Ovarian cysts are common benign growths on the ovaries, affecting a significant proportion of women during their reproductive years. While most are asymptomatic and resolve spontaneously, a subset can present with symptoms such as pelvic pain, bloating, or irregular menstrual cycles. A small percentage of these cysts, particularly complex ovarian cysts, may harbor malignant potential.

Typically, a laparoscopic approach under general anesthesia is the preferred method for surgical management of ovarian cysts due to its minimally invasive nature, reduced postoperative pain, and faster recovery time. However, in certain cases, such as patients with significant comorbidities, a different anesthetic approach may be necessary to ensure patient safety and optimal outcomes.

• 50-year-old female scheduled for laparoscopic bilateral salpingo-oophorectomy for a 7 cm complex cyst of the right ovary in preparation for lung transplantation, where an open approach under neuraxial anesthesia was chosen

• Significant past medical history: stage IV COPD with chronic hypoxic respiratory failure on 4L nasal cannula at baseline and listed for lung transplantation, HTN, HLD, IBS, and endometriosis, without significant surgical history to suggest a contraindication to neuraxial anesthesia. 

• Significant social history: 25 years smoking history (quit 7 year prior). 

• Preoperative physical examination without gross deformities of the lumbar spine. 

• Preoperative studies: CBC and CMP within normal limits; TTE with an EF of 55%, mild-moderate reduced RV dysfunction, and grade 1 diastolic dysfunction; CT of the chest with severe emphysema and a spiculated nodule at the right upper lobe; biopsies of the lung nodules without evidence of malignancy; PFTs showed a FEV1 of 0.97L (36% of predicted), an FEV1/FVC ratio of 39 (48% of predicted), TLC of 5.91L, and a DLCO of 5.27 mL/min/mmHg.

• Preoperative sedation was provided with a combination of 2 mg midazolam and 100 mcg of fentanyl prior to neuraxial anesthesia. 

• An epidural catheter was placed at L3-L4 level via a loss of resistance technique. A test dose of 3 cc of 1.5% lidocaine with 1:200,000 epinephrine was administered to confirm correct epidural placement. The patient was bolused with 20 cc of 2% lidocaine to achieve a T5-T6 sensory level.

• The surgery was completed without complications. The epidural catheter was removed on the same day. The patient was admitted for overnight observation and discharged home on postoperative day one. Postoperative pain was managed with oral and intravenous analgesics.