Introduction

Dermoid cysts of the ovary are also referred as ovarian teratomas. These types of ovarian cyst can occur at any age. These are slow-growing tumors occur from infancy to the postmenopausal years, but the prime age of detection is in the childbearing years. More than 50% of benign teratomas are discovered in women between the ages of 25 and 50 years. Dermoid cyst varies in size from a few millimeters to 25 cm in diameter although they have been reported to weigh as much as 7657 g in an asymptomatic woman. However, 80% are less than 10 cm. These tumors may be single or multiple in the same ovary. Up to 15% of women with ovarian teratomas have them in both ovaries.

Dermoid cysts originate from totipotential germ cells (which are present at birth) that differentiate abnormally, developing characteristics of mature dermal cells. These cysts may contain tissue, such as hair, skin, teeth, bone, thyroid tissue etc.

Although the large majority (about 98%) of these tumors are benign, the remaining fraction (about 2%) becomes cancerous (malignant).

Mature cystic teratoma (dermoid cyst) filled with hair and keratinous debris with one solid nodular area
Dermoid cyst

What are the symptoms with Dermoid Cyst?

About 50% to 60% of patients with dermoid cysts are asymptomatic and are discovered during a routine pelvic examination or coincidentally visualized during pelvic imaging. Presenting symptoms of dermoid include pain and the sensation of pelvic pressure. Patient can present with severe pain if complications like torsion, rupture, infection, hemorrhage happens. Three medical diseases also may be associated with dermoid cysts: thyrotoxicosis, carcinoid syndrome, and autoimmune hemolytic anemia, the latter two being quite rare.

How is a Dermoid Cyst Diagnosed?

A pelvic exam may reveal the presence of an ovarian cyst. But to confirm the type of cyst a pelvic ultrasound or sometimes an MRI pelvis is required.

Is Ovarian Dermoid cyst dangerous and what are the Complications associated with dermoid cyst?

Dermoid cysts usually grow very slowly. Small dermoid cysts, less than 6 cm in diameter, grow slowly at an approximate rate of 2 mm per year and does not cause much pain unless it goes into some complications like ovarian torsion, rupture etc.

Ovarian torsion. Torsion of a dermoid is the most frequent complication, occurring in 3.5% to 11% of cases. Cysts that become large may cause the ovary to move out of its usual position in the pelvis. This increases the chance of twisting of the ovary which causes severe pain abdomen. This cruciating pain is due to the compromised vascularity (blood flow) to the ovary due to torsion. Torsion is more common in younger women.

Rupture. Dermoid cyst can rarely rupture and can cause severe pain and internal bleeding. Rupture or perforation of the contents of a dermoid into the peritoneal cavity or an adjacent organ is a potentially serious complication. The incidence varies between 0.7% and 4.6%. However, most series report less than 1%. Rupture is more common in pregnancy. Spillage of the greasy contents in the dermoid cyst can create problems with adhesions, pain, Intestinal obstruction etc.
Infection and malignant degeneration are all unusual complications of dermoid, occurring in less than 1% of patients.

Dermoid Cyst During Pregnancy

When a teratoma is diagnosed incidentally during pregnancy, conservative management is acceptable. Though dermoid have a higher incidence of torsion and potential for rupture during pregnancy, most large series have not shown that an aggressive approach to asymptomatic teratomas less than 10 cm confers any advantage for the mother or pregnancy. Laparoscopy is safe during pregnancy; the treatment is cystectomy.

Treatment of choice

Dermoid cyst cannot be cured with medical management and surgical removal is the only option Operative treatment of benign cystic teratomas is cystectomy with preservation of as much normal ovarian tissue as possible. Laparoscopic cystectomy is an accepted approach. The laparoscopic approach has become increasingly accepted since 1989. Because most patients with cystic teratomas are of reproductive age, a conservative approach is ideal; laparoscopy may minimize adhesion formation and thus decrease the chance of compromising fertility.

How Is Laparoscopic Cyst removal done?

Laparoscopic surgeries are performed under general anesthesia. After pneumoperitoneum is achieved, diagnostic laparoscopy is done to thoroughly evaluate the pelvis and upper abdomen. First, peritoneal washing is obtained. Then, ovaries are closely examined for potential gross malignancy. Laparoscopic removal of dermoid cysts is performed by briefly creating a cleavage plane between the cyst and stroma of ovary with gentle dissection, and the cyst is enucleated. During cystectomy maximum caution is taken to prevent the spill of the cyst content. If spillage did occur, copious irrigation of the abdominal cavity is done to wash out cyst contents. After enucleation of the cyst, cyst wall with contents is placed in an impermeable bag and then aspirated in the bag and removed through a 12 mm trocar. A few sutures are often used to approximate the ovarian edges when the cyst size is large. Suturing is minimized in most cases to reduce postoperative adhesion formation.

Video of Laparoscopic Dermoid Cyst Removal

Benefits of Laparoscopic cystectomy over Laparotomy (Open Surgery)

One of the advantages of laparoscopic management of dermoid cysts is decreased adhesion formation and thus decrease the chance of compromising fertility. As has previously been established, hospital stay, blood loss, patient morbidity, and cosmetic results may be significantly better with laparoscopy compared to laparotomy. Laparoscopic management of dermoid cysts is safe and a beneficial procedure when performed by an experienced surgeon.

Dr. Alphy S Puthiyidom
Gynecologist and Laparoscopic Surgeon
Mediclinic Welcare Hospital, Dubai
Mob: +971556690655

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