Ovarian dermoid cysts, also known as mature cystic teratomas, are among the most common benign ovarian tumors, representing about 10–20% of all ovarian neoplasms. They are germ cell tumors containing elements from ectoderm, mesoderm, and endoderm, such as hair, sebaceous material, cartilage, or bone. Dermoid cysts are typically unilateral, but bilateral involvement is reported in 10–15% of cases.

Traditionally, laparotomy was the standard approach for dermoid cyst removal. However, with the evolution of minimally invasive gynecologic surgery, laparoscopic management has become the gold standard. It offers reduced postoperative pain, quicker recovery, shorter hospital stay, and superior cosmetic results, even in bilateral disease.

Clinical Presentation

Patients with dermoid cysts may present with:

Lower abdominal pain or pelvic discomfort.

Abdominal distension or palpable mass.

Pressure symptoms on bladder or rectum.

Acute pain due to torsion, rupture, or infection.

Incidental detection during imaging for unrelated reasons.

In bilateral cases, symptoms may be more pronounced due to the greater tumor burden.

Preoperative Evaluation

Before laparoscopic management, careful evaluation is crucial:

History and examination – to assess pain, mass, or pressure symptoms.

Ultrasound (USG) – typically reveals a complex adnexal mass with hyperechoic areas, calcifications, or “tip of the iceberg” sign.

MRI or CT scan – occasionally required to confirm diagnosis and rule out malignancy.

Tumor markers – CA-125, AFP, and beta-hCG are checked to exclude malignant germ cell tumors, especially in younger women.

Indications for Laparoscopic Management

Laparoscopic removal of bilateral dermoid cysts is indicated in:

Symptomatic cysts (pain, mass effect, torsion risk).

Cysts >5 cm in diameter.

Bilateral dermoid cysts requiring ovarian preservation.

Reproductive-age women desiring fertility conservation.

Laparoscopic Surgical Techniques
Patient Preparation

General anesthesia with lithotomy position.

Bladder catheterization to prevent injury.

Prophylactic antibiotics to reduce infection risk.

Port Placement

Umbilical port for camera.

Two or three accessory ports for instruments, usually in the lower quadrants.

Surgical Steps

Inspection: The pelvis and abdomen are examined to confirm bilateral dermoid cysts and rule out complications.

Adhesiolysis: Adhesions from prior surgery or cyst rupture are carefully released.

Ovarian Cystectomy:

The ovary is stabilized with atraumatic forceps.

A cortical incision is made over the cyst.

Gentle dissection is carried out to separate the cyst wall from normal ovarian tissue.

Care is taken to preserve healthy ovarian tissue, especially in young patients.

Spillage Management: Dermoid cysts often rupture intraoperatively, releasing sebaceous material, hair, and debris.

Copious peritoneal lavage with warm saline is performed to prevent chemical peritonitis.

Endobags are used to retrieve cysts and minimize spillage.

Hemostasis: Achieved using bipolar coagulation or sutures, ensuring minimal damage to ovarian tissue.

Closure: Ovarian edges may be re-approximated with fine absorbable sutures to restore anatomy.

Special Considerations in Bilateral Cysts

Fertility Preservation: Both ovaries should be conserved whenever possible, especially in reproductive-age women.

Ovarian Reserve: Excessive cautery or aggressive dissection must be avoided to preserve ovarian function.

Risk of Recurrence: Patients must be counseled about the possibility of recurrence in either ovary.

Malignancy Suspicion: If any suspicious features are observed (solid areas, irregular borders, ascites), frozen section biopsy is recommended.

Postoperative Care

Patients are usually discharged within 24–48 hours.

Analgesics and antibiotics are prescribed.

Early ambulation is encouraged.

Follow-up includes:

Histopathological confirmation of dermoid cyst.

Monitoring of ovarian function and menstrual cycles.

Repeat ultrasound after 6–12 months.

Complications

Though rare, possible complications include:

Intraoperative rupture leading to chemical peritonitis (minimized by lavage).

Ovarian damage resulting in reduced fertility potential.

Infection or abscess formation.

Recurrence if incomplete excision of cyst wall.

Malignancy risk – <2% cases may harbor malignant transformation, requiring more radical surgery.

Outcomes and Prognosis

Excellent prognosis when dermoid cysts are managed laparoscopically.

Ovarian conservation is possible in most cases, maintaining fertility and hormonal function.

Recurrence rates are low (2–10%) with meticulous cyst wall removal.

Faster recovery and return to daily activities compared to laparotomy.

Conclusion

Laparoscopic management of bilateral dermoid cysts is safe, effective, and fertility-preserving. The minimally invasive approach allows precise excision, minimal ovarian damage, and rapid patient recovery. The use of endobags and copious irrigation reduces complications associated with cyst rupture and spillage.

For young women with bilateral dermoid cysts, laparoscopy offers the ideal balance between oncological safety, ovarian conservation, and cosmetic outcomes. With experienced hands and appropriate case selection, it remains the gold standard technique for managing bilateral dermoid cysts.