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Laparoscopic Management Of Ovarian Dermoid Cysts: A Review Of 47 Cases

Authors:

Abstract

Mature cystic teratomas, often referred to as dermoid cysts, are the most common germ cell tumors of the ovary. In the recent years, transvaginal sonographic diagnosis of ovarian dermoid cysts together with laparoscopic approach have greatly improved the treatment of this benign lesion. We retrospectively reviewed the outcome of laparoscopic surgery for suspected ovarian dermoid cysts. The preoperative findings, operative techniques and postoperative complications were retrospectively reviewed in women who underwent laparoscopic surgery for dermoid cysts, between January 2000 and May 2003. In 47 women aged 21 to 53 years (median, 38.8 years), 93.6% had a unilateral cyst with a diameter of 17 to 108 mm (median, 51 mm). Clinical presentations were pain (62%), abnormal vaginal bleeding (21%) and ovarian torsion (2%), whilst 17% were diagnosed incidentally during routine examination. Surgery included cystectomy (57%), total (36%) or partial oophorectomy (6.4%) and laparoscopy-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (2%). During the cyst extraction, minimal spillage occurred in 42.5% of the cases and none developed chemical peritonitis. In 2 patients, conversion to laparotomy (4.3%) was required, one for sigmoid colon injury and one for malignant ovarian tumor detected via frozen section. The median operating time was 80 minutes (range, 35-180 minutes). Using strict adherence to guidelines for preoperative clinical assessment and intra-operative management, laparoscopic treatment of dermoid cysts appears to be a safe procedure.
VOLUME 24 | ISSUE 5 | SEPTEMBER-
OCTOBER 2004
Original Article Font size:
Laparoscopic Management Of Ovarian
Dermoid Cysts: A Review Of 47 Cases
Muberra Koçak, MD; Berna Dilbaz, MD; Nilgun Ozturk, MD; Suat Dede, MD; Metin Altay,
MD; Serdar Dilbaz, MD; Ali Haberal, MD
From the Department of Obstetrics, SSK Maternity and Women's Health Teaching
Hospital, Ankara, Turkey
How to cite this article:
M Koçak, B Dilbaz, N Ozturk, S Dede, M Altay, S Dilbaz, A Haberal, Laparoscopic
Management of Ovarian Dermoid Cysts: a Review of 47 Cases. 2004; 24(5): 357-360
DOI: 10.5144/0256-4947.2004.357
Abstract
Background: Mature cystic teratomas, often referred to as dermoid
cysts, are the most common germ cell tumors of the ovary. In the recent
years, transvaginal sonographic diagnosis of ovarian dermoid cysts
together with laparoscopic approach have greatly improved the treatment
of this benign lesion. We retrospectively reviewed the outcome of
laparoscopic surgery for suspected ovarian dermoid cysts. Patients and
Methods: The preoperative findings, operative techniques and
postoperative complications were retrospectively reviewed in women who
underwent laparoscopic surgery for dermoid cysts, between January 2000
and May 2003. Results: In 47 women aged 21 to 53 years (median, 38.8
years), 93.6% had a unilateral cyst with a diameter of 17 to 108 mm
(median, 51 mm). Clinical presentations were pain (62%), abnormal
vaginal bleeding (21%) and ovarian torsion (2%), whilst 17% were
diagnosed incidentally during routine examination. Surgery included
cystectomy (57%), total (36%) or partial oophorectomy (6.4%) and
laparoscopy-assisted vaginal hysterectomy with bilateral salpingo-
oophorectomy (2%). During the cyst extraction, minimal spillage occurred
in 42.5% of the cases and none developed chemical peritonitis. In 2
patients, conversion to laparotomy (4.3%) was required, one for sigmoid
colon injury and one for malignant ovarian tumor detected via frozen
section. The median operating time was 80 minutes (range, 35-180
minutes). Conclusion: Using strict adherence to guidelines for
preoperative clinical assessment and intra-operative management,
laparoscopic treatment of dermoid cysts appears to be a safe procedure.
Ann Saudi Med 2004; 24(5): 357-360
Key words: Ovarian dermoid cyst, laparoscopy, safety, adverse events
Mature cystic teratoma of the ovary (dermoid cyst) usually occurs during
the reproductive period and represents 5% to 25% of all ovarian
neoplasms.1,2 Although less than 3% of dermoid cysts managed by
surgery prove to be malignant, a benign cystic teratoma may appear to be
suspiciously malignant during the initial scan due to its complex solid and
cystic nature.3-5
High-quality vaginal ultrasound transducers are now the first preoperative
work-up method of choice for the assessment of adnexal masses; in
clinical practice other imaging methods are rarely needed. Expectant
management with a follow-up ultrasound examination may be appropriate
in asymptomatic dermoid cysts. However, if associated with adnexal
torsion (16%), pain, or with rupture leading to chemical peritonitis (3-
7%), surgical treatment may become necessary.5-7 The management of a
dermoid cyst therefore depends more on its symptoms and clinical
findings than the very small risk of actual malignancy.8,9 A decision can
then be made between conservative management, laparoscopic surgery or
laparotomy depending upon the patients' symptoms, age, clinical findings
and ultrasonographic features.10
Laparoscopy represents a major improvement in surgery because of its
better magnification, reduced invasiveness, and shorter hospitalization.
Ovarian surgery is one of the most frequently performed laparoscopic
procedures in routine practice. Laparoscopic removal of dermoid cysts was
first described in 1989 by Nezhat et al and now, more liberal use of the
operative laparoscopy has led to the treatment of many suspected cases
of dermoid cysts.7,11 Many studies have shown that laparoscopic treatment
of adnexal masses is safe even in postmenopausal women who are at
greater risk of developing a malign ovarian neoplasm.12-15
The extraction of an intact cyst within a bag (closed technique) is the
recommended technique for the removal of dermoid cysts.11,14 Rupture of
the cyst with spillage of its fluid content may be deleterious with
teratomas. Chemical peritonitis and granuloma formation with intestinal
obstruction have been reported after laparoscopic removal of benign cystic
teratomas due to spillage.16 Adequate intraabdominal isolation within an
Endobag to avoid the most common event of spillage during laparoscopic
removal of dermoid cysts is now advocated by several investigators.1718
On the other hand, unilateral adnexal masses in women of reproductive
age are benign in up to 95% of cases and laparoscopic surgery is
perceived as a less invasive technique for women who are thought to have
a dermoid cyst.15,24
We retrospectively reviewed the diagnosis and removal of benign cystic
teratomas via laparoscopy in 47 women.
Patients and Methods
A total of 47 patients were admitted to the SSK Maternity and Women's
Health Teaching Hospital Endoscopic Surgery Clinic between January 2000
and May 2003, with a confirmed diagnosis of dermoid cyst. The patients
presented with lower abdominal pain or a palpable adnexal mass. The
findings on transvaginal ultrasound imaging determined patient selection.
For ultrasonographic examination, an EUB 505 Hitachi (Tokyo, Japan) was
used with a 6.5 MHz transvaginal probe. Patients who had adverse
features such as large or multilocular cysts with thick septa, solid areas,
or neovascularization seen with color Doppler and a low resistance index
(RI) were excluded from the study. An abnormal result on serum tumor
markers was also an exclusion criteria.
All procedures were performed under general anesthesia and endotracheal
intubation. A fiberoptic laparoscope (K. Storz Gmbh & Co; Tuttlingen,
Germany) together with a standard Veress needle was used routinely and
all the procedures were recorded via a laparoscopic camera and a video
recorder. Following the insertion of the second and third operative trocars
under direct vision, we carried out a thorough inspection of the abdominal
cavity, including the subdiaphragmatic area. The fluid from the pouch of
Douglas was aspirated for cytology before any contamination, and
peritoneal washings were sent for cytology. The ovaries were inspected to
ensure that the cyst wall was smooth and there was no vegetation or
other evidence to suggest malignancy.
The pelvic and abdominal peritoneal and ovarian surfaces were thoroughly
examined. The size and the intra-ovarian location of the cyst were
determined in order to select the proper site for the ovarian incision. The
dissection was facilitated by aquadissection with an irrigating probe and
either ovarian cystectomy or adnexectomy, according to the presence of a
normal ovarian tissue and patient age, was applied with great care to
avoid rupture of the cyst wall. During the course of this manipulation to
free the cyst, a wide-bore suction irrigator device was used to remove this
material and vigorous washing was carried out using at least 10 liters of
saline solution in case of rupture of the cyst wall and the leakage of the
contents. The operation specimen was placed within an Endobag, and
dermoid cysts were then decompressed by incision and aspiration of their
contents. Following decompression, the bag was drawn through the
second port or through the abdominal wall after removing the port. All
specimens were sent for frozen section and histopathological examination
for definitive pathology data. Once hemostasis by bipolar electrocautery
was completed, the entire abdominal cavity was thoroughly cleansed,
removing all blood, clots and debris. Approximately one liter of isotonic
irrigating fluid was left in the abdomen. The incisions were sutured after
careful removal of the trocar. In the case of a fascial incision >2 cm,
fascial stitches were placed.
The patients were on a general diet for 24 hours and oral analgesics were
prescribed in required cases. Prophylactic antibiotics were given once in all
cases. Forty-five of the patients were discharged from the hospital within
24 to 36 hours, and all patients were invited for a postoperative control 1
month and 3 months after the initial surgery.
Results
The median age of the patient group was 38.8 years (range, 21-53 years).
The main indications for surgery were lower abdominal pain (62%),
abnormal vaginal bleeding (21%), incidental findings during routine
clinical examination (17%) and ovarian torsion (2%). Medical history
showed that 38% of the patients had a previous laparotomy mainly for
either cesarean section (n=8), appendectomy (n=6), adnexal surgery
(n=3) or cholecystectomy (n=l). Slightly elevated serum levels of Ca 125
and Ca 19.9 (<40 mIU/mL) were found in 6.4% (n=3) and 8.5% (n=4) of
the patients, respectively.
Median cyst diameter measured by transvaginal ultrasonography was 51
mm (range, 17-108 mm). In this series of women, 44 (94%) unilateral
and three (6%) bilateral dermoid cysts were recorded. On the ultrasound
examination, 19 (55.7%) had full characteristics of dermoid cysts by an
echogenic focus with acoustic shadowing situated within a predominantly
cystic mass. In the remaining 44.3% of the cases, the cysts had a mixed
echogenic component and were definitely identified as dermoid cysts at
the time of the laparoscopic surgery and final histopathological
examination.
During laparoscopic surgery, 27 patients required no other surgery than
cystectomy (57%), whilst 43% underwent either unilateral salpingo-
oophorectomy (n=17), partial oophorectomy (n=3) or laparoscopy
assisted vaginal hysterectomy (n=l). Minimal intra-abdominal spillage (1-2
cc) occurred in 20 cases (42.5%). There was no intraoperative
complication in 98% of the patients and only one patient with dense pelvic
adhesions required a conversion to laparotomy to manage sigmoid colon
injury.
The frozen section analysis and the final histopathological reports were
reputed to be benign for 46 of the cases, confirming the diagnosis of
mature cystic teratomas. In one of the cases, with typical dermoid cyst
characteristics observed during ultrasonographic examination, a granulosa
cell tumor was detected by frozen section analysis. Immediate staging
laparotomy through a midline incision was performed. This was an early
ovarian malignancy defined by accurate means of staging, as stage Ia.
Median operating time was 80 minutes (range, 35-180 minutes) and
estimated blood loss was less than 50 mL in the present series. After the
operation, no postoperative complication such as chemical peritonitis,
fever or postoperative bleeding was encountered. All patients were
discharged within 48 hours, except one patient with sigmoid injury and
another, in which frozen section revealed an ovarian carcinoma and who
had a laparotomy and was eventually discharged 96 hours post-
operatively. In the follow-up, all patients were seen after the first and the
third month of initial surgery. Minor complaints were reported, which were
not due to the procedure itself. All physical examinations, pelvic
sonograms and laboratory findings were within normal limits.
Discussion
Laparoscopic surgery has become a valuable tool in both diagnostic and
operative gynecologic procedures. In many cases, laparoscopy may
replace conventional laparotomy for diagnosis and treatment of adnexal
masses.12-15 However, the negative effect of an intraoperative rupture and
spillage of malign cells during laparoscopic surgery on the prognosis of
patients with early stage ovarian cancer is still controversial. On the other
hand, mature cystic teratomas, commonly referred as dermoid cysts,
comprise some 40% to 50% of all benign ovarian neoplasms. Certain
characteristics, such as hair and sebum or irregular solid components
within fluid-containing masses on ultrasound examination, may help to
distinguish malign neoplasms from benign dermoid cysts, but malignant
degeneration of the ovary may present in 1% to 3% of all cystic
teratomas.4,10,18-20
A presumptive diagnosis of dermoid cysts often can be made during the
initial clinical evaluation, but special features such as the existence of
septa or solid components and papillamatous structures may appear,
mimicking other malign ovarian mass that would mandate against
laparoscopic removal.21 Improved ultrasound techniques and scoring
systems have made the preoperative diagnosis of dermoid cysts more
common. Although, Benacerref et al reported a 15% failure rate in
differentiation of benign and malignant cysts during transvaginal
ultrasonographic diagnosis of complicated cysts,22 histologic results
revealed the accurate benign diagnosis in 97% of the cases in our study
group. Careful preoperative evaluation of the patients and a precise
definition of the cysts with transvaginal ultrasonography allowed us to use
laparoscopic surgery for dermoid cysts with special features.
Tumor markers, especially Ca 125 and Ca 19-9 have a special predictive
value in premenopausal women with dermoid cysts.23 In the present
series, slightly elevated levels of Ca 19-9 and Ca 125 were found in 8.5%
and 6.4% of the patients, respectively.
The role of laparoscopic surgery in the uncontrolled spillage of dermoid
cyst contents has been addressed by Huss, Coccia and Langebrekke et
al.16-18 Recent studies have shown that dermoid cysts can often be
removed laparoscopically using a closed technique with controlled
spillage.24-26 When intraoperative spillage does occur, use of copious saline
irrigation until the lavage is clear is recommended to minimize the
potential risk of chemical peritonitis or excess adhesion formation. In
Zanettas series of 49 women who underwent laparoscopic cystectomy for
dermoid cysts, it was reported that spillage had occurred in 43 cases
(88%), but no case of peritonitis was recorded.27 The incidence of spillage
was 42.5% in our study group and the rate of chemical peritonitis was nil
in 47 cases undergoing laparoscopic dermoid surgery. The main question
in endoscopic surgery is the risk of spreading an early ovarian cancer
because of spillage, which may compromise patient survival unless
additional therapies are administered. In one large published series of
1011 women with ovarian cysts that was managed laparoscopi-cally and
with a careful approach, the risk of operating on an undetected
malignancy was found to be less than 3%.24 Nezhat and Balen stated that
all benign dermoid cysts could be treated by laparoscopic surgery by
relying on the experience of the surgeon and the use of appropriate
technique.7,28 Nezhat reported in his ten years experience that a total of
39 intraoperative spillages occurred in 81 patients with dermoid cysts with
no case of chemical peritonitis, but one case had incisional infection in the
umbilicus.29
Laparoscopic ovarian surgery is now a method of choice due to its
advantages, most of which focus on preserving ovarian tissue and
minimizing postoperative adhesion formation in reproductive age
women.30,31 This study demonstrated similar outcomes in patients treated
via laparoscopy for dermoid cysts. Although there were no clinically
relevant adverse effects, this study did not have sufficient power to detect
changes in serious rare adverse outcomes.
In conclusion, dermoid cysts, most of which are benign, can be efficiently
treated via endoscopic surgery using closed technique to avoid spillage of
the cyst contents into the abdominal cavity. The fear of missing a
diagnosis of early malignancy dictates a strict policy of meticulous
preoperative evaluation and use of frozen section in complex cysts.
However, prospective controlled clinical trials with a large number of
patients are necessary to compare conventional methods with laparoscopy
in cases with teratomas and to assess more rare events like undetected
malignancy, chemical peritonitis or excess adhesion formation.
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745.
... Acute pain may be a result of torsion, hemorrhage into the mass, or rupture of the mass into peritoneal cavity. In studies done by Sendag et al. [6] Koçak et al. [7] and Shawki et al. [5] , 97.87 %, 94% and 85.20% women were found to have unilateral dermoid cyst and same is concluded from our study. Mean duration of surgery in our study is 119 minutes which is comparable to operative time reported by Nezhat et al. [2] Koçak et al. [7] and Sendag et al. [6] which are 103.0, ...
... In studies done by Sendag et al. [6] Koçak et al. [7] and Shawki et al. [5] , 97.87 %, 94% and 85.20% women were found to have unilateral dermoid cyst and same is concluded from our study. Mean duration of surgery in our study is 119 minutes which is comparable to operative time reported by Nezhat et al. [2] Koçak et al. [7] and Sendag et al. [6] which are 103.0, 80.0 and 64.60 minutes respectively. ...
... One of the main advantages of minimal access surgery is less operative blood loss. This was corroborated by our study which has 24.72ml as the mean blood loss for laparoscopic procedures and this result is comparable to studies done by Koçak et al. [7] and Nezhat et al. [2] which reported blood loss of 50 ml and 84 ml respectively. The mean hospital stay in present study was 3.5 days which is comparable to studies by Koçak et al. [7] Sendag et al. [6] and Shawki et al. [5] where mean hospital stay was 2,1.6 and 0.9 days respectively. ...
... Transient fever after surgery for a benign ovarian cyst was also found to be rare, with only 6 reported events out of the 572 cases in total (1.0%) and 5 events out of the 264 cases in patients with intraoperative spillage (1.9%) [17,18,28,31,38,40,41]. Two studies excluded for the metaanalysis owing to lack of events in both arms were RCTs [17,18], and the other 2 were observational studies [31,40]. ...
... Transient fever after surgery for a benign ovarian cyst was also found to be rare, with only 6 reported events out of the 572 cases in total (1.0%) and 5 events out of the 264 cases in patients with intraoperative spillage (1.9%) [17,18,28,31,38,40,41]. Two studies excluded for the metaanalysis owing to lack of events in both arms were RCTs [17,18], and the other 2 were observational studies [31,40]. Three observational studies included in our meta-analysis failed to show a significant difference in the transient fever rate between the groups [28,38,41]. ...
Article
Objective To review short- and long-term complications associated with intraoperative rupture of benign ovarian cysts. Data Sources The Cochrane Central Register of Controlled Trials, BIOSIS, Medline (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar were searched using the following terms and their combinations: “spillage,” “rupture,” “leakage,” “ovarian cyst,” “teratoma,” “dermoid,” “operative,” “surgery,” “outcome.” Methods of Study Selection Randomized controlled and observational studies evaluating the operative outcomes of surgical treatment of ovarian cysts with intraoperative spillage compared with those of surgical treatment of ovarian cysts without spillage were included. A systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. Tabulation, Integration, and Results A total of 28 studies were included in the qualitative analysis and 12 in the quantitative analysis. Ovarian cyst diameter was not found to be associated with the risk for spillage (relative risk [RR] 0.75; 95% confidence interval [CI], –0.33 to 1.82). Intraoperative benign ovarian cyst rupture was not associated with adverse short- and long-term outcomes such as reoperation (RR 1.16; 95% CI, 0.39–3.48), infertility (RR 0.73; 95% CI, 0.15–3.63), transient fever (RR 3.22; 95% CI, 0.83–12.51), and readmission (RR 1.00; 95% CI, 0.33–2.98). However, intraoperative spillage was found to be associated with increased risk for benign recurrence (RR 3.1; 95% CI, 1.05–9.14). A subgroup analysis of the studies that included only dermoid cysts showed an association between intraoperative cyst rupture and postoperative chemical peritonitis (RR 9.36; 95% CI, 1.20–73.28). Conclusion Intraoperative ovarian cyst spillage of a benign cyst is associated with limited adverse clinical outcomes. Although the surgical approach (minimally invasive vs open) should not be affected by the concern regarding an intraoperative cyst rupture, maximal efforts should be made to prevent intra-abdominal spillage.
... Less than 3% of dermoid cysts are malignant. Management mainly includes laparoscopic resection and extraction within a bag [7,8]. ...
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Background Anti-N-Methyl-d-Aspartate encephalitis is a subcategory of auto-immune encephalitis. It is known for its aggressive presenting symptoms and rapid deterioration, yet it is treatment responsive. It is associated in 50 % to ovarian teratoma. Case We report the case of a 19 year old female patient presenting for a psychiatric disorder of sudden onset with rapid deterioration. Neurologic imaging was in favor of encephalitis, and CSF studies revealed Anti NMDA receptors. Further abdominal imaging showed a right ovarian teratoma of 4 cm. Laparoscopic ovarian cyst resection was done, and corticotherapy, IVIG and anticonvulsants were given. We report complete resolution of symptoms after 7 months. Conclusion Anti-NMDA receptor encephalitis with ovarian teratoma is a rare entity with rapid deterioration. Early diagnosis, surgical resection and proper medical treatment are essential for the management of this disease.
... Dermoid kistlerde en sık izlenen komplikasyon torsiyondur. Koçak ve ark., yaptıkları çalışmada dermoid kistlerde torsiyon oranını %2 olarak bulmuşlardır (20). Bizim çalışmamızda %4,76 oranında torsiyon tespit edilmiştir. ...
... Tumor markers especially CA 125 and CA 19-9 have a special predictive value in women with dermoid cyst. 6 The patient was taken up for emergency laparoscopy once we got the report. We had great difficulty in operating on this patient because of marked distension of bowel loops as a result of sigmoiditis. ...
... If required, additional treatment for ruptured teratomas should include removal of both the ruptured cyst and the spilled content. Laparoscopic surgery can be a safe and effective procedure [10][11][12][13]; compared to laparotomy, it is associated with a lower incidence of postoperative fever and urinary tract infection, a lower postoperative pain score, a shorter duration of hospitalization, and a lower cost [14]. Due to all of these benefits, we consider laparoscopic surgery the technique of choice for removing residual cystic components and performing peritoneal lavage. ...
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Objective To obtain a better understanding of the clinical course and the subsequent complications of teratoma rupture. Case We report a rare case of chemical peritonitis and pleuritis caused by teratoma rupture during ultrasonographically guided transvaginal oocyte retrieval (TVOR). The patient initially presented with nonspecific and digestive symptoms after TVOR, but the condition deteriorated rapidly after three weeks with peritonitis and septic shock. Thus, exploratory laparoscopy was performed with the findings of a ruptured teratoma at left adnexa, severe adhesions, and purulent fluid in her peritoneal cavity. Bilateral pleuritis was also noted after the operation, which was suspected to be caused by chemical irritation of the spilled contents of the teratoma. The patient's condition improved after surgical treatment and was discharged 28 days after admission. Conclusion Our case showed that the timing of peritoneal irritation caused by teratoma rupture converting to severe chemical peritonitis was approximately 3 weeks. Physicians should avoid cyst puncture during TVOR and closely observe or even perform surgical treatment when iatrogenic teratoma ruptures are suspected.
... In cases of dermoid cyst, 6.4% pa ents had bilateral ovarian dermoid cysts, 62% had presented with pain abdomen, and 25% with abnormal vaginal bleeding, 2% with torsion and, 7 in 17%, dermoid cysts were diagnosed incidentally. In our study, 48.78 %( 40 pa ents) presented with pain abdomen, 15.85%( 13) pa ents with abnormal uterine bleeding, 24.39% (20) pa ents with subfer lity and 4 cases of dermoid cyst were incidental findings. ...
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p> Introduction: Spillage of contents of the dermoid cyst during surgery may cause chemical peritonitis and spillage is more likely to occur during laparoscopic surgery for the removal of the ovarian dermoid cyst. Thorough washing of peritoneal cavity with physiological solution greatly reduces the incidence of chemical peritonitis. Objective: To study the outcome of laparoscopic treatment of ovarian dermoid cysts. Methodology: This is a hospital based cross-sectional study conducted at Birat Medical College and Teaching Hospital from 2012 April to 2016 April. All patients being operated by laparoscopy for ovarian dermoid cysts were enrolled in the study. Occurrence of spillage of dermoid contents during surgery and development of symptoms and signs of chemical peritonitis in postoperative period were main outcome measures. The collected data was entered in Microsoft Excel and analyzed by SPSS software version17. Results: Eighty nine ovarian dermoid cysts from 82 patients 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 peritonitis. Conclusion: The risk of chemical peritonitis is negligible with spillage of dermoid content during laparoscopic procedure when peritoneal cavity is washed thoroughly. Birat Journal of Health Sciences Vol.2/No.3/Issue 4/Sep- Dec 2017, Page: 273-276 </p
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