The Use of Ovarian Wall as an Endobag During Laparoscopic Removal of a Giant Dermoid Cyst: A New Approach

Abstract

Introduction Asymptomatic adnexal masses are diagnosed incidentally in 4% of pregnancies (1). Majority of them are benign and are of ovarian origin (1). Giant cysts, though uncommon, are challenging to the surgeon, in their removal. Such huge cysts were conventionally managed by laparotomy. In spite of all the advantages inherent to minimal access surgery, many surgeons refrain from removing them laparoscopically due to the risk of malignancy and the spillage of contents. This is a case report where a giant benign cystic teratoma (dermoid cyst) of 27 cm size was successfully excised laparoscopically. The greatest challenge was the retrieval of the huge specimen which would not fit into the largest endobag. The cyst was successfully removed using the ovarian wall as the endobag, which curtailed peritoneal soiling by the intra-cystic contents. We hope that this paper will add to the emerging evidence on the safety of laparoscopy in removing such gigantic cysts, refuting the myth that spillage of contents and its complications increases in proportion with cyst size. To the best of our knowledge, this is the largest reported ovarian cyst, removed laparoscopically in Qatar. Case Presentation The patient was a 32-year-old woman Gravida 3 Para 2 Live 2, who was referred to Obstetrics and Gynecology Department at 9 weeks of gestation with missed miscarriage and an incidental finding of a huge 21-cm ovarian cyst by ultrasonography. She was asymptomatic and was diagnosed to have this ovarian cyst during her viability scan at 7 weeks of gestation. On evaluation, she had no risk factors suggestive of a malignant potential like loss of appetite, abdominal bloating, loss of weight, dyspepsia or family history of breast/ gastrointestinal/ ovarian cancer. Physical examination showed a pelvic mass occupying the hypogastrium, bilateral iliac quadrants and reaching up to the umbilicus. The mass was not tender and there was no ascites, pleural effusion, palpable lymph nodes or hepatomegaly. No pressure symptoms like varicose veins were present. A repeat abdominopelvic ultrasound showed a 21-cm adnexal multi-locular cyst/cystadenoma with no solid component. The tumor markers CA-125, serum alpha-fetoprotein (AFP), serum lactate dehydrogenase (LDH), carcinoembryonic antigen (CEA) were tested and found to be within normal limits. The management options, both laparotomy and laparoscopic surgery, were discussed with the patient, including their pros and cons. Patient opted for laparoscopic removal as her primary concern was to avoid a large abdominal scar. Informed consent was obtained, and she was posted for elective operative laparoscopy after Abstract Objectives: Incidental finding of an asymptomatic giant ovarian mass is unusual during pregnancy. Addressing such voluminous cysts laparoscopically is controversial, and a challenge to the surgeon. This article describes on how we tackled a 27-cm ovarian cyst using the ovarian wall itself as the endobag. Case Presentation: A 32-year-old lady was referred to Obstetrics and Gynecology Depar...