A torted ovarian dermoid cyst represents one of the most urgent gynecological surgical emergencies. Dermoid cysts, also known as mature cystic teratomas, are common benign ovarian tumors that contain elements derived from all three germ layers, such as hair, fat, and sometimes teeth or bone. While most dermoid cysts remain asymptomatic, they can predispose the ovary to torsion due to their weight and irregular structure. When torsion occurs, the blood supply to the ovary is compromised, leading to acute pelvic pain, ischemia, and the risk of ovarian necrosis. Laparoscopic surgery has become the gold standard for both diagnosis and treatment, combining precision with minimal invasiveness.

Clinical Presentation

Patients with a torted dermoid cyst typically present with sudden onset of severe lower abdominal pain, often localized to one side. The pain may be associated with nausea, vomiting, and sometimes low-grade fever due to ischemia. On examination, tenderness in the adnexal region, guarding, and rebound tenderness may be evident. Ultrasound with Doppler flow studies usually reveals an enlarged ovary with a heterogeneous mass and reduced or absent blood flow, suggesting torsion. Prompt surgical intervention is crucial to prevent irreversible ovarian damage.

Laparoscopic Approach

Laparoscopy offers several advantages in managing a torted dermoid cyst: reduced postoperative pain, shorter hospital stay, better cosmetic outcome, and rapid recovery. The primary objective is to untwist the ovary and preserve ovarian tissue whenever possible, especially in young women of reproductive age. If the ovary is necrotic or severely damaged, however, oophorectomy may be unavoidable.

The patient is placed in a lithotomy position under general anesthesia. A Veress needle or open (Hasson) technique is used to create pneumoperitoneum. Standard ports are inserted: a 10 mm umbilical port for the laparoscope and two or three ancillary 5 mm ports in the lower abdomen for operative instruments.

Intraoperative Findings

Upon inspection, the surgeon identifies the twisted adnexa, which usually appears edematous, congested, and sometimes bluish or blackish in color depending on the duration of torsion. The dermoid cyst is often large, irregular, and adherent to surrounding structures. The initial step is careful detorsion of the twisted ovary and tube, performed gently to avoid rupture or avulsion of fragile vessels. Even ovaries that appear dusky may recover after restoration of blood flow, so detorsion should always be attempted before deciding on resection.

Cyst Resection Technique

After detorsion, the cystectomy is performed. The ovarian cortex is incised using monopolar energy or cold scissors over the most prominent part of the cyst. Blunt and sharp dissection techniques are employed to peel the cyst wall away from the normal ovarian tissue. Dermoid cysts often contain sebaceous material and hair, which can spill during the procedure. To minimize spillage, the cyst may be placed inside an endobag before excision. If accidental rupture occurs, copious irrigation with warm saline is essential to prevent chemical peritonitis.

The resected cyst is extracted carefully, usually within an endobag through the umbilical port. The ovarian tissue is reconstructed using fine absorbable sutures or bipolar coagulation to achieve hemostasis and preserve ovarian function. If the ovary is non-viable or extensively damaged, unilateral oophorectomy with or without salpingectomy may be necessary.

Postoperative Care

Patients typically recover quickly after laparoscopic resection. Postoperative care includes adequate analgesia, early ambulation, and monitoring for complications such as bleeding, infection, or peritonitis due to spillage. Antibiotics are administered if indicated. Most patients are discharged within 24–48 hours. Fertility preservation is discussed, and follow-up imaging may be scheduled to ensure ovarian recovery.

Advantages of Laparoscopy

Compared with laparotomy, laparoscopy provides:

Smaller incisions and minimal scarring.

Reduced postoperative pain.

Shorter hospital stay and faster return to daily activities.

Enhanced visualization of pelvic anatomy for precise surgery.

Better fertility preservation due to conservative management of ovarian tissue.

Conclusion

Laparoscopic resection of a torted ovarian dermoid cyst is a safe and effective procedure when performed promptly. Early intervention not only relieves acute symptoms but also preserves ovarian function in the majority of cases. By employing careful surgical techniques such as detorsion, cystectomy within an endobag, and meticulous hemostasis, surgeons can minimize complications and optimize patient outcomes. With growing expertise in minimally invasive gynecological surgery, laparoscopy continues to stand as the preferred approach for managing this complex but common condition.