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Laparoscopic conservative removal of ovarian dermoid cysts
May 1996, Vol. 3, No. 3
TheJournalof the American Association of Gynecologic Laparoscopists
Laparoscopic Conservative Removal of Ovarian Dermoid Cysts Dov Luxman, M.D., Jacob R. Cohen, M.D., and Menachem P. David, M.D.
Abstract We compared the efficacy of two dissection methods of ovarian dermoM laparoscopic cystectomy in 41 women (age 17-38 yrs) who desired future fertility. Blunt dissection and scissors were used in 21 patients (group A), and aquadissection in 20 (group B). The mean size of the cysts was comparable in both groups. The mean operating time for aquadissection was 59.3 minutes compared with 78.4 minutes for blunt dissection and scissors (p <0.05). Intraoperative spillage was significantly less common with aquadissection because with this method it is easier to avoid cyst rupture. No complication occurred with either method. Hospital stay was similar in both groups. Operative taparoscopy is a safe and effective method in the management of ovarian dermoid cysts.
presumably benign adnexal masses, including ovarian dermoid cysts.iZ-t4 In some studies, rupture of dermoid cysts during laparoscopy resulted in no adverse effects. 14, 15
Approximately 20% of all ovarian tumors are germ cell tumors. The majority of germ cell tumors are benign cystic teratomas or dermoid cysts, and occur predominantly in young women. ~Malignancy, usually of the squamous type, has been reported in 1% to 3% of all ovarian teratomas.2It is frequently argued that intraperitoneal spill of the dermoid contents may set up a granulomatous reaction in the peritoneum that grossly may be indistinguishable from tuberculosis or carcinomatosis.3-6Other reported complications related to rupture are acute peritonitis,7, 8peritoneal melan0sis, 9mucinous ascites,l~ and ovarian torsion resulting in infarction. H Since the last decade, operative laparoscopy has almost totally replaced laparotomy in the treatment of
Materials and Methods From January 1992 through December 1994, 57 women underwent laparoscopy for ovarian dermoid cysts. The preoperative diagnosis was established by pelvic examination, transvaginal sonography, plain abdominal film, and computerized tomographic scan. Sonographic appearance and CA 125 levels were used to minimize the risk of malignancy.
From the Department of Obstetrics and Gynecology "B," Serlin Maternity Hospital, Sourasky Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (all authors). Address reprint requests to Dov Luxman, M.D., Department of Obstetrics and Gynecology "B," Serlin Maternity Hospital, 15 Ein Dor Street, Tel Aviv 67441, Israel; fax 972 3692 5718. Presented at the 23rd annual meeting of the American Association Gynecologic Laparoscopists, New York City, October 18-23, 1994.
409
Laparoscopic Removal of 9
Dermoid Cysts Luxman et al
Subjects Inclusion criteria were unilateral dermoid cyst, largest diameter below 10 cm, no previous pelvic surgery, and desire for future fertility. Sixteen women were excluded from the study due to bilateral dermold cysts (3 patients), largest diameter greater than 10 cm (2), pelvic adhesions (3), intraoperative diagnosis of endometrioma (2), intraoperative suspicion of malignancy (2), and perimenopausal or postmenopausal status (4). Those with dermoid cysts larger than 10 cm were scheduled for laparotomy. The final study population consisted of 41 women of reproductive age (mean 31 yrs, range 17-38 yrs) who desired future fertility.
analysis was performed using the two-sample t test for continuous variables and ~2 test or Fisher's exact test for discrete variables. A probability of 0.05 or less was considered significant. Results
The mean age of group A women was 27.3 + 9.2 years and of group B 32.1 + 6.9 (no statistical difference). The CA 125 levels were within the normal range (<35 IU/ml) in all patients. The mean sizes of the dermoid cysts were 5.9 + 2.1 cm in group A and 6.2 + 2.4 in group B (no statistical difference). Operating time was 78.4 + 32.6 minutes in group A and 59.3 + 21.6 minutes in group B (p <0.05). The time required to dissect the cyst from the ovary was 43.7 + 22.1 minutes and 30.5 + 13.3, respectively (p <0.05). Intraoperative spillage of cyst contents occurred in five patients (23.8%) in group A and one (5%) in group B (p <0.05). In cases of spillage, thorough peritoneal lavage with 5 to 6 L lactated Ringer's solution was performed with maximum removal of fatty and hairy material. Postoperative complications in group A were one case of excessive bleeding from an extended abdominal incision, and two wound infections. None of the women in group B had short- or long-term postoperative complications. Most (19 both groups) were discharged the morning after surgery.
Techniques Laparoscopy was carried out under general anesthesia with endotracheat intubation. A pneumoperitoneum of 15 to 17 mm Hg was established by carbon dioxide insuffiator and maintained relatively constant throughout the operation. A 10- or 12-mm cannula was inserted through an infraumbilical incision through which the laparoscope with a high-resolution video camera attached to its eyepiece was introduced to the abdominal cavity. Two additional puncture sites were 10 mm in the right and 5 mm in the left lower quadrants. The entire abdominal cavity was inspected. The involved ovary was elevated by grasping and by placing traction on the utero-ovarian ligament. A small incision was made in the cyst capsule with miniscissors. For shelling the cyst out the ovary, the women were randomly divided into two groups: those managed by blunt dissection and scissors (group A, 21 patients), and by aquadissection (group B, 20 patients). A random number sequence was undertaken to allocate patients to the groups. Aquadissection using a 5-mm Monofil-bivalent rinsing tube (Wisap, Munich, Germany) was accomplished by a jet of normal saline or lactated Ringer's solution at a pressure of 300 mm Hg through a suction-irrigation device (Irrigator; Biomedical Dynamics, Bumsville, MN). After separating the cyst from the ovary, the cyst bed was inspected under water and bleeding vessels were fulgurated as required. The ovary was dropped back into its position without suturing the edges. The cyst was extracted from the abdominal cavity through an extended incision of one of the cannula sites or in an impermeable sac. Spillage, operation time, hospital stay, and intraoperative and postoperative complications were recorded and compared between the groups. Statistical
Discussion
The last decade witnessed a dramatic change in adnexal surgery, with conditions previously treated by laparotomy managed successfully by laparoscopy. This includes ovarian dermoid cysts. Ideally, rupture of ovarian cysts should be avoided. The possibility of intraabdominal spill of contents of a misdiagnosed malignant ovarian tumor during operative laparoscopy will always remain a threat. 16' 17 However, improved preoperative diagnostic modalities such as transvaginal ultrasonography, tumor markers, and videolaparoscopy may help to minimize this threat. The yield of color Doppler flow imaging in distinguishing benign from malignant ovarian tumors is controversial. Whereas some claim high diagnostic accuracy,18.19 others contend that this modality alone is relatively nonspecific and advocate a multiprocedure evaluation of ovarian tumors including color Doppler.20, 21 Nevertheless, keeping the cyst intact as long as possible facilitates its dissection from the ovary. 410
May 1996, Vol. 3, No. 3
TheJournal of the American Association of Gynecologic Laparoscopists
10. Holdsworth RJ, McCulloch AS, Duncan ID: Mucinous ascites associatedwith rupture of benign ovarianteratoma. Case report. Br J Obstet Gynaecol 97:952-954, 1990
We found that after locating the appropriate surgical plane, aquadissection was far more advantageous than sharp dissection in terms of operating time, 59.3 and 78.4 minutes, respectively, and frequency of spilling cyst contents, 5% and 23.8%, respectively. In all cases of rupture and spillage of sebaceous and hairy material, the abdominal cavity was thoroughly washed and material was removed under direct vision. No early or late complications related to spillage were observed. We conclude that laparoscopic conservative cystectomy of ovarian dermoid cysts of less than 10 cm in young women is safe and efficient.
11. Patoja E, Noy MA, Axtmayer RW, et al: Ovarian dermoids and their complications. Comprehensive historical review. Obstet Gynecol Surv 30:1-20, 1975 12. Reich H, McGlynn F, Sekel L, et al: Laparoscopic management of ovarian dermoid cysts. J Reprod Med 37:640--644, 1992 13. Manyonda IT, Baggish MS, Bower S, et al: Combined laparoscopic and micro-laparotomy removal of benign cystic teratoma. Br J Obstet Gynaeco1100:284-286, 1993
References
14. Nezhat C, Winer WR, Nezhat F: Laparoscopic removal of dermoid cysts. Obstet Gynecol 73:278-280, 1989
1. Jones HW, Wentz AC, Bumett LS: Novak's Textbook of Gynecology, 11th ed. Baltimore, Williams & Wilkins, 1988, pp 831-833
15. Bruhat MA, Mage G, Pouly J, et al: Operative Laparoscopy. New York, McGraw-Hill, 1992, pp 202-203
2. DiSaia PS, Creasman WT: Clinical Gynecologic Oncology, 4th ed. St. Louis, Mosby-Year Book, 1993, p 316
16. Maiman M, Seltzer V, Boyce J: Laparoscopic excision of ovarian neoplasms subsequently found to be malignant. Obstet Gynecol 77:563-565, 1991
3. Kistner RW: Intraperitoneal rupture of benign cystic teratomas: Review of the literature with a report of two cases. Obstet Gynecol Surv 7:603-609, 1952
17. Nezhat F, Nezhat C, Welander CE, et al: Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses. Am J Obstet Gynecol 167:790-796, 1992
4. Stuart GC, Smith JP. Ruptured benign cystic teratoma mimicking gynecologic malignancy. Gynecol Oncol 16:139-143, 1983 5. Waxman M, Boyce JC: Intraperitoneal rupture of benign cystic ovarian teratoma. Obstet Gynecol 48(1 suppl):9S-13S 6. Ranney B: Iatrogenicspillagefrom benign cystic teratoma causing severe peritoneal granulomatous adhesions. Report of a case. Obstet Gynecol 35:562-564, 1970 7. Ferrero A, Cespedes M, Cantarero JM, et al: Peritonitis due to rupture of retroperitoneal teratoma: Computed tomography diagnosis. Gastrointest Radiol 15:251-252, 1990
18. Kurjak A, Shalan H, Kupesic S, et al: Transvaginal color Doppler sonography in the assessment of pelvic tumor vascularity. Ultrasound Obstet Gynecol 3:137-154, 1993 19. Hata K, Hata T, Kitao M: Intratumoral peak systolic velocity as a new possible predictor for detection of adnexal malignancy. Am J Obstet Gynecol 172: 1496-1500, 1995
8. Semchyshyn S: Rupture of ovarian benign cystic teratoma causing acute abdomen [letter]. Can J Surg 20:282-283, 1977
20. Carter RJ, Lau M, Fowler JM, et al: Blood flow characteristics of ovarian tumors: Implications for ovarian cancer screening. Am J Obstet Gynecol 172:901-907, 1995
9. Fukushima M, Sharpe L, Okagaki T: Peritoneal melanosis secondary to a benign dermoid cyst of the ovary: A case report with ultrastructural study. Int J Gynecol Pathol 2:403-409, 1984
21. Chou CY, Chang CH, Yao BL, et al: Ultrasonography and serum CA-125 in the differentiation of benign and malignantovarian tumors. J Clin Ultrasound22:491-496, 1994
411
TheJournalof the American Association of Gynecologic Laparoscopists
Laparoscopic Conservative Removal of Ovarian Dermoid Cysts Dov Luxman, M.D., Jacob R. Cohen, M.D., and Menachem P. David, M.D.
Abstract We compared the efficacy of two dissection methods of ovarian dermoM laparoscopic cystectomy in 41 women (age 17-38 yrs) who desired future fertility. Blunt dissection and scissors were used in 21 patients (group A), and aquadissection in 20 (group B). The mean size of the cysts was comparable in both groups. The mean operating time for aquadissection was 59.3 minutes compared with 78.4 minutes for blunt dissection and scissors (p <0.05). Intraoperative spillage was significantly less common with aquadissection because with this method it is easier to avoid cyst rupture. No complication occurred with either method. Hospital stay was similar in both groups. Operative taparoscopy is a safe and effective method in the management of ovarian dermoid cysts.
presumably benign adnexal masses, including ovarian dermoid cysts.iZ-t4 In some studies, rupture of dermoid cysts during laparoscopy resulted in no adverse effects. 14, 15
Approximately 20% of all ovarian tumors are germ cell tumors. The majority of germ cell tumors are benign cystic teratomas or dermoid cysts, and occur predominantly in young women. ~Malignancy, usually of the squamous type, has been reported in 1% to 3% of all ovarian teratomas.2It is frequently argued that intraperitoneal spill of the dermoid contents may set up a granulomatous reaction in the peritoneum that grossly may be indistinguishable from tuberculosis or carcinomatosis.3-6Other reported complications related to rupture are acute peritonitis,7, 8peritoneal melan0sis, 9mucinous ascites,l~ and ovarian torsion resulting in infarction. H Since the last decade, operative laparoscopy has almost totally replaced laparotomy in the treatment of
Materials and Methods From January 1992 through December 1994, 57 women underwent laparoscopy for ovarian dermoid cysts. The preoperative diagnosis was established by pelvic examination, transvaginal sonography, plain abdominal film, and computerized tomographic scan. Sonographic appearance and CA 125 levels were used to minimize the risk of malignancy.
From the Department of Obstetrics and Gynecology "B," Serlin Maternity Hospital, Sourasky Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (all authors). Address reprint requests to Dov Luxman, M.D., Department of Obstetrics and Gynecology "B," Serlin Maternity Hospital, 15 Ein Dor Street, Tel Aviv 67441, Israel; fax 972 3692 5718. Presented at the 23rd annual meeting of the American Association Gynecologic Laparoscopists, New York City, October 18-23, 1994.
409
Laparoscopic Removal of 9
Dermoid Cysts Luxman et al
Subjects Inclusion criteria were unilateral dermoid cyst, largest diameter below 10 cm, no previous pelvic surgery, and desire for future fertility. Sixteen women were excluded from the study due to bilateral dermold cysts (3 patients), largest diameter greater than 10 cm (2), pelvic adhesions (3), intraoperative diagnosis of endometrioma (2), intraoperative suspicion of malignancy (2), and perimenopausal or postmenopausal status (4). Those with dermoid cysts larger than 10 cm were scheduled for laparotomy. The final study population consisted of 41 women of reproductive age (mean 31 yrs, range 17-38 yrs) who desired future fertility.
analysis was performed using the two-sample t test for continuous variables and ~2 test or Fisher's exact test for discrete variables. A probability of 0.05 or less was considered significant. Results
The mean age of group A women was 27.3 + 9.2 years and of group B 32.1 + 6.9 (no statistical difference). The CA 125 levels were within the normal range (<35 IU/ml) in all patients. The mean sizes of the dermoid cysts were 5.9 + 2.1 cm in group A and 6.2 + 2.4 in group B (no statistical difference). Operating time was 78.4 + 32.6 minutes in group A and 59.3 + 21.6 minutes in group B (p <0.05). The time required to dissect the cyst from the ovary was 43.7 + 22.1 minutes and 30.5 + 13.3, respectively (p <0.05). Intraoperative spillage of cyst contents occurred in five patients (23.8%) in group A and one (5%) in group B (p <0.05). In cases of spillage, thorough peritoneal lavage with 5 to 6 L lactated Ringer's solution was performed with maximum removal of fatty and hairy material. Postoperative complications in group A were one case of excessive bleeding from an extended abdominal incision, and two wound infections. None of the women in group B had short- or long-term postoperative complications. Most (19 both groups) were discharged the morning after surgery.
Techniques Laparoscopy was carried out under general anesthesia with endotracheat intubation. A pneumoperitoneum of 15 to 17 mm Hg was established by carbon dioxide insuffiator and maintained relatively constant throughout the operation. A 10- or 12-mm cannula was inserted through an infraumbilical incision through which the laparoscope with a high-resolution video camera attached to its eyepiece was introduced to the abdominal cavity. Two additional puncture sites were 10 mm in the right and 5 mm in the left lower quadrants. The entire abdominal cavity was inspected. The involved ovary was elevated by grasping and by placing traction on the utero-ovarian ligament. A small incision was made in the cyst capsule with miniscissors. For shelling the cyst out the ovary, the women were randomly divided into two groups: those managed by blunt dissection and scissors (group A, 21 patients), and by aquadissection (group B, 20 patients). A random number sequence was undertaken to allocate patients to the groups. Aquadissection using a 5-mm Monofil-bivalent rinsing tube (Wisap, Munich, Germany) was accomplished by a jet of normal saline or lactated Ringer's solution at a pressure of 300 mm Hg through a suction-irrigation device (Irrigator; Biomedical Dynamics, Bumsville, MN). After separating the cyst from the ovary, the cyst bed was inspected under water and bleeding vessels were fulgurated as required. The ovary was dropped back into its position without suturing the edges. The cyst was extracted from the abdominal cavity through an extended incision of one of the cannula sites or in an impermeable sac. Spillage, operation time, hospital stay, and intraoperative and postoperative complications were recorded and compared between the groups. Statistical
Discussion
The last decade witnessed a dramatic change in adnexal surgery, with conditions previously treated by laparotomy managed successfully by laparoscopy. This includes ovarian dermoid cysts. Ideally, rupture of ovarian cysts should be avoided. The possibility of intraabdominal spill of contents of a misdiagnosed malignant ovarian tumor during operative laparoscopy will always remain a threat. 16' 17 However, improved preoperative diagnostic modalities such as transvaginal ultrasonography, tumor markers, and videolaparoscopy may help to minimize this threat. The yield of color Doppler flow imaging in distinguishing benign from malignant ovarian tumors is controversial. Whereas some claim high diagnostic accuracy,18.19 others contend that this modality alone is relatively nonspecific and advocate a multiprocedure evaluation of ovarian tumors including color Doppler.20, 21 Nevertheless, keeping the cyst intact as long as possible facilitates its dissection from the ovary. 410
May 1996, Vol. 3, No. 3
TheJournal of the American Association of Gynecologic Laparoscopists
10. Holdsworth RJ, McCulloch AS, Duncan ID: Mucinous ascites associatedwith rupture of benign ovarianteratoma. Case report. Br J Obstet Gynaecol 97:952-954, 1990
We found that after locating the appropriate surgical plane, aquadissection was far more advantageous than sharp dissection in terms of operating time, 59.3 and 78.4 minutes, respectively, and frequency of spilling cyst contents, 5% and 23.8%, respectively. In all cases of rupture and spillage of sebaceous and hairy material, the abdominal cavity was thoroughly washed and material was removed under direct vision. No early or late complications related to spillage were observed. We conclude that laparoscopic conservative cystectomy of ovarian dermoid cysts of less than 10 cm in young women is safe and efficient.
11. Patoja E, Noy MA, Axtmayer RW, et al: Ovarian dermoids and their complications. Comprehensive historical review. Obstet Gynecol Surv 30:1-20, 1975 12. Reich H, McGlynn F, Sekel L, et al: Laparoscopic management of ovarian dermoid cysts. J Reprod Med 37:640--644, 1992 13. Manyonda IT, Baggish MS, Bower S, et al: Combined laparoscopic and micro-laparotomy removal of benign cystic teratoma. Br J Obstet Gynaeco1100:284-286, 1993
References
14. Nezhat C, Winer WR, Nezhat F: Laparoscopic removal of dermoid cysts. Obstet Gynecol 73:278-280, 1989
1. Jones HW, Wentz AC, Bumett LS: Novak's Textbook of Gynecology, 11th ed. Baltimore, Williams & Wilkins, 1988, pp 831-833
15. Bruhat MA, Mage G, Pouly J, et al: Operative Laparoscopy. New York, McGraw-Hill, 1992, pp 202-203
2. DiSaia PS, Creasman WT: Clinical Gynecologic Oncology, 4th ed. St. Louis, Mosby-Year Book, 1993, p 316
16. Maiman M, Seltzer V, Boyce J: Laparoscopic excision of ovarian neoplasms subsequently found to be malignant. Obstet Gynecol 77:563-565, 1991
3. Kistner RW: Intraperitoneal rupture of benign cystic teratomas: Review of the literature with a report of two cases. Obstet Gynecol Surv 7:603-609, 1952
17. Nezhat F, Nezhat C, Welander CE, et al: Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses. Am J Obstet Gynecol 167:790-796, 1992
4. Stuart GC, Smith JP. Ruptured benign cystic teratoma mimicking gynecologic malignancy. Gynecol Oncol 16:139-143, 1983 5. Waxman M, Boyce JC: Intraperitoneal rupture of benign cystic ovarian teratoma. Obstet Gynecol 48(1 suppl):9S-13S 6. Ranney B: Iatrogenicspillagefrom benign cystic teratoma causing severe peritoneal granulomatous adhesions. Report of a case. Obstet Gynecol 35:562-564, 1970 7. Ferrero A, Cespedes M, Cantarero JM, et al: Peritonitis due to rupture of retroperitoneal teratoma: Computed tomography diagnosis. Gastrointest Radiol 15:251-252, 1990
18. Kurjak A, Shalan H, Kupesic S, et al: Transvaginal color Doppler sonography in the assessment of pelvic tumor vascularity. Ultrasound Obstet Gynecol 3:137-154, 1993 19. Hata K, Hata T, Kitao M: Intratumoral peak systolic velocity as a new possible predictor for detection of adnexal malignancy. Am J Obstet Gynecol 172: 1496-1500, 1995
8. Semchyshyn S: Rupture of ovarian benign cystic teratoma causing acute abdomen [letter]. Can J Surg 20:282-283, 1977
20. Carter RJ, Lau M, Fowler JM, et al: Blood flow characteristics of ovarian tumors: Implications for ovarian cancer screening. Am J Obstet Gynecol 172:901-907, 1995
9. Fukushima M, Sharpe L, Okagaki T: Peritoneal melanosis secondary to a benign dermoid cyst of the ovary: A case report with ultrastructural study. Int J Gynecol Pathol 2:403-409, 1984
21. Chou CY, Chang CH, Yao BL, et al: Ultrasonography and serum CA-125 in the differentiation of benign and malignantovarian tumors. J Clin Ultrasound22:491-496, 1994
411