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Excision of ovarian dermoid cyst by laparoscopy and by laparotomy
Gynecology
Excision of ovarian dermoid cyst by laparoscopy and by laparotomy Perry
Lin, MD, Tommaso
Montreal,
Falcone,
MD, and Togas
Tulandi,
MD
Quebec, Canada
OBJECTIVES: Our purpose was to evaluate the efficacy of laparoscopic ovarian dermoid cystectomy and to compare the operative course, postoperative course, and complications between the laparoscopy and the laparotomy techniques. STUDY DESIGN: The safety and efficacy of laparoscopic ovarian dermoid cystectomy were evaluated in 40 women. Twenty-nine of 40 patients underwent laparoscopic excision of a solitary dermoid cyst without any additional procedure. The operative course, the postoperative course, and complications among these 29 women were compared with those of 26 other women who underwent a similar procedure by laparotomy. RESULTS: Spillage of the cyst’s content did not lead to any complication. The operating time in the laparoscopy group was 73.5 c 4.7 minutes and in the laparotomy group it was 41.4 c 2.9 minutes. The duration of hospitalization was significantly shorter in the laparoscopy group (0.7 +- 0.2 days) than in the laparotomy group (3.8 + 0.1 days). CONCLUSIONS: Although ovarian dermoid cystectomy by laparoscopy is associated with a longer operating time than by laparotomy, the duration of hospitalization is shorter and recovery is faster. Spillage of the contents of the dermoid cyst does not lead to any complication; perhaps this is due to the liberal irrigation of the peritoneal cavity. (AM J OBSTET GYNECOL 1995;173:769-71.)
Key words:
Ovarian
dermoid
cyst, laparoscopy,
ovarian
Advances in endoscopic surgery have allowed laparoscopic conduct of procedures that previously required laparotomy. This includes excision of dermoid cyst. There are many advantages of laparoscopic surgery, such as reduction of hospitalization and recovery time. To date, most series of laparoscopic excision of dermoid cyst have remained small and no direct comparison to the conventional laparotomy technique has been made. I-4 The purpose of the current study was to evaluate the efficacy of laparoscopic ovarian dermoid cystectomy and to compare the operative course, postoperative course, and complications between laparoscopy and laparotomy.
Material and methods From March 1991 to May 1994 laparoscopic excision of ovarian dermoid cyst was performed in 40 women From the Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University. Received for publication July 28, 1994; revised December 8, 1994; accepted December 29, 1994. Reprint requests: Togas Tulandi, MD, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, 687 Pine Ave. W., Montreal, Quebec, H3A IAI Canada. Copyright 0 1995 by Mosby-Year Book, Inc. 0002-9378/95 $5.00 + 0 &/l/63687
cystectomy by the senior authors (T.F. and T.T.). Over the same time period 26 women underwent a similar procedure by laparotomy. These procedures were performed by other surgeons in our institution. Excision of a solitary ovarian dermoid cyst without any additional procedure was done in 29 women in the laparoscopy group and in all women in the laparotomy group. The patient profile, symptoms, and operative and postoperative courses of these two groups of patients were compared. Those who underwent other procedures such as oophorectomy, excision of bilateral ovarian dermoid cyst, or endometrioma were not included in the statistical analysis. Laparoscopic ovarian cystectomy was conducted by first enucleating and separating the cyst from the normal ovarian tissue, which was done by a combination of sharp and hydrodissection. A 5 mm suction irrigator was used to deflate the cyst before removal from the abdominal cavity. The cyst was removed with a 10 mm secondary trocar. The ovarian defect was left open or inverted by coagulating the inner surface of the ovarian defect if the defect was too large. If this was still insufficient, the defect was sutured with a few sutures of 4-O polydioxanone. Hemostasis was achieved with bipolar coagulation. At the completion of the procedure, the 769
770
Lin, Falcone, and Tulandi
September 1995 Am J Obstet Gynecol
Table I. Comparison between excision of solitary dermoid cyst by laparoscopy and by laparotomy Surgical technique
Laparoscopy
No. of patients Age 04 Cyst diameter (cm) Operating time (min) Blood loss > 100 ml Spillage Hospital stay (days) Transient fever
29 31.4 +- 1.2 4.4 f 0.3 73.5 2 4.7 1 (3.4%) 29 (100%) 0.7 f 0.2 4/29 (13.8%)
Luparotomy
26 31.2 + 1.4 5.5 I? 0.4* 41.4 2 2.9t 3 (11.5%) 1(3.8%)X 3.8 rt O.lt 7126 (26.9%)
*p < 0.05. tp < 0.001 $p < 0.01.
peritoneal cavity was carefully lavaged until the irrigation fluid was devoid of any hair or sebum material. Ringer’s lactate solution (500 to 100 ml) was then left in the peritoneal cavity. Data were analyzed by Student t test and Fisher’s exact test.
Results The age of the women in the laparoscopic group was 31.4 2 1.2 years (range 19 to 59 years). A total of 44 ovarian dermoid cysts were removed. Three women had a dermoid cyst on each ovary and another had two dermoid cysts in one ovary. Aside from an oophorectomy in a postmenopausal woman, all others underwent an ovarian cystectomy. Eight women underwent additional procedures, including resection of ovarian endometriomas and myomectomy. There were no intraoperative complications and no conversion to laparotomy was needed. Blood loss was minimal, and in only two women did blood loss clearly exceed 100 ml (300 and 500 ml). Spillage of cyst content to a varying extent occurred in all cases. Eighteen patients (45%) were operated on as outpatients and another 12 (30%) as short-stay patients (hospitalization < 24 hours). Transient postoperative fever (~38” C for ~24 hours) was noted in four patients. Another had fever that lasted 3 days; this resolved with antibiotics. Another patient had decreasing hemoglobin from 13.3 to 7.3 gm but stabilized without transfusion or reoperation. Seventeen patients had at least 1 year of follow-up and they were all well. Comparison between the laparoscopy and laparotomy groups is depicted in Table I. The mean size of the dermoid cyst was significantly larger in the laparotomy group than in the laparoscopy group. The operating time appeared to be shorter in the laparotomy group, but this procedure was performed by different surgeons. The hospitalization time in the laparoscopic group was shorter. In these 29 patients blood loss during the laparoscopy was very minimal. In the lapa-
rotomy group three patients had blood loss > 100 ml. Spillage of the contents of the cyst occurred to a certain extent in all patients in the laparoscopic group and in only one patient in the laparotomy group. Nevertheless, there was no significant difference in the incidence of postoperative fever between the two groups. Resumption of bowel function, defined as the first documented passage of flatus after surgery, was 1.2 ? 0.2 days in the laparoscopy group and 2.1 -C 0.2 days in the laparotomy group. We had the opportunity to reevalute the condition of the pelvic organs in a patient 1 year after laparoscopic ovarian cystectomy. In spite of the spillage of the cyst’s contents at the initial surgery, we found only minimal periadnexal adhesions on the previous site of the cyst. The opposite adnexa was normal and there was no evidence of granulomatous implants.
Comment Dermoid cyst or mature cystic teratoma is the most common type of ovarian neoplasm occurring during a woman’s reproductive life.5, 6 The origin of these germ cell tumors is unclear, but it has been speculated that they arise by meiosis II nondisjunction7 or by abnormal parthenogenetic duplication of oocyte haploid chromosomes.6 The typical dermoid cyst may thus contain all three embryonic tissue layers, and nearly all somatic cell types have been found in these tumors.‘, 6 Dermoid cyst is easily identified during surgery or ultrasonography by the typical sebaceous fluid content and hair material. Before the advent of modern surgical techniques dermoid cysts produced some morbidity and mortality because of their propensity for torsion leading to ovarian infarction, for rupture leading to severe chemical peritonitis, and for fistulization through nearly all pelvic viscera.6 The treatment is therefore surgical excision. The use of transvaginal ultrasonography has made preoperative diagnosis of dermoid cyst more accurate. Many authors have reported laparoscopic excision of dermoid cyst.1-4 The laparoscopic technique reduces hospitalization and recovery time and the cosmetic outcome is imrjroved with the smaller incision. However, the unique environment of laparoscopy that requires deflation of the surgical specimen before extraction results in the higher incidence of leakage of cyst’s contents. This is in contrast to the conventional precautions to minimize leakage during laparotomy. Intraoperative spillage of dermoid cyst contents has potential short- and long-term complications. The release of highly inflammatory cyst material may lead to postoperative chemical peritonitis, resulting in febrile morbidity, ileus, and possibly the need for reoperation. Theoretic long-term problems include the risk of dermoid elements seeding in the peritoneal cavity producing granulomas, extensive adhesions, or fistula formation.‘. ’ Malignant element spillage may also lead to cancer dissemination.““’
Volume 173, Am J Obstet
Number
3, Part
Lin, Falcone,
1
and Tulandi
771
Gynecol
In our series spillage of the cyst’s contents occurred to a certain degree in all patients, yet there was no difference in the incidence of postoperative fever or other complications between the laparoscopy and the laparotomy groups. Spillage may be reduced by use of a larger suction probe or eliminated by use of a laparoscopic bag. None of our patients required a laparotomy, readmission, or reoperation. Spillage of the contents of the cyst did not appear to induce the development of granulomatous peritonitis.‘, 3 This may be due to the liberal irrigation of the peritoneal cavity and to the instillation of a large amount of Ringer’s lactate solution at the completion of the surgery.’ Implants of dermoid cells in the rectus muscle and fistulas to the bladder and rectum were recently reported.” The cyst was removed with considerable difficulty through both a colpotomy incision and through a secondary trocar. It appeared that during removal of the cyst some of the cells were inadvertently left embedded in the muscle, resulting in the parasitic growth and fistulous tract. Unrecognized injury to the bladder and rectum is also a possibility. This report suggests the importance of careful extraction of the cyst. Our current technique is to place the intact cyst in a laparoscopic bag, and aspiration of the cyst’s contents is done inside the bag, preventing spillage into the peritoneal cavity. Malignant degeneration of a dermoid cyst is a rare occurrence.*-” The estimated incidence is 1.8%, and most of the cases are diagnosed after the age of 40 years and the cysts are > 10 cm.‘, ’ It suggests that dermoid cysts of < 10 cm in women ~40 years old are unlikely to be malignant. It seems that the different occurrence of malignant dermoid cysts in young and older women indicates a time-related degeneration from benign to malignant over a period of two decades.]’
In summary, we presented a series of 40 women who successfully underwent laparoscopic excision of dermoid cyst. The laparoscopic approach may take longer than laparotomy, but the hospitalization time is reduced and recovery is faster. In our patients spillage of dermoid cyst does not lead to any complication, perhaps because of liberal irrigation of the peritoneal cavity. REFERENCES 1. Bollen N, Camus M, Tournaye H, Demunk L, Devroey P. Laparoscopic removal of benign mature teratoma. Hum Renrod 1992;7:1429-32. 2. Neihat C, Winer WK, Nezhat F. Laparoscopic removal of dermoid cysts. Obstet Gynecol 1989;73:278-80. _ 3. Reich H, McGlynn F, Sekel L, Taylor P. Laparoscopic management of ovarian dermoid cysts. J Reprod Med 1992;37:640-4. 4. Labastida R, Llueca J, Gomez T, et al. Laparoscopic 5.
removal of dermoid cysts. Gynecol Endosc 1994;3:9-Il. Petersen WF, Prevost EC, Edmunds FT, Hundley JM, Morris
FK.
OBSTET
GYNECOL
Benign
cystic
teratomas
of the
ovary.
AM J
1955;70:368-82.
6. Pantoja E, Noy MA, Axtmayer RW, Colon FE, Pelegrina I. Ovarian dermoids and their complications: comprehensive historical review. Obstet Gynecol Surv 1975;30:1-20. 7. Gerald PS. Origin of teratomas. N Engl J Med 1975;292: 103-4. 8. Caruso PA, Marsh MR, Minkowitz S, Karten G. An intensive clinicopathologic study of 305 teratomas of the ovary. Cancer 1971;27:343-8. 9. Petersen WF. Malignant degeneration of benign cystic teratomas of the ovary: a collective review of the literature. Obstet Gynecol Surv 1957;12:793-830. 10. Genadry R, Parmley T, Woodruff JD. Secondary malignancies in benign cystic teratomas. Gynecol Oncol 1979;S: 246-51. 11. Keil KH, Julian TM. Trichouria, pneumaturia, urosepsis, and bowel fistulization after pelviscopic cystectomy of mature ovarian teratoma. J Gynecol Surg 1993;9:235-9.
Excision of ovarian dermoid cyst by laparoscopy and by laparotomy Perry
Lin, MD, Tommaso
Montreal,
Falcone,
MD, and Togas
Tulandi,
MD
Quebec, Canada
OBJECTIVES: Our purpose was to evaluate the efficacy of laparoscopic ovarian dermoid cystectomy and to compare the operative course, postoperative course, and complications between the laparoscopy and the laparotomy techniques. STUDY DESIGN: The safety and efficacy of laparoscopic ovarian dermoid cystectomy were evaluated in 40 women. Twenty-nine of 40 patients underwent laparoscopic excision of a solitary dermoid cyst without any additional procedure. The operative course, the postoperative course, and complications among these 29 women were compared with those of 26 other women who underwent a similar procedure by laparotomy. RESULTS: Spillage of the cyst’s content did not lead to any complication. The operating time in the laparoscopy group was 73.5 c 4.7 minutes and in the laparotomy group it was 41.4 c 2.9 minutes. The duration of hospitalization was significantly shorter in the laparoscopy group (0.7 +- 0.2 days) than in the laparotomy group (3.8 + 0.1 days). CONCLUSIONS: Although ovarian dermoid cystectomy by laparoscopy is associated with a longer operating time than by laparotomy, the duration of hospitalization is shorter and recovery is faster. Spillage of the contents of the dermoid cyst does not lead to any complication; perhaps this is due to the liberal irrigation of the peritoneal cavity. (AM J OBSTET GYNECOL 1995;173:769-71.)
Key words:
Ovarian
dermoid
cyst, laparoscopy,
ovarian
Advances in endoscopic surgery have allowed laparoscopic conduct of procedures that previously required laparotomy. This includes excision of dermoid cyst. There are many advantages of laparoscopic surgery, such as reduction of hospitalization and recovery time. To date, most series of laparoscopic excision of dermoid cyst have remained small and no direct comparison to the conventional laparotomy technique has been made. I-4 The purpose of the current study was to evaluate the efficacy of laparoscopic ovarian dermoid cystectomy and to compare the operative course, postoperative course, and complications between laparoscopy and laparotomy.
Material and methods From March 1991 to May 1994 laparoscopic excision of ovarian dermoid cyst was performed in 40 women From the Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University. Received for publication July 28, 1994; revised December 8, 1994; accepted December 29, 1994. Reprint requests: Togas Tulandi, MD, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, 687 Pine Ave. W., Montreal, Quebec, H3A IAI Canada. Copyright 0 1995 by Mosby-Year Book, Inc. 0002-9378/95 $5.00 + 0 &/l/63687
cystectomy by the senior authors (T.F. and T.T.). Over the same time period 26 women underwent a similar procedure by laparotomy. These procedures were performed by other surgeons in our institution. Excision of a solitary ovarian dermoid cyst without any additional procedure was done in 29 women in the laparoscopy group and in all women in the laparotomy group. The patient profile, symptoms, and operative and postoperative courses of these two groups of patients were compared. Those who underwent other procedures such as oophorectomy, excision of bilateral ovarian dermoid cyst, or endometrioma were not included in the statistical analysis. Laparoscopic ovarian cystectomy was conducted by first enucleating and separating the cyst from the normal ovarian tissue, which was done by a combination of sharp and hydrodissection. A 5 mm suction irrigator was used to deflate the cyst before removal from the abdominal cavity. The cyst was removed with a 10 mm secondary trocar. The ovarian defect was left open or inverted by coagulating the inner surface of the ovarian defect if the defect was too large. If this was still insufficient, the defect was sutured with a few sutures of 4-O polydioxanone. Hemostasis was achieved with bipolar coagulation. At the completion of the procedure, the 769
770
Lin, Falcone, and Tulandi
September 1995 Am J Obstet Gynecol
Table I. Comparison between excision of solitary dermoid cyst by laparoscopy and by laparotomy Surgical technique
Laparoscopy
No. of patients Age 04 Cyst diameter (cm) Operating time (min) Blood loss > 100 ml Spillage Hospital stay (days) Transient fever
29 31.4 +- 1.2 4.4 f 0.3 73.5 2 4.7 1 (3.4%) 29 (100%) 0.7 f 0.2 4/29 (13.8%)
Luparotomy
26 31.2 + 1.4 5.5 I? 0.4* 41.4 2 2.9t 3 (11.5%) 1(3.8%)X 3.8 rt O.lt 7126 (26.9%)
*p < 0.05. tp < 0.001 $p < 0.01.
peritoneal cavity was carefully lavaged until the irrigation fluid was devoid of any hair or sebum material. Ringer’s lactate solution (500 to 100 ml) was then left in the peritoneal cavity. Data were analyzed by Student t test and Fisher’s exact test.
Results The age of the women in the laparoscopic group was 31.4 2 1.2 years (range 19 to 59 years). A total of 44 ovarian dermoid cysts were removed. Three women had a dermoid cyst on each ovary and another had two dermoid cysts in one ovary. Aside from an oophorectomy in a postmenopausal woman, all others underwent an ovarian cystectomy. Eight women underwent additional procedures, including resection of ovarian endometriomas and myomectomy. There were no intraoperative complications and no conversion to laparotomy was needed. Blood loss was minimal, and in only two women did blood loss clearly exceed 100 ml (300 and 500 ml). Spillage of cyst content to a varying extent occurred in all cases. Eighteen patients (45%) were operated on as outpatients and another 12 (30%) as short-stay patients (hospitalization < 24 hours). Transient postoperative fever (~38” C for ~24 hours) was noted in four patients. Another had fever that lasted 3 days; this resolved with antibiotics. Another patient had decreasing hemoglobin from 13.3 to 7.3 gm but stabilized without transfusion or reoperation. Seventeen patients had at least 1 year of follow-up and they were all well. Comparison between the laparoscopy and laparotomy groups is depicted in Table I. The mean size of the dermoid cyst was significantly larger in the laparotomy group than in the laparoscopy group. The operating time appeared to be shorter in the laparotomy group, but this procedure was performed by different surgeons. The hospitalization time in the laparoscopic group was shorter. In these 29 patients blood loss during the laparoscopy was very minimal. In the lapa-
rotomy group three patients had blood loss > 100 ml. Spillage of the contents of the cyst occurred to a certain extent in all patients in the laparoscopic group and in only one patient in the laparotomy group. Nevertheless, there was no significant difference in the incidence of postoperative fever between the two groups. Resumption of bowel function, defined as the first documented passage of flatus after surgery, was 1.2 ? 0.2 days in the laparoscopy group and 2.1 -C 0.2 days in the laparotomy group. We had the opportunity to reevalute the condition of the pelvic organs in a patient 1 year after laparoscopic ovarian cystectomy. In spite of the spillage of the cyst’s contents at the initial surgery, we found only minimal periadnexal adhesions on the previous site of the cyst. The opposite adnexa was normal and there was no evidence of granulomatous implants.
Comment Dermoid cyst or mature cystic teratoma is the most common type of ovarian neoplasm occurring during a woman’s reproductive life.5, 6 The origin of these germ cell tumors is unclear, but it has been speculated that they arise by meiosis II nondisjunction7 or by abnormal parthenogenetic duplication of oocyte haploid chromosomes.6 The typical dermoid cyst may thus contain all three embryonic tissue layers, and nearly all somatic cell types have been found in these tumors.‘, 6 Dermoid cyst is easily identified during surgery or ultrasonography by the typical sebaceous fluid content and hair material. Before the advent of modern surgical techniques dermoid cysts produced some morbidity and mortality because of their propensity for torsion leading to ovarian infarction, for rupture leading to severe chemical peritonitis, and for fistulization through nearly all pelvic viscera.6 The treatment is therefore surgical excision. The use of transvaginal ultrasonography has made preoperative diagnosis of dermoid cyst more accurate. Many authors have reported laparoscopic excision of dermoid cyst.1-4 The laparoscopic technique reduces hospitalization and recovery time and the cosmetic outcome is imrjroved with the smaller incision. However, the unique environment of laparoscopy that requires deflation of the surgical specimen before extraction results in the higher incidence of leakage of cyst’s contents. This is in contrast to the conventional precautions to minimize leakage during laparotomy. Intraoperative spillage of dermoid cyst contents has potential short- and long-term complications. The release of highly inflammatory cyst material may lead to postoperative chemical peritonitis, resulting in febrile morbidity, ileus, and possibly the need for reoperation. Theoretic long-term problems include the risk of dermoid elements seeding in the peritoneal cavity producing granulomas, extensive adhesions, or fistula formation.‘. ’ Malignant element spillage may also lead to cancer dissemination.““’
Volume 173, Am J Obstet
Number
3, Part
Lin, Falcone,
1
and Tulandi
771
Gynecol
In our series spillage of the cyst’s contents occurred to a certain degree in all patients, yet there was no difference in the incidence of postoperative fever or other complications between the laparoscopy and the laparotomy groups. Spillage may be reduced by use of a larger suction probe or eliminated by use of a laparoscopic bag. None of our patients required a laparotomy, readmission, or reoperation. Spillage of the contents of the cyst did not appear to induce the development of granulomatous peritonitis.‘, 3 This may be due to the liberal irrigation of the peritoneal cavity and to the instillation of a large amount of Ringer’s lactate solution at the completion of the surgery.’ Implants of dermoid cells in the rectus muscle and fistulas to the bladder and rectum were recently reported.” The cyst was removed with considerable difficulty through both a colpotomy incision and through a secondary trocar. It appeared that during removal of the cyst some of the cells were inadvertently left embedded in the muscle, resulting in the parasitic growth and fistulous tract. Unrecognized injury to the bladder and rectum is also a possibility. This report suggests the importance of careful extraction of the cyst. Our current technique is to place the intact cyst in a laparoscopic bag, and aspiration of the cyst’s contents is done inside the bag, preventing spillage into the peritoneal cavity. Malignant degeneration of a dermoid cyst is a rare occurrence.*-” The estimated incidence is 1.8%, and most of the cases are diagnosed after the age of 40 years and the cysts are > 10 cm.‘, ’ It suggests that dermoid cysts of < 10 cm in women ~40 years old are unlikely to be malignant. It seems that the different occurrence of malignant dermoid cysts in young and older women indicates a time-related degeneration from benign to malignant over a period of two decades.]’
In summary, we presented a series of 40 women who successfully underwent laparoscopic excision of dermoid cyst. The laparoscopic approach may take longer than laparotomy, but the hospitalization time is reduced and recovery is faster. In our patients spillage of dermoid cyst does not lead to any complication, perhaps because of liberal irrigation of the peritoneal cavity. REFERENCES 1. Bollen N, Camus M, Tournaye H, Demunk L, Devroey P. Laparoscopic removal of benign mature teratoma. Hum Renrod 1992;7:1429-32. 2. Neihat C, Winer WK, Nezhat F. Laparoscopic removal of dermoid cysts. Obstet Gynecol 1989;73:278-80. _ 3. Reich H, McGlynn F, Sekel L, Taylor P. Laparoscopic management of ovarian dermoid cysts. J Reprod Med 1992;37:640-4. 4. Labastida R, Llueca J, Gomez T, et al. Laparoscopic 5.
removal of dermoid cysts. Gynecol Endosc 1994;3:9-Il. Petersen WF, Prevost EC, Edmunds FT, Hundley JM, Morris
FK.
OBSTET
GYNECOL
Benign
cystic
teratomas
of the
ovary.
AM J
1955;70:368-82.
6. Pantoja E, Noy MA, Axtmayer RW, Colon FE, Pelegrina I. Ovarian dermoids and their complications: comprehensive historical review. Obstet Gynecol Surv 1975;30:1-20. 7. Gerald PS. Origin of teratomas. N Engl J Med 1975;292: 103-4. 8. Caruso PA, Marsh MR, Minkowitz S, Karten G. An intensive clinicopathologic study of 305 teratomas of the ovary. Cancer 1971;27:343-8. 9. Petersen WF. Malignant degeneration of benign cystic teratomas of the ovary: a collective review of the literature. Obstet Gynecol Surv 1957;12:793-830. 10. Genadry R, Parmley T, Woodruff JD. Secondary malignancies in benign cystic teratomas. Gynecol Oncol 1979;S: 246-51. 11. Keil KH, Julian TM. Trichouria, pneumaturia, urosepsis, and bowel fistulization after pelviscopic cystectomy of mature ovarian teratoma. J Gynecol Surg 1993;9:235-9.