Dermoid cysts, also known as mature cystic teratomas, are one of the most common benign ovarian tumors, accounting for approximately 10–20% of all ovarian neoplasms. These cysts are composed of multiple tissue types derived from germ cells, including skin, hair, fat, teeth, and sometimes even cartilage. While generally benign, dermoid cysts can cause pelvic pain, ovarian torsion, or pressure symptoms if they grow large.

Laparoscopic removal of ovarian dermoid cysts has become the preferred surgical approach due to its minimally invasive nature, faster recovery, and improved cosmetic outcomes. However, one of the major challenges in laparoscopic management is preventing spillage of cyst contents, which can cause chemical peritonitis, adhesions, or infection if not handled carefully.

Dr. R. K. Mishra, a world-renowned expert in minimally invasive surgery, has emphasized techniques to safely excise ovarian dermoid cysts laparoscopically without spillage, ensuring patient safety and optimal outcomes.

Clinical Presentation

Patients with ovarian dermoid cysts may be asymptomatic, with the cyst discovered incidentally on ultrasound or during pelvic examination. Symptomatic patients may present with:

Lower abdominal or pelvic pain

Abdominal fullness or bloating

Irregular menstruation in some cases

Acute pain due to ovarian torsion or cyst rupture

Large cysts may cause compression of adjacent structures such as the bladder or rectum, leading to urinary or bowel symptoms.

Indications for Surgical Removal

Surgical intervention is indicated for:

Symptomatic cysts causing pain or pressure

Large cysts (usually >5–6 cm) due to increased risk of torsion

Rapidly growing cysts

Suspicious features on imaging that may indicate malignancy

Reproductive-age women in whom fertility preservation is desired

Laparoscopic cystectomy is the preferred approach, as it preserves ovarian tissue while safely removing the cyst.

Preoperative Evaluation

A thorough preoperative assessment includes:

Pelvic ultrasound or MRI to characterize the cyst

Tumor markers (CA-125, AFP, beta-HCG) if malignancy is suspected

Assessment of ovarian reserve for women planning future fertility

Discussion with the patient regarding risks, benefits, and the importance of avoiding spillage

Laparoscopic Technique for Removal Without Spillage
Patient Positioning and Port Placement

The patient is placed in a lithotomy or supine position under general anesthesia. Pneumoperitoneum is created using a Veress needle or open (Hasson) technique. A primary umbilical port is used for the camera, with additional lateral ports for instruments.

Pelvic Exploration

The surgeon systematically inspects the pelvic cavity, uterus, and both ovaries to confirm the diagnosis and identify adhesions.

Cyst Mobilization

The ovary is carefully mobilized using atraumatic graspers. The cyst is gently separated from surrounding ovarian tissue. Maintaining the integrity of the cyst wall is critical to prevent spillage.

Use of Endobag

Dr. R. K. Mishra emphasizes the use of an endoscopic retrieval bag (endobag). The cyst is carefully placed inside the bag while still within the abdominal cavity. This provides a barrier, preventing any contents from contaminating the peritoneal cavity if the cyst ruptures during manipulation.

Cyst Aspiration (Optional)

In cases of large cysts, controlled aspiration inside the endobag may reduce its size for safe extraction. Aspiration must always be performed inside the bag to avoid spillage.

Cyst Removal

The cyst, now safely contained within the endobag, is extracted through the umbilical port. Care is taken to avoid tearing the bag or cyst wall.

Hemostasis and Ovarian Reconstruction

After cyst removal, the ovary is inspected for residual tissue, and bleeding points are coagulated. The ovarian cortex may be sutured or left intact depending on tissue preservation.

Closure

All ports are removed, and small incisions are closed with absorbable sutures.

Advantages of Laparoscopic Removal

Minimally Invasive – Small incisions, less postoperative pain, faster recovery

Ovarian Preservation – Maintains fertility potential

Reduced Risk of Adhesions – Compared to open surgery

Cosmetic Benefits – Minimal scarring

Safety – Use of endobag prevents spillage and chemical peritonitis

Risks and Complications

Even with careful technique, potential risks include:

Accidental cyst rupture leading to chemical peritonitis

Bleeding or hematoma formation

Infection

Injury to adjacent structures such as bowel, bladder, or ureters

Recurrence if cyst wall remnants remain

Proper surgical planning and expertise significantly reduce these risks.

Conclusion

Dermoid cysts of the ovary are common benign tumors that can be effectively managed with laparoscopic cystectomy. The key to a safe procedure lies in avoiding spillage of cyst contents, preserving ovarian tissue, and ensuring meticulous surgical technique.

Under the guidance of experts like Dr. R. K. Mishra, laparoscopic removal of ovarian dermoid cysts has become a safe, effective, and patient-friendly procedure. By combining minimally invasive technology with precision handling, patients experience faster recovery, reduced pain, preserved fertility, and excellent cosmetic results.