It varies, by patient, by doctor. Many patients go straight to a gyn/onc for surgery even without a certainty of cancer because these surgeons are the best bet if cancer is detected during surgery that was not truly confirmed in pre-op testing. CA-125 is one of those pre-op tests. Gyn's are also good at the surgery part, but are not cancer specialists.
Normally, the routine is:
1. Decide what surgery will be done, what will be removed, discuss all the different options available, what type of surgeon will do the operation
2. Prepare the patient accordingly (some of this is prep the patient does at home the day prior, such as laxatives)
4. Run tests while still in OR for cancer; if negative, surgery is done. If positive, more surgery may be required. A laparoscopy may be upgraded to a laparotomy if required. Some surgeons can do all the surgery required (even if cancer) using laparoscopy. Some are much more comfortable going with open surgery (laparotomy) in that event.
5. Run full pathology after surgery. If negative, no follow up other than routine post-op examination. If positive (something not found during surgery), then some type of follow up plan is developed, whether it be more surgery, chemo (or both) or just more frequent future exams (that is if cancer was completely contained within the cyst with no sign of spread). If your surgeon was just a gyn, then a gyn/onc referral would occur if further treatment is required.
Many doctors want to eliminate the risk of internal spillage of cancer cells from a cyst, waiting for pathology, waiting to test/treat surrounding organs, etc. by just skipping laparoscopy and going for laparotomy instead, where they can remove the cyst, etc. and also do an exploratory and washing of surrounding organs. The patient may also be prepped for the possibility of some kind of repair/reconstructive surgery if cancer is found (full bowel cleanse pre-op with prescription laxatives). This is a "better safe than sorry" approach doctors take and sometimes it is more than is necessary, especially if all turns out to be benign. But if not, the patient is already prepped for initial treatments and no precious time is lost.
When there's a really good chance of it being benign, they just schedule laparoscopy and go after just the cyst (best case), but an ovary/tube may be lost if the cyst did too much damage. If the cyst is larger than the incision, they bag it/debulk it and remove it. This is where the possibility of spillage may occur. The contents are supposed to remain contained, but sometimes it is not. If any cancer were present that was otherwise contained, if even a single cell escapes, it could get into the body and get a chance to spread. The most cautious doctors prefer laparotomy where they can carefully lift the cyst out undisturbed. It is bigger surgery and many people try to avoid it, though...patients and doctors alike.
I had the full laparotomy/exploratory/bowel cleanse (BSO procedure) for my surgery (by a gyn/onc) and was one of the fortunate ones that didn't really need that much precaution (it was all benign), but I have no regrets. I felt much better afterwards knowing all was checked. The problem I had was the cyst was putting pressure on bowels. I assumed the doctor made sure no damage was done there and maybe had to rearrange whatever organs the cyst displaced to get me back to normal internally.
I have read others' stories and for laparoscopy, many ladies did not have the bowel cleanse as part of their pre-op preparations. They just had to be on a clear liquid diet for roughly 24 hours prior.
Lots of choices and unfortunately it can be a guessing game since nobody is 100% certain prior to surgery if the situation is benign or cancer. Smaller cysts are better candidates for laparoscopy than larger ones. Size/type of cyst, imaging tests, age, menopause status (pre or post), and CA-125 results are all weighed in the decision process. I know you mentioned other cancer diagnostic tests in other posts and hopefully they will be more accurate and widely available in the future since CA-125 results are so uncertain. For now, many doctors only use CA-125.
Does that help you understand things a bit better?
Thank you so much for the detailed explanation, it is starting to make sense.
In what situations do they use the "frozen section" to determine further action?
Sorry, I do not know the answer to that. That would be a question for the surgeon.