration while far less invasive than excision of the cyst but does have a much higher recurrence rate of 50% within the next year compared to excision.2 With a higher chance of complications from a more invasive procedure, the recurrence rate is far lower at 10% with excision.4 Though this patient had a dorsal wrist ganglion cyst, volar wrist cyst have a greater complication rate and a higher recurrence rate due to the complexity of the volar wrist’s neurovasculature. If symptomatic relief is the patient’s primary concern, a conservative method is preferred, while surgical excision will decrease the likelihood of recurrence. 

No special considerations were indicated for this patient. 

This procedure is done under local anesthesia only. Local anesthetic is injected on top and around the ganglion with an incision made on top of the cyst taking precaution not to penetrate it. A mosquito hemostat is used to blunt dissect around the ganglion as much as possible.  As this ganglion cyst penetrates deeper in between the tendons of the wrist, the decision to make an incision into the cyst to evacuate the gel-like fluid is made. This is done to avoid injury to the structures underneath and give the surgeon the ability to extract the cyst wall while he dissects out the inferior border that is adjacent to the underlying tendons. Mosquito hemostats are attached to both sides of the incision on the cyst to ensure a point of reference with the cyst wall while dissecting. Electrocautery is used throughout the procedure to separate the cyst wall off surrounding soft tissue. Since this cyst dives deeper into the underlying tendons, a marsupialization procedure is executed. Marsupialization is performed with the cyst wall sutured to the surrounding soft tissue to form a continuous surface from the exterior surface to the interior surface of the cyst. This is done so the cyst is able to remain open and drain freely. Hydrogen peroxide is then used inside the incision for its hemostasis and antiseptic properties. Subcuticular suturing of the overlying skin is done with precaution not to close the cyst wall due to the increase chance of recurrence.  

This procedure is completed in 10-15 minutes, so it is done in an outpatient setting with the patient discharged soon after. Prognosis for ganglion cyst excision is excellent, providing immediately pain and cosmetic relief. Potential complications of surgery are infection, tendon injury, decrease range of motion of the joint involved and neurovascular injury. The time frame of another ganglion cyst varies from patient to patient. For some patients it is just months before another one arises, for some years and others it never will. In a rural setting, procedures like these can be utilized to improve the quality of life to patients who may have to wait several months for simple elective procedures. 

Minimal equipment is necessary for ganglion cyst excision. 

  • Antiseptic cleansing solution
  • Local anesthesia in syringe
  • Scalpel
  • Sterile supplies – bandages, drapes, gauze, gloves
  • Small tipped hemostats (mosquito)
  • Suture supplies

Nothing to disclose

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online. 

Citations

  1. Giard MC, Pineda C. Ganglion cyst versus synovial cyst? Ultrasound characteristics through a review of the literature. Rheumatol Int. 2015 Apr;35(4):597-605. doi: 10.1007/s00296-014-3120-1. Epub 2014 Sep 5. PMID: 25190552.
  2. Suen M, Fung B, Lung CP. Treatment of ganglion cysts. ISRN Orthop. 2013 May 28;2013:940615. doi: 10.1155/2013/940615. PMID: 24967120; PMCID: PMC4045351.
  3. Coffey MJ, Rahman MF, Thirkannad SM. Pediatric ganglion cysts of the hand and wrist: an epidemiologic analysis. Hand (N Y). 2008;3(4):359-362. doi:10.1007/s11552-008-9122-2
  4. Kang L, Akelman E, Weiss AP. Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain. J Hand Surg Am. 2008 Apr;33(4):471-5. doi: 10.1016/j.jhsa.2008.01.009. PMID: 18406949.