Shah NH *, Shah VN **, Paranjpe SH ***
(* Hon. Endosopic Surgeon Wadia Hospital & Railway Hospital, Byculla, ** Anesthesiologist, *** Director: Velankar Hospital & Paranjpe Maternity Home, Chembur, Mumbai, India.)
Mature cystic teratomas are mostly benign. 0.1-0.2% of cases may undergo malignant transformation. They are usually asymptomatic but sometimes may present with acute abdomen due to torsion of cyst, infection, or cyst rupture. Here we present a case of a 23 year old woman non gravid with previous one abortion who came to us with lower abdominal pain for last 6 months, with bilateral dermoid cysts of ovary, which is a rare presentation. Both the dermoid cysts were enucleated laparoscopically and placed in an endobag and retrieved by morcellation. Six month follow up showed no evidence of recurrence.
An ovarian dermoid cyst or a benign cystic mature teratoma is a benign tumor arising from the germinal cells. In approximately 80 % of the cases, it occurs in young women aged 20 to 30 years and accounts for 18% of all benign ovarian tumors. Most of the time, dermoid cysts are unilateral, but they are bilateral in 10 to 15% of cases. Laparotomy has been the preferred procedure for the management of dermoid cysts because of the risk of chemical peritonitis occuring from spillage of its contents. We have done morcellation in an endobag, which preserves the benefits of the laparoscopic approach while maintaining the safety of non spillage of contents as achieved in a laparotomy.
A 23 year old non gravid woman with previous one abortion presented to us with pain in the lower abdomen for the past 6 months. The pain was as dull aching, non radiating. There was no associated vaginal discharge, increased urinary frequency, fever, or bowel symptoms. Her menses were regular with a 30 day cycle, and no history of associated dysmenorrhea or menorrhagia. No significant medical or surgical history was present. On examination, her abdomen was soft with no guarding, rigidity or tenderness. Per speculum examination showed no vaginal discharge. Per vaginal examination showed a normal-sized uterus with bilateral adnexal masses of 5 x 4 cm on the left and 4 x 6 cm on the right. The ultrasound scan was suggestive of a bilateral dermoid cyst. The uterus was normal (58 x 32 x 29 mm) with endometrial thickness of 8 mm. All preoperative investigations including CA 125 were within normal limits.
A laparoscopic bilateral cystectomy was done with “in bag” morcellation. Histopathology report confirmed mature cystic teratomas. A 6 months follow-up of this patient was done and there was no recurrence or any signs of granulomatous peritonitis, and she had regular menses after surgery.
Figure 1. Bilateral dermoid cysts seen.
Figure 2. After enucleation of the dermoid cysts.
Dermoid cysts may be formed by elements arising from all three of the germinal layers, but in ovarian dermoids, ectodermic discrimination frequently occurs. Usually, the diameter of an ovarian dermoid is <10 cm and is rarely >15 cm. On histology, lipidic substance, hair, sebaceous secretions, hair follicles, and bone calcifications are seen in half of the cases; organoid morphology (teeth, bone) are seen in 30% of the cases.  Surti et al  theorized 5 mechanisms of origin of a dermoid cyst which were:
• Error of meiosis 1
• Error of meiosis 2
• End reduplication of an haploid egg cell
• Premiotic germ cell undergoing mitotic division
• Fusion of two ova.
This being said, the few bilateral cases which had been studied, did not show preponderance of any mechanism.
Usually, the symptoms arise severely with pelvic pain, and in a few of the cases, the symptoms are related with menstrual irregularities. Torsion is the most common complication, whereas rupture and infection are rare. Malignant transformation occurs in 1 to 2% of the cases, commonly arising from squamous epithelial cells. The diagnosis of ovarian dermoid can be made confidently on an ultrasound. In one study, experienced radiologists achieved 100 % positive predictive value in cases where ≥ 2 characteristic sonographic features were present. It has also been reported that women with bilateral or multiple dermoid cysts have more predisposition for development of ovarian germ cell neoplasms in later life.
Literature suggests that dermoid cysts be removed by laparotomy only, because of the presence of the risk of spillage of sebaceous and hairy material in the peritoneum, causing granulomatous peritonitis in some cases. As of now, laparoscopic management of a dermoid cyst with a morcellation bag is considered a safe option.
The only concern is the skill of the operating surgeon. In the presence of a skilled laparoscopic surgeon, appropriately assisted by well-trained assistants, the procedure maintains the basic conventions of the abdominal approach. Furthermore, reduced tissue handling and drying, which is distinctive in laparoscopy, may contribute to reducing adhesion formation after laparoscopy. However in case intra- operative spillage occurs, cyst contents should be removed immediately from the peritoneal cavity and repeated washing and aspiration should be done.
To conclude, laparoscopic management of bilateral, mature cystic teratomas by an experienced surgeon could yield results as good as laparotomy.
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Shah NH, Shah VN, Paranjpe SH. Rare Case of Bilateral Dermoid Cysts Managed Laparoscopically. JPGO 2015. Volume 3 No. 5. Available from: http://www.jpgo.org/2016/05/rare-case-of-bilateral-dermoid-cysts.html