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Laparoscopic management of a ruptured benign dermoid cyst during advanced pregnancy
Journal of Minimally Invasive Gynecology (2005) 21, 377–378
Laparoscopic management of a ruptured benign dermoid cyst during advanced pregnancy Horace Roman, MD, Marie Accoceberry, MD, Franck Bolandard, MD, Nicolas Bourdel, MD, Yann Lenglet, MD, and Michel Canis, MD, PhD From the Department of Obstetrics, Gynecology and Reproductive Medicine, University Hospital, Polyclinique, ClermontFerrand, France (all authors). KEYWORDS: Benign dermoid cyst; Teratoma; Laparoscopy; Pregnancy
Abstract. Benign cystic teratomas in pregnant women may be responsible for complications such as torsion, rupture and obstruction of labor. A woman in her 31st week of pregnancy with torsion of a large dermoid cyst and lipogranulomatosis peritonitis due to spilled cyst contents was managed laparoscopically with a favorable outcome. Trocar sites were selected according to the uterine size. Open laparoscopy allowed protection of the gravid uterus from penetrative injuries. Laparoscopic management of a voluminous adnexal mass may be safely performed during advanced pregnancy. © 2005 AAGL. All rights reserved.
Benign cystic teratomas are the most frequent ovarian tumors discovered during pregnancy (24%-40%)1,2 and may be responsible for complications such as torsion, rupture, and obstruction of labor. Their removal by laparoscopy has been reported as being safe and free of obstetric complications3-6; however, their management in an emergency setting is associated with increased obstetric morbidity. We report the case of a woman in her 31st week of pregnancy who had chemical peritonitis due to torsion and rupture of a dermoid cyst and who was managed laparoscopically in an emergency setting.
Case report A 26-year-old pregnant woman, gravida 3, para 1 (one previous voluntary abortion, one healthy infant delivered by cesarean section), and no previous gynecologic pathology, Corresponding author: Horace Roman, MD, Department of Obstetrics, Gynecology and Reproductive Medicine, CHU Polyclinique, Boulevard Leon Malfreyt, 63033 Clermont-Ferrand, France. E-mail: [email protected] Submitted October 4, 2004. Accepted for publication February 7, 2005.
1553-4650/$ -see front matter © 2005 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.05.010
had sudden, severe pelvic pain, nausea, and vomiting at 31 weeks’ gestation. Clinical examination found a 29-cm highcontractile uterus and increased pain on palpation of the left side of the uterus. Ultrasound examination showed a normal-weight fetus and a 10-cm heterogeneous mass located behind the uterus. Pelvic computed tomography scan revealed a left heterogeneous pelvic tumor situated in the pouch of Douglas, measuring 10 ⫻ 8 ⫻ 7 cm, containing fat tissue and calcifications (Figure 1). The torsion of a dermoid cyst of the left ovary was suspected. Emergency surgery was performed on the patient. Preoperatively, 12 mg of betamethasone was administered followed by general anesthesia with curarization and endotracheal intubation. The 10-mm trocar was placed in the left upper quadrant using an open technique. Lipogranulomatous peritonitis with white spots covering the peritoneal surfaces and the uterus was found. Two 5-mm trocars were placed under visual control, one through the umbilicus and the second laterally in the left flank at umbilical level. The intraabdominal pressure was maintained up to 10 mm Hg, and the peak insufflation up to 10 L/min. The patient was placed in the Trendelenburg position, and the operative table inclined toward the right side. In order to avoid the risk
378
Journal of Minimally Invasive Gynecology, Vol 21, No 4, July/August 2005
Figure 1 Pelvic computed tomography scan showing dermoid cyst in the pouch of Douglas.
of fetal acidosis, maternal hyperventilation managed by the anesthetist maintained end-tidal CO2 pressures between 29 and 32 mm Hg. Maternal oxygen blood saturation varied from 97% to 100%. The left adnexa, completely twisted, edematous, and bluish-black in color, was mobilized from the pouch of Douglas using two atraumatic forceps. The left ovary had the appearance of a ruptured dermoid cyst, free of vegetation and macroscopically benign. The cyst contents were aspirated with a 10-mm aspiration device, and the adnexa was pulled through the left flank incision, enlarged up to 3 cm. An extra-abdominal left cystectomy was attempted, but the absence of normal ovarian tissue required left oophorectomy. Ovarian hilus vessel ligation was performed using absorbable polyglycolic acid suture, followed by section using scissors. Copious irrigation of the pelvis, uterus, and upper abdomen was performed at the end of the procedure. The duration of the operation was 50 minutes. Postoperative histologic examination confirmed the diagnosis of a dermoid cyst. Pregnancy outcome was favorable. Nifedipine was administrated for 48 hours, and no threat of premature labor was noted. The patient was discharged 4 days later. She had spontaneous labor at 40 weeks’ gestation and delivered vaginally a healthy baby weighing 2980 g.
Discussion This case confirms that laparoscopic management of a voluminous adnexal mass may be performed safely during advanced pregnancy. Trocar sites should be selected according to uterine size and data from preoperative tests.5 Open
laparoscopy appears to be a good technique, allowing protection of the gravid uterus from penetrative injuries that are likely to occur during insufflation and insertion of the first trocar.3,4 In order to ensure both good visualization of the left adnexa and uterus protection, the 10-mm trocar was introduced in the left upper quadrant.3,6 The insertion of the two 5-mm trocars formed a triangle permitting adequate exposure of the operative field and unhindered instrument movement. The combination of left-sided laparoscopy and patient-inclined position made exploration of the left adnexa possible. The rate of complications resulting from dermoid cysts in pregnant women can be as high as 22%.2 However, the adnexa generally are located behind the pregnant uterus, making diagnosis difficult. In pregnant women with undiagnosed severe abdominal pain, the laparoscopic approach could safely eliminate a nonsurgical etiology or allow appropriate surgical treatment. In our patient, the painful uterine contractions could have been due to chemical peritonitis. However, the acute abdominal pain was probably secondary to adnexal torsion and not to rupture of the dermoid cyst. A leak or rupture of the dermoid is most likely to have preceded the acute event as it would take several days for a visible inflammatory process like lipogranulomatosis to develop. The outcome was favorable after adnexectomy and the removal of the spilled cyst contents along with peritoneal irrigation with saline solution, although all the white spots on the uterus and peritoneum were left alone.7 Nifedipine treatment was given as additional prophylaxis to avoid the danger of premature labor. The patient did not require a new caesarean section, subsequently, we could not make a perioperative statement regarding the evolution of lipogranulomatous spots or new peritoneal adhesions formation.
References 1. Peterson W, Prevost E, Edmunds F, et al. Benign cystic teratomas of the ovary: a clinico-statistical study of 1,007 cases with a review of the literature. Am J Obstet Gynecol. 1955;70:368-382. 2. Tawa K. Ovarian tumors in pregnancy. Am J Obstet Gynecol. 1964;90: 511-516. 3. Parker WH, Childers JM, Canis M, et al. Laparoscopic management of benign cystic teratomas during pregnancy. Am J Obstet Gynecol. 1996; 174:1499-1501. 4. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol. 2003;108:217-222. 5. Moore RD, Smith WG. Laparoscopic management of adnexal masses in pregnant women. J Reprod Med. 1999;44:97-100. 6. Stepp KJ, Tulikangas PK, Goldberg JM, et al. Laparoscopy for adnexal masses in the second trimester of pregnancy. J Am Assoc Gynecol Laparosc. 2003;10:55-59. 7. Wiberg N, Kiss K, Dalsgaard L. Lipogranuloma peritonealis caused by spontaneous rupture of a benign cystic ovarian teratoma. Acta Obstet Gynecol Scand. 2003;82:91-94.
Laparoscopic management of a ruptured benign dermoid cyst during advanced pregnancy Horace Roman, MD, Marie Accoceberry, MD, Franck Bolandard, MD, Nicolas Bourdel, MD, Yann Lenglet, MD, and Michel Canis, MD, PhD From the Department of Obstetrics, Gynecology and Reproductive Medicine, University Hospital, Polyclinique, ClermontFerrand, France (all authors). KEYWORDS: Benign dermoid cyst; Teratoma; Laparoscopy; Pregnancy
Abstract. Benign cystic teratomas in pregnant women may be responsible for complications such as torsion, rupture and obstruction of labor. A woman in her 31st week of pregnancy with torsion of a large dermoid cyst and lipogranulomatosis peritonitis due to spilled cyst contents was managed laparoscopically with a favorable outcome. Trocar sites were selected according to the uterine size. Open laparoscopy allowed protection of the gravid uterus from penetrative injuries. Laparoscopic management of a voluminous adnexal mass may be safely performed during advanced pregnancy. © 2005 AAGL. All rights reserved.
Benign cystic teratomas are the most frequent ovarian tumors discovered during pregnancy (24%-40%)1,2 and may be responsible for complications such as torsion, rupture, and obstruction of labor. Their removal by laparoscopy has been reported as being safe and free of obstetric complications3-6; however, their management in an emergency setting is associated with increased obstetric morbidity. We report the case of a woman in her 31st week of pregnancy who had chemical peritonitis due to torsion and rupture of a dermoid cyst and who was managed laparoscopically in an emergency setting.
Case report A 26-year-old pregnant woman, gravida 3, para 1 (one previous voluntary abortion, one healthy infant delivered by cesarean section), and no previous gynecologic pathology, Corresponding author: Horace Roman, MD, Department of Obstetrics, Gynecology and Reproductive Medicine, CHU Polyclinique, Boulevard Leon Malfreyt, 63033 Clermont-Ferrand, France. E-mail: [email protected] Submitted October 4, 2004. Accepted for publication February 7, 2005.
1553-4650/$ -see front matter © 2005 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.05.010
had sudden, severe pelvic pain, nausea, and vomiting at 31 weeks’ gestation. Clinical examination found a 29-cm highcontractile uterus and increased pain on palpation of the left side of the uterus. Ultrasound examination showed a normal-weight fetus and a 10-cm heterogeneous mass located behind the uterus. Pelvic computed tomography scan revealed a left heterogeneous pelvic tumor situated in the pouch of Douglas, measuring 10 ⫻ 8 ⫻ 7 cm, containing fat tissue and calcifications (Figure 1). The torsion of a dermoid cyst of the left ovary was suspected. Emergency surgery was performed on the patient. Preoperatively, 12 mg of betamethasone was administered followed by general anesthesia with curarization and endotracheal intubation. The 10-mm trocar was placed in the left upper quadrant using an open technique. Lipogranulomatous peritonitis with white spots covering the peritoneal surfaces and the uterus was found. Two 5-mm trocars were placed under visual control, one through the umbilicus and the second laterally in the left flank at umbilical level. The intraabdominal pressure was maintained up to 10 mm Hg, and the peak insufflation up to 10 L/min. The patient was placed in the Trendelenburg position, and the operative table inclined toward the right side. In order to avoid the risk
378
Journal of Minimally Invasive Gynecology, Vol 21, No 4, July/August 2005
Figure 1 Pelvic computed tomography scan showing dermoid cyst in the pouch of Douglas.
of fetal acidosis, maternal hyperventilation managed by the anesthetist maintained end-tidal CO2 pressures between 29 and 32 mm Hg. Maternal oxygen blood saturation varied from 97% to 100%. The left adnexa, completely twisted, edematous, and bluish-black in color, was mobilized from the pouch of Douglas using two atraumatic forceps. The left ovary had the appearance of a ruptured dermoid cyst, free of vegetation and macroscopically benign. The cyst contents were aspirated with a 10-mm aspiration device, and the adnexa was pulled through the left flank incision, enlarged up to 3 cm. An extra-abdominal left cystectomy was attempted, but the absence of normal ovarian tissue required left oophorectomy. Ovarian hilus vessel ligation was performed using absorbable polyglycolic acid suture, followed by section using scissors. Copious irrigation of the pelvis, uterus, and upper abdomen was performed at the end of the procedure. The duration of the operation was 50 minutes. Postoperative histologic examination confirmed the diagnosis of a dermoid cyst. Pregnancy outcome was favorable. Nifedipine was administrated for 48 hours, and no threat of premature labor was noted. The patient was discharged 4 days later. She had spontaneous labor at 40 weeks’ gestation and delivered vaginally a healthy baby weighing 2980 g.
Discussion This case confirms that laparoscopic management of a voluminous adnexal mass may be performed safely during advanced pregnancy. Trocar sites should be selected according to uterine size and data from preoperative tests.5 Open
laparoscopy appears to be a good technique, allowing protection of the gravid uterus from penetrative injuries that are likely to occur during insufflation and insertion of the first trocar.3,4 In order to ensure both good visualization of the left adnexa and uterus protection, the 10-mm trocar was introduced in the left upper quadrant.3,6 The insertion of the two 5-mm trocars formed a triangle permitting adequate exposure of the operative field and unhindered instrument movement. The combination of left-sided laparoscopy and patient-inclined position made exploration of the left adnexa possible. The rate of complications resulting from dermoid cysts in pregnant women can be as high as 22%.2 However, the adnexa generally are located behind the pregnant uterus, making diagnosis difficult. In pregnant women with undiagnosed severe abdominal pain, the laparoscopic approach could safely eliminate a nonsurgical etiology or allow appropriate surgical treatment. In our patient, the painful uterine contractions could have been due to chemical peritonitis. However, the acute abdominal pain was probably secondary to adnexal torsion and not to rupture of the dermoid cyst. A leak or rupture of the dermoid is most likely to have preceded the acute event as it would take several days for a visible inflammatory process like lipogranulomatosis to develop. The outcome was favorable after adnexectomy and the removal of the spilled cyst contents along with peritoneal irrigation with saline solution, although all the white spots on the uterus and peritoneum were left alone.7 Nifedipine treatment was given as additional prophylaxis to avoid the danger of premature labor. The patient did not require a new caesarean section, subsequently, we could not make a perioperative statement regarding the evolution of lipogranulomatous spots or new peritoneal adhesions formation.
References 1. Peterson W, Prevost E, Edmunds F, et al. Benign cystic teratomas of the ovary: a clinico-statistical study of 1,007 cases with a review of the literature. Am J Obstet Gynecol. 1955;70:368-382. 2. Tawa K. Ovarian tumors in pregnancy. Am J Obstet Gynecol. 1964;90: 511-516. 3. Parker WH, Childers JM, Canis M, et al. Laparoscopic management of benign cystic teratomas during pregnancy. Am J Obstet Gynecol. 1996; 174:1499-1501. 4. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol. 2003;108:217-222. 5. Moore RD, Smith WG. Laparoscopic management of adnexal masses in pregnant women. J Reprod Med. 1999;44:97-100. 6. Stepp KJ, Tulikangas PK, Goldberg JM, et al. Laparoscopy for adnexal masses in the second trimester of pregnancy. J Am Assoc Gynecol Laparosc. 2003;10:55-59. 7. Wiberg N, Kiss K, Dalsgaard L. Lipogranuloma peritonealis caused by spontaneous rupture of a benign cystic ovarian teratoma. Acta Obstet Gynecol Scand. 2003;82:91-94.