This document describes the excision of a ganglion cyst. It begins by defining ganglion cysts and their common locations. It then discusses the symptoms, physical exam findings, imaging and treatment options. The main treatment discussed is surgical excision via a transverse incision over the cyst and scapholunate ligament. The cyst is dissected out and excised at its stalk, with hemostasis and wound closure following. Complications of both aspiration and excision are noted.

1. EXCISION OF A GANGLION
DrSeeyan Shah
PGResident,
DepttofOrthopaedics,
GMCSrinagar.

2. • Ganglion Cysts are mucin-filled synovial cysts
and are the most common masses found in
the wrist and hand.

3. Incidence
• common
• most common hand mass (60-70%)
Anatomic location
• dorsal carpal (70%): originate from SL articulation
• volar carpal (20%): originate from radiocarpal or STT joint
• volar retinacular (10%) : originate from herniated tendon
sheath fluid
• dorsal DIP joint (mucous cyst, associated with Heberden's
nodes)
• may also occur in the lower extremity: most commonly
about the knee

5. Mechanism
• trauma
• mucoid degeneration
• synovial herniation
Pathophysiology
• filled with fluid from tendon sheath or joint
• no true epithelial lining
Associated conditions
• median or ulnar nerve compression : may be caused by
volar ganglion
• hand ischemia due to vascular occlusion: may be caused by
volar ganglion

7. Symptoms
• usually asymptomatic
• may cause issues with cosmesis
Physical exam
• Inspection: transilluminates (transmits light through
tissue)
• Palpation: firm and well circumscribed, often fixed to
deep tissue but not to overlying skin
• Vascular exam: Allen's test to ensure radial and ulnar
artery flow for volar wrist ganglions

9. Imaging
• Radiographs: normal
• Ultrasound:
useful for differentiating cyst from vascular
aneurysm
may provide image localization for aspiration while
avoiding artery
• MRI: indications
not routinely indicated
Findings:shows well marginated mass with
homogenous fluid signal intensity

10. • Biopsy:
not routinely indicated,
will show mucin-filled sac with no true
epithelial/synovial lining

11. Treatment
Nonoperative:
• Observation
 first line of treatment in adults
 children
 76% resolve within 1 year in pediatric patients
• Closed rupture
 home remedy
 high recurrence
• Aspiration
 second line of treatment in adults with dorsal ganglions
 aspiration typically avoided on volar aspect of wrist due to
radial artery
 Outcomes: higher recurrence rate (50%) than surgical resection
but minimal risk so reasonable to attempt

13. Aspiration

14. Endoscopic Excision

15. Operative: Surgical Excision
Transverse Incision
• Identify ganglion cyst
• the cyst is typically dorsal to the scapholunate ligament
• the scapholunate ligament is typically distal to Lister`s tubercle in
the third and fourth compartment interval
• Mark the transverse incision
• mark the incision over the scapholunate ligament and entire cyst
• Make transverse incision
• be sure to include the scapholunate ligament in the incision

17. Deep Dissection
• Dissect through subcutaneous tissue
• use blunt dissection
• Identify and protect neurovascular stuctures
• protect and preserve any branches of the dorsal radial
and ulnar sensory nerves
• Incise the extensor retinaculum in a transverse
fashion

18. Cyst Visualization
• Identify the cyst
• the cyst is usually between the third and fourth
extensor compartments
• Visualize the entire cyst
• retract the tendons of the second and third
compartment radially
• retract the tendons of the fourth compartment ulnarly

20. Cyst Excision
• Identify stalk of the cyst
• incise the dorsal wrist capsule transversely
• trace the cyst down to the stalk
• the stalk usually arises from the dorsal aspect of the scapholunate
interosseous membrane
• Excise the cyst at the base of the stalk
• Send the specimen to pathology
• Cauterize the site of origin
• use bipolar cautery

23. Joint Inspection
• Inspect the joint for any abnormalities
• Allow the capsular tissues and tendons to
return to their anatomic position
• avoid closure of the capsule to prevent joint
stiffness

24. Checking tendons after cyst removal

25. Wound Closure
• Irrigation and hemostasis
• copiously irrigate the wound
• Superficial closure
• use running subcuticular nonabsorbable monofilament suture
• Dressing and immediate immobilization
• dress with antibiotic ointment
• place a bulky hand dressing and a plaster palmar splint in the
neutral position

26. Complications
• With aspiration
infection (rare)
neurovascular injury
• With excision
infection
neurovascular injury (radial artery most common)
injury to scapholunate interosseous ligament
stiffness

27. Thank You