Operative laparoscopy ovarian dermoid cyst for the treatment of large

[)epurtntetlts ofOhsterrics and O.vnecolog'. King Abdulo:i: Universitv, Jeddoh, .\ctudi ,4rabio

ABSTRACT

Objective: To assess the etl'ectiveness of operative laparoscopy tbr treatment o1'large ovarian du'moid crst.

Materials and Methods: From.lanuar''1 1997 through .lanuarr'2007. all operative Iaparoscop;'notes at King Abdulaziz Universit;- Hospital..leddah. Saudi Arabia lvele revierved. Inclusion criteria included women u'ith ovarian dermoid cyst (less than

l0

cm)" wele revierved. Ten u'omen r,vith ovarian dermoid cysts 8 cm

+

2 (mean.t SD) under',r,ent ovarian laparoscopic cystectonr) bv the sarne surgeon. The age r,vas 27 + 7 \'ears (mean + _{SD). They} all had normal tumor markers

(CA

125. CE,A. alpha l'etoprotein. and beta hur.nan chorionic gonadotropin). Eight women were multiparous and two \vomen rvere nulliparous. l-he plesenting s)- mptoms rvere pelvi-abdominal

plin

in

sir

\\omen.

secondan

inf'ertilitf in two

rvomen. and abnormal r"aginal blceding

in

tri,o rr'or-rrcn. E.ight \\omen had Lrnilateral derrnclid cyst and t\\,o women had biiateral dermoici c1'sts.

Results: [,aparoscopic ovrlian c-\stect(]nr-\ rres successlully done in all *orrrerr.'l'here rvas no conversion to lapalatomr in this selies. The rnean operative time rvas 90

t l5

nrinutes. Llstirnated blood loss r,ras

i00 t50

ml. There rvere ncr

intraoperative complications. l-listologl'showed benign cystic teraloma. l-ong telm lbllorv up (7 + _{3 ,r,ears)} shou'ed no recurrence

oi

the cyst and

flve

\\omen got pregnant atler the procedure (trvo inf'ertilit)- \\'onren.

trro

pler ious nulliparoLrs women and onc multipalous r.r'orlan).

Conclusion: Laparoscopic ovarian c]-stectom)'is eflectivc

fbl

large ovalian dermoid ^cysts.

Keywords:

Middle East Ferrilitl Societr' .loumal Copvright' Middle East FertilitV Society'

Operative laparoscopy ovarian dermoid cyst

Nora

N.

Sahly, M.8.. Ch.B.

Amal

Shobkshi. M D.

Mature cystic teratorxas also termed

dennoid

cysts, are the rnost colrtl1on benign

ovarian tumors.

They

account

for

up

to

58%

of

benign and 44%

of all ovarian tlrmors (l). Most (80%)

occur

during reproductive years and only

¹

5%

^after

menopause.

They are bilateral in up to

^{159't, and}

they grow slowly. In premenopausal wolren growth rate of

1.8

crr/year was

documented (2).

Traditional

treatment

options include

laparoscopy

Corresponding ALrthor: Proltssor Abdulrahim Rouzi. PO Box 802 ^I 5. .leddah ^{2 I} 589" Saudi Arabia

Vol. l4.No

I

²⁰⁰⁹

for the treatment of large

Sharifa

A. Alsibiani"

Arab Boarcl

AbdLrlrahim

A.

Rouzi. F.R.CI.S.C

and laparatorni,. Advantages to retrove

dennoid cysts

laparoscopically include small incisions.

less

post-operative

pair.r,

short hospital stay,

^earlier

recovery and improved

qLrality

of life in the

post-

operative period. Laparoscopy is usualli'

done

for srnall

cysts because

of the technical diificulties

to remove large

derrroid

cysts and t'ear

of

peritonitis

with

rupture. However. there are

few

reporls

in

the literatr-rre

of

laparoscopv

for

^large

ovarian

dermoid cysts. The ob.jective

of this

retrospective study is to assess

the effectiveness of operative

laparoscopy

for

treatment

of

large ovarian dermoid cyst.

Sahly et al. Lopcrt'oscLtp.t'.[or lrealment of derrnoid t:.t'.sts i,t[.l- sJ

MATERIALS AND METHODS

Between January 1997 and January 2001. all operative laparoscopy notes at King Abdulaziz University Hospital, Jeddah. Saudi Arabia

were

reviewed. The records of women with

large

ovarian derrnoid c),st were identified

and

examined. Inclusion criteria included

rnaximal diarneter

of the cyst was

less

than l0 cm, tumor markers and radiological picture suggestive of benign

disease,

and

absence

of

contraindications

for operative laparoscopy. Data regarding

age,

gravidity, clinical presentation, bilaterality, ultrasound and cornputed tornography

findings.

operating

tirne,

estirnated

blood loss.

presence

ol

intraoperative and postoperative

cornplications.

conversion

to

laparatomy, dLrration

of

admission to

the hospital, and long term follow up

were extracted

frorn the hospital files. All women

had

mechanical borvel preparation and

^received

preoperative one dose

prophvlactic antibiotic.

RESULTS

Ten wornen

with ovarian derrroid

cysts 8 crn

* 2 (rnean + SD) underwent ovarian

laparoscopic cystectomy

by

the same slrrgeon

(Rouzi AA)

using

the same technique. All wolren

received

mechanical bowel preparation. Laparoscopy

was

done under general anesthesia through

sub-

umbilical incision. Secondary and tertiary

punctures

were

made

through 5 mrn incisions

in

the right and left lower quadrants under

direct

vision. After detailed visualization of

the

abdorninal cavity, the cyst was aspirated

and ovarian

cystectolny

was done

in the

usual rnanner.

The

specimens

was removed via 10 mm

trocar

placed in the middle supra-pubic area and

were

sent to the histopathology department.

Copious

abdorninal lavage with warn normal saline

was done

to

ensllre

that all contents of the cyst

were rernoved.

The

age was

27 + 7

years (rnean

+ $p).

They

all

had preoperative

pelvic

r-rltrasor,rnd

with

or

without computed tomography which

were

suggestive of benign ovarian cysts and

nonnal

tumor

markers

(CA

125.

CEA. alpha

fetoprotein,

and beta human chorionic gonadotropin).

Eight

women were

mr-rltiparous

and two women

were

ttulliparous. The

presenting syrnptotns were

pelvi-

abdou-rinal

pain in six women,

secondary

inferlility in trvo women,

and

abnormal vaginal bleeding

in

two women. Eight

rvomen

had unilateral

derrnoid

cyst

and

two women had bilateral derrnoid

cysts.

Laparoscopic

ovarian

cystectom-v was successf

ully done in

al

I worlen. There was no conversion

to laparatornl,

in this

series.

The

rnean operative tirne

was 90 + l5 rninutes. Estirnated blood loss

was

300 +50 rrl. There were no intraoperative

or

postoperative cornplications. Histology

showed benign cvstic teratoma. Long term

follow

up (7 + 3

years)

showed no

recurrence

ol the cyst and five women got pregnant after the procedure (two int'eftilit), wotren. two

previous nulliparous women and one rnultiparor-rs woman).

DISCUSSION

Mature cystic teratoma is the

cornmonest

ovarian neoplasrn in women in the

reproductive

vears. Ectoderrnal, endodermal, and

nresodenral layers are

the origin ol its

components.

Clinically.

it is

usr-ral11'

asyrnptornatic or

^present

with

some

gastrointestinal discornlort. However,

acute

abdominal pain due to rupture or torsion

^rnay

happen. Malignant transfonnation is rare.

Age

more than 40 years, high

tr,rmor

markers (CEA, SCC, CAl9-9, AFP, and CAl25). and size

more than 90

mm

are

important lactors in differentiation

between

benign

and

rnalignant cyst (3).

Malignant

transfbrmation occur in cysts

1,52

rnrn in

size (4).

Laparoscopic removal for large ovarian cysts

^has

been repofted before in srnall case

series.

Eltabbakh et al, in 2008, published the

largest

prospective

case series

done over

seven years by the sarne surgeon

involving thirty

three wornen (5).

They

concluded

that

laparoscopy was feasible and safe.

With respect to dermoid cysts, the first laparoscopic cystectolny was performed in

1989

(6). Since then laparoscopy is the rnost

frequent sr-rrgical

approach lor the treatrnent. The risk of chemical peritonitis is minimized by the

^r-rse

of

laparoscopic endobag.

With

^large

ovarian the

risk

of intraoperative spillage is

increased. However,

careful

and

copious

lavage

ofthe

peritoneal cavity

Sahly et al. Laparoscop.t'Jor treatntent oJ tlerrnoicl cr'srs

has been shown

to

be

effective (7,8).

Hessarni et al, reported no chernical

peritonitis in l2

laparoscopic

cyst excisions where spillage occurred in

^all

women (9). Sirnilarlir, in our study there

was

intraoperative spillage during puncturing the

cyst

in all

^cases

with no chemical peritonitis due

to

excessive peritoneal washing. ln addition,

the outcome

ol our

approach

to

large

dennoid

cysts is

encouraging. Therefore, in properly

selected

women with

^large

dennoid cysts

laparoscopy

is

a

reasonable

treatment option. Fufther studies

^are

needed to

confirm

our

findings.

REFERENCES

l.

Correrci .lT Jr. L.icciardi F. Bergh PA. Gregori C. Breen .lL. Mature c;-stic teratoma: a clinicopathologic evaluation

ol5l7

^{cases and review} o1'the literature. Obstet Clnecol

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2.

Caspi B" Appelman Z, rabinerson D, Zalel Y. Tulandi T.

Shoham Z: The growth pattern 01'ovarian den.troid cysts: a prospective study in prer.nenopausal and posttnent'rpausal women. Ferril sreril 1997, 6B(3):501-5.

3.Devoize L. Collangettes D. Le Bou€dec G. Mishellanl F. Orliaguet'I. Dallel R. Baudet-Pornmel M. Ciant mature ovarian cystic teratoma including more than 300 teeth.

Oral Surg Orai Med

Oral

Pathol Oral Radiol Endod 200ti: I 05:e76-e79.

Kikknva F. Nawa A. Tarnakoshi K. Ishikaiva ['{. Kuzr-r1,a

K.

Suganuma

N" et al.

Diagrrosis

of

squamous cell carcinonra arising

fiour

nrature cystic teratorna

ol

the ovary. Cancer I 998:82:2249-55.

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CH.

Charboneau

AM.

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Laparoscopic surgery

firr

large benign ovarian cysts.

C;necol Oncol 2008:I08:72-6.

Nezhat C. Winer WK. Nezhat F: Laparoscopic removal

ol

derrnoid cysts. Obstet Clnecol 1989. 73:278-281.

l-in P. Falcone

I.

J'ulandi

I.

Llxcision olovarian dermoid

clst by

laparoscopl and

h\

laparotonr\'. Aur

.l

Obstet Cynecol 1995:173(i Pt l):769-71.

Canrpo S. Carcea N. l.apar,rscopie er'nser\ati\e eruisior.l

ol ovarian dcrnroid c-y-sts \\'ith and *ithout an endobag. ^.l Arr Assoc Cynecol l-aparosc 1998:5: 165-70.

Hcssarri

SH"

Kohaninr

Il. Grazi RV:

Laparoscopic

excision

ol

benign dermoid cysts

rvith

controlled intraoperative spillage.

.l Am

Assoc Gynacol Laparosc

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Receivecl October I 0. ]A08: ret,isecl crnd accepted Jantrnt I 2. 2009 -).

6.

Sahly ct ^al. L,crpnrosco1t.t .fbr Ireatntent of tlerntoicl c.t'sts rI E FSJ