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Removal of Ganglion Cyst

Ganglion cyst removal, or ganglionectomy, is the removal of a fluid-filled sac on the skin of the wrist, finger, or sole of the foot. The cyst is attached to a tendon or a joint through its fibers and contains synovial fluid, which is the clear liquid that lubricates the joints and tendons of the body. The surgical procedure is performed in a doc tor’s office. It entails aspiration, or draining fluid from the cyst with a large hypodermic needle. The cyst may also be excised (removed by cutting).

Purpose

Ganglion cysts are sacs that contain the synovial fluid found in joints and tendons. They are the most common forms of soft tissue growth on the hand and are distinguished by their sticky liquid contents. The cystic structures are attached to tendon sheaths via a long thin tube-like arm. About 65% of ganglion cysts occur on the upper surface of the wrist, with another 20%–25% on the volar (palm) surface of the hand. Most of the remaining 10%–15% of ganglion cysts occur on the sheath of the flexor tendon. In a few cases, the cysts emerge on the sole of the foot.

Ganglion cysts have appeared in medical writing from the time of Hippocrates. Their exact cause is unknown. There are some indications, however, that ganglion cysts result from trauma to or deterioration of the tissue lining in the joints that secretes synovial fluid.

Ganglion cysts can emerge quite quickly, and can disappear just as fast. They are benign growths, usually causing problems in the functioning of the joints or tendons of the hand or finger only when they are large. Many people do not seek medical attention for ganglion cysts unless they cause pain, affect the movement of the nearby tendons, or become particularly unsightly.

An old traditional treatment for a ganglion cyst was to hit it with a Bible, since the cysts can burst when struck. Today, cysts are removed surgically by aspiration but often reappear. Surgical excision is the most reliable treatment for ganglion cysts, but aspiration is the more common form of therapy.

Demographics

Ganglion cysts account for 50%–70% of all soft tissue tumors of the hand and wrist. They are most likely to occur in adults between the ages of 20 and 50, with the female: male ratio being about 3: 1. Most ganglion cysts are visible; however, some are occult (hidden). Occult cysts may be diagnosed because the patient feels pain in that part of the hand or has noticed that the tendon cannot move normally. In about 10% of cases, there is associated trauma.

Description

Patients are given a local or regional anesthetic in a doctor’s office. Two methods are used to remove the cysts. Most physicians use the more conservative procedure, which is known as aspiration.

Aspiration

  • An 18- or 22-gauge needle attached to a 20–30-mL syringe is inserted into the cyst. The doctor removes the fluid slowly by suction.
  • The doctor may inject a medication into the joint after the fluid has been withdrawn.
  • A compression dressing is applied to the site.
  • The patient remains in the office for about 30 minutes.

Excision

Some ganglion cysts are so large that the doctor recommends excision. This procedure also takes place in the physician’s office with local or regional anesthetic.

Excision of a ganglion cyst is performed as follows:

  • The physician palpates, or feels, the borders of the sac with the fingers and marks the sac and its periphery.
  • The sac is cut away with a scalpel.
  • The doctor closes the incision with sutures and applies a bandage.
  • The patient is asked to remain in the office for at least 30 minutes.

Diagnosis/Preparation

Ganglion cysts are fairly easy to diagnose because they are usually visible and pliable to the touch. They are distinguished from other growths by their location near tendons or joints and by their fluid consistency. Ganglion cysts are sometimes confused with a carpal boss (a bony, non-mobile spur on the top of the wrist), but can usually be distinguished by the fact that they can be moved and are usually less painful for the patient.

The doctor may schedule one or more imaging studies of the hand and wrist. An x-ray may reveal bone or joint abnormalities. Ultrasound may be used to diagnose the presence of occult cysts.

Aftercare

Patients should avoid strenuous physical activity for at least 48 hours after surgery and report any signs of infection or inflammation to their physician. A follow-up appointment should be scheduled within three weeks of aspiration or excision. Excision may result in some stiffness after the surgery and some difficulties in flexing the hand because of scar tissue formation.

Risks

Aspiration has very few complications as a treatment for ganglion cysts; the most common aftereffects are infection or a reaction to the cortisone injection. Complications of excision include some stiffness in the hand and scar formation. Ganglion cysts recur after excision in about 5–15% of cases, usually because the cyst was not completely removed.

Normal results

Aspirated ganglion cysts disappear and cause no further symptoms in 27–67% of cases. They may, however, reoccur and require repeated aspiration. Aspiration combined with an injection of cortisone has more success than aspiration by itself. Excision is a much more reliable procedure, however, and the stiffness that the patient may experience after the procedure eventually goes away. The formation of a small scar is normal.

Morbidity and mortality rates

The only risks for ganglion cyst removal are infections or inflammation due to the cortisone injection. There is a small risk of damage to nearby nerves or blood vessels.

Alternatives

Alternatives to aspiration and excision in the treatment of ganglion cysts include watchful waiting and resting the affected hand or foot. It is quite common for ganglion cysts to fade away without any surgical treatment.

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Ganglion Cysts

Ganglion cysts are fluid-filled sacs. They can occur at any joint in your body, but are most common around the wrist. Ganglion cysts may also appear on the feet.

Ganglion cysts form when the natural lubricating fluid leaks out of a joint or tendon, making a little sac (or cyst).

Symptoms of ganglion cysts

The main symptom of a ganglion cyst is a swelling in the area affected. They tend to be smooth and round and can vary in size. Some can be large and prominent, while others are so small that you can’t feel or see them. Sometimes they shrink or grow, and may even disappear altogether, only to reappear at a later date.

If a ganglion cyst puts pressure on a nerve, you may experience discomfort or altered movement.

Causes of ganglion cysts

It’s not usually known what causes the fluid to leak out of your joint or tendon, leading to the development of a ganglion cyst.

However, women are more likely to get ganglion cysts than men, and you are most likely to get them in your 20s to 40s. Sometimes, ganglion cysts form after an injury or after placing too much stress on a joint or tendon (for example, following repeated stress on the wrist in gymnasts). However, most people have not had an injury and the cause is unknown.

Diagnosis of ganglion cysts

Your GP can usually make a diagnosis just by feeling and looking at the lump, and asking questions about your symptoms. He or she might shine a small bright light through the lump, as this can help to confirm that the fluid inside is clear.

If necessary, your GP may ask to draw some fluid out of the lump into a needle. He or she will send the fluid to a laboratory for analysis to confirm that the lump is a ganglion. Sometimes, your GP may suggest referral for an X-ray or other test, such as an ultrasound or MRI, to rule out other conditions or to check for small ganglion cysts that aren’t visible.

Treatment of ganglion cysts

Ganglion cysts are harmless and aren’t cancerous. Many disappear on their own without any treatment, and often they don’t cause any trouble. Because of this, most people don’t need any specific treatment. Instead, your GP will just keep an eye on your cyst and wait to see if it disappears on its own over time.

Non-surgical treatments

If your ganglion cyst is painful or is affecting how you move your hand (or foot), you can have it drained to reduce the swelling. This is called aspiration. A needle is used to puncture the cyst, and the fluid is drained away. Aspiration is done under local anaesthesia, so the skin over the area will be numb but you will stay awake. Aspiration reduces the swelling, but it’s likely that your ganglion cyst will come back later.

Surgery

If you want to have your ganglion cyst removed and aspiration doesn’t help, your doctor may recommend surgery to remove it. However, there is still no guarantee that your ganglion cyst won’t return and you may need to pay for the surgery.

Surgery to remove a ganglion involves cutting the skin over where your ganglion is, and removing the ganglion from the joint or tendon lining. Afterwards, the cut will be closed with stitches and covered with a dressing.

Most ganglions are removed under local or regional anaesthesia as a day-case procedure. This means that the treatment area will be completely numb but you will stay awake. Local anaesthesia numbs the small area that is being operated on, while regional anaesthesia numbs the whole limb. You may be offered general anaesthesia for larger ganglions on the wrist or ankle. This means you will be asleep during the operation. Your surgeon will advise which type of anaesthesia is most suitable for you.

If the ganglion has been removed from your hand or wrist, your nurse may put your arm in a sling. He or she may also give you a splint or cast to support your arm or leg. Before you go home your nurse will give you some advice about caring for your healing wounds and a date for a follow-up appointment.

The area will feel sore, stiff and swollen for a few days after surgery. Complete recovery can take two to six weeks.

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