Laparoscopic Surgery for Benign Cystic Teratoma - Dr. R.K. Mishra

Laparoscopic Surgery for Benign Cystic Teratoma

These germ cell tumors occur predominantly in young women. A cystic teratoma contains sebaceous material that is irritating to peritoneal surfaces and can cause chemical peritonitis and possible adhesions. The surgeon should avoid rupturing the cyst. If the cyst is ruptured during excision, it is important to clean the body cavity of all sebaceous material and hair. If it ruptures at the time of excision, without spending much time, the suction-irrigator is placed in the cyst, the contents aspirated, and the cavity copiously irrigated. The interior of the cyst is inspected and its lining is grasped and removed from the ovary. The lining is removed from the pelvis through a 10 mm port. In the case of an intact cyst, an Endobag may be necessary. A colpotomy can be made through which the cyst is incised and drained and its capsule removed. These same procedures can be performed through a mini-laparotomy incision. The cyst wall is punctured and the contents rapidly aspirated. The wall is removed, placed in an Endobag, and removed through the cul-de-sac or through one of the port wound.

Extraction of Ovary
 Extraction of ovary

Following removal, it is critical to irrigate the pelvis copiously with 5 to 10 L of warm Ringer’s lactate. The sebaceous material is less dense than water and will float, facilitating removal. Occasionally, when the cyst is mainly solid, it can be removed intact without rupturing. The cyst wall should be sent for histopathological examination. The pelvis is irrigated with lactated Ringer's solution until all evidence of sebaceous material is removed because incomplete removal of this material can cause peritonitis. During irrigation, the ovarian stroma is inspected to verify hemostasis. If bleeding is present, bleeder points are controlled with a monopolar fulguration or bipolar forceps. If the teratomas are greater than 8 cm, the ovary can be placed in the cul-de-sac adjacent to a colpotomy incision.

A cyst is removed transvaginally which minimizes the risk of contamination of the upper abdomen and port wound and maintains a minimally invasive approach. The vagina should be cleaned thoroughly and prepared with betadine before colpotomy. In elderly women or for those patients in whom the ovary and tube cannot be conserved, salpingo-oophorectomy should be considered. When the cyst wall is benign and the tissue is fragmented, it can be removed through a 10 mm suprapubic port. No tissue should be left in the pelvic cavity or on the abdominal wall. Contamination of the anterior abdominal wall should be avoided and if this happens, all tissue must be removed and the incision copiously irrigated and washed. Abdominal wall metastasis has been reported following contamination of the wall during laparoscopy for ovarian cancer.

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