LAPAROSCOPIC MANAGEMENT OF OVARIAN DERMOID CYSTS IN BIRAT MEDICAL COLLEGE , TEACHING HOSPITAL

Methodology This is a hospital based cross-sec onal study conducted at Birat Medical College and Teaching Hospital from 2012 April to 2016 April. All pa ents being operated by laparoscopy for ovarian dermoid cysts were enrolled in the study. Occurrence of spillage of dermoid contents during surgery and development of symtomps and signs of chemical peritoni s in postopera ve period were main outcome measures. The collected data was entered in Microso Excel and analyzed by SPSS so ware version17.


Objec ve
To study the outcome of laparoscopic treatment of ovarian dermoid cysts.

Methodology
This is a hospital based cross-sec onal study conducted at Birat Medical College and Teaching Hospital from 2012 April to 2016 April.All pa ents being operated by laparoscopy for ovarian dermoid cysts were enrolled in the study.Occurrence of spillage of dermoid contents during surgery and development of symtomps and signs of chemical peritoni s in postopera ve period were main outcome measures.The collected data was entered in Microso Excel and analyzed by SPSS so ware version17.

Results
Eighty nine ovarian dermoid cysts from 82 pa ents were managed by laparoscopy.Among 89 cysts, 54(60.76%)cysts were removed by laparoscopic cystectomy, 21(23.59%)cysts were removed by laparoscopic salpingo-ophorectomy and 14(15.73%)cysts were removed by salpingo-ophorectomy with hysterectomy.Spillage of dermoid content occurred in 50 (56.17%)cysts removal.There was no conversion to laparotomy and no case of chemical peritoni s.

Conclusion
The risk of chemical peritoni s is negligible with spillage of dermoid content during laparoscopic procedure when peritoneal cavity is washed thoroughly.

INTRODUCTION
Dermoid cysts of ovary are the common germinal ovarian tumour in women of reproduc ve age.Dermoid cysts account for 20-25% of the all ovarian tumours and are 1 bilateral in 10-15% of the cases.
Majority of the dermoid cysts are asymptoma c.They are o en discovered incidentally in pelvic examina on and during ultrasonographic scan of abdomen.The risk of complica ons such as torsion, spontaneous rupture of with risk of chemical peritoni s and malignancy changes make the surgical treatment necessary a er diagnosing dermoid cyst.Tradi onal method of treatment of dermoid cyst of ovary is cystectomy or oophorectomy by laparotomy.As the most pa ents with ovarian dermoid cysts are of reproduc ve age, a conserva ve approach is ideal.Laparoscopy may minimize the adhesion forma on and 2 thus decrease the chances of compromising fer lity.Laparoscopy is the standard treatment of the ovarian dermoid cyst and provides many advantages over 3 laparotomy.However, laparoscopic treatment could result in chemical peritoni s by spilled contents of a ruptured 4 dermoid cyst .Contents of ovarian dermoid cyst may spill a er spontaneous rupture or during cystectomy or during removal of the cyst.Therefore, it is very important to act promptly.We analyzed the outcome of removal of 89 ovarian dermoid cysts by laparoscopic route in 82 pa ents.

METHODOLOGY
This is a hospital based cross-sec onal study conducted at Birat Medical College and Teaching Hospital from 2012 April to 2016 April.All pa ents who were being operated by laparoscopy for treatment of ovarian dermoid cysts were included in the study a er taking informed consent.Eighty nine ovarian dermoid cysts were treated by laparoscopy route in 82 pa ents during above men oned period.
Age of pa ents, size of ovarian cysts in ultrasound scan, opera ve techniques (cystectomy, salpingo-ophorectomy or hysterectomy with salpingo-ophorectomy), occurrence of spillage of dermoid contents during surgery or during removal of the cysts , method of specimen removal (use of endobag or not), route of removal of the specimen (umbilical port, lateral port, posterior culpotomy or colpotomy a er hysterectomy) were recorded.During hospital stay in postopera ve period, development of symptoms and signs of chemical peritoni s such as increasing pain in abdomen with abdominal distension, decreased bowel sounds and fever were noted.Later, histopathological reports of the opera ve specimen were also collected.The collected data was entered in Microso Excel and analyzed by SPSS so ware version 17. Frequency table was obtained and mean was calculated.

RESULTS
Eighty nine ovarian dermoid cysts from 82 pa ents were removed by laparoscopy.The mean age of pa ents was 30.1 years, ranging from 17 years to 54 years.Mean size of dermoid cysts was 6.29cm, ranging from 3cm to 10 cm.Among 82 pa ents, 7(8.53%) pa ents had bilateral ovarian dermoid cysts.
Forty pa ents (48.78%) had presented with variable degree of lower abdominal pain.Dermoid cysts were detected in 20 (24.39%) pa ents while inves ga ng for subfer lity, in 13 (15.85%)pa ents while inves ga ng for abnormal uterine bleeding.Four (4.84%) pa ents had presented with oligomenorrhoea.Five cases (6.09%) had presented with symptoms of torsion of the cyst.One pa ent had 6 weeks pregnancy with twisted ovarian dermoid cyst.In 4 (4.89%)pa ents, ovarian dermoid cyst was diagnosed incidentally by ultrasonography while inves ga ng for other medical problems.
In postopera ve period, symptoms and sigs of chemical peritoni s such as increased abdominal pain, abdominal distension, decreased bowel sounds and fever were not noted in any pa ent.A er discharge from hospital, 3 pa ents came with umbilical port site infec on with pus forma on and one pa ent came with serous collec on at umbilical port site.All 4 cases were managed subsequently.There was no conversion to laparotomy.
Mature cys c teratoma was confirmed by histopathology in 88 cysts (98.87%).One case proved to be immature cys c teratoma.Laparoscopy should be considered the method of choice for removal of benign ovarian cys c teratomas as it offers the advantage of fewer postopera ve adhesions, reduced pain, shorter hospital stay and be er cosme c results.Nezhat CR et al conducted a study in which 93 ovarian dermoid cysts from 81 pa ents were treated by laparoscopic surgery.Cystectomy was performed in 70 cases and salpingo-ophorectomy was performed in 14 cases.Spillage of the cyst content occurred during procedure in 39(41.93%)cysts.There were no intraopera ve complica on and no case of chemical peritoni s 2 was noted.This study also has the similar finding.Total of 89 dermoid cysts were removed from 82 pa ents.Spillage of the dermoid contents occurred while removing 50 cysts (56.17%) in 45 pa ents.Spillage occurred either during cystectomy procedure or during extrac on of cyst out of abdominal cavity.The peritoneal cavity was thoroughly cleaned with normal saline solu on.The peritoneal cavity was drained for 24 -48 hours so as to drain remaining dermoid content.No intraopera ve or postopera ve complica on occurred.No cases of peritoni s noted.
In a study by Godinjac Z et al, 63 cases of ovarian dermoid cysts were managed by laparoscopic surgery and rupture of the cyst occurred in 38(60.32%) of 56 pa ents with cystectomy and 3(42.9%) of 7 pa ents in whom adnexectomy was performed.No intraopera ve or postopera ve complica ons 3 occurred there was no case of chemical peritoni s.Forty seven pa ents with dermoid cysts underwent cystectomy in 57% and oophorectomy in 36% of pa ents, spillage of the dermoid contents occurred in 42.5% of pa ents.None developed chemical peritoni s and concluded that laparoscopic treatment of dermoid cyst appears to be safe  removal with no further complica on to fetus and mother.
Similarly, in a case series, 12 women with pregnancy of 9 -17 weeks had laparoscopic removal of ovarian dermoid cysts.Spillage occurred in 10(93%) women.But no pa ent had evidence of chemical peritoni s.There were no intraopera ve 18 or postopera ve complicaion to mother or fetus.

LIMITATIONS OF STUDY
The findings of this study cannot be generalized in a large popula on due to its small sample size.

CONCLUSION
From this study, it can be concluded that spillage of dermoid contents can occur significantly during laparoscopic procedure for removal of ovarian dermoid cysts but incidence of chemical peritoni s in postopera ve period is very rare when the peritoneal cavity is abundantly washed with physiological solu on.

Table 4 . Spillage according to routes of specimen removal. (n = 89)Table 3 . Spillage of dermoid content according to procedure for removal of the cysts. (n=89) Routes of specimen removal Procedures Number of cysts removed Number of cysts removed
Malignant transforma on occurs in less than 2% of the dermoid cysts in women of all ages.The risk of torsion with dermoid cyst is approximately 15%, and it occurs more frequently than with other ovarian tumour, perhaps 6 because of high fat content of most dermoid cysts.In our study, only one case was proved to be immature cys c teratoma.Remaining 88 cysts of 89 dermoid cysts were mature cys c teratoma.Five cases (6.09%) presented with symptom of torsion of the cyst.In cases of dermoid cyst, 6.4% pa ents had bilateral ovarian Berg C et al retrospec vely surveyed 83 pa ents undergone laparoscopic removal of benign dermoid cyst.In 59 cases with cystectomy, spill of content occurred in 39(66%) cases.Salpingo-ophorectomy was done in 24 pa ents and spill of the content occurred in 8(29%) of pa ents.No intraopera ve or postopera ve complica on occurred and there was no In present study, there was one pa ent with 6 weeks pregnancy with twisted ovarian dermoid cyst which was managed by laparoscopic cystectomy without any undesirable effects to mother and the embryo.De Santos et al reported a case with 18 weeks pregnancy with twisted ovarian cyst of 15 cm who underwent laparoscopic cyst 17