Ovarian teratomas, most commonly represented by mature cystic teratomas (dermoid cysts), are benign germ cell tumors that account for nearly 20–25% of all ovarian neoplasms. They typically affect women in their reproductive years and are often discovered incidentally during imaging for unrelated complaints. While usually benign, teratomas can cause complications such as ovarian torsion, rupture, or, in rare cases, malignant transformation. With the advent of minimally invasive surgery, laparoscopic management has become the preferred approach for the diagnosis and treatment of ovarian teratomas, providing excellent outcomes with minimal morbidity.

Understanding Ovarian Teratomas

Ovarian teratomas arise from totipotent germ cells and can contain tissues derived from all three germ layers: ectoderm, mesoderm, and endoderm. Mature cystic teratomas typically contain sebaceous material, hair, teeth, or cartilage. They are usually unilateral, but bilateral cases occur in 10–15% of women.

Clinical features include:

Lower abdominal pain or pressure.

A palpable adnexal mass.

Menstrual irregularities in some cases.

Complications like torsion or rupture leading to acute abdomen.

Rarely, infection or malignant transformation.

Diagnosis

Diagnosis relies on a combination of clinical evaluation and imaging.

Ultrasound (USG): First-line tool, showing echogenic areas with shadowing (“tip of the iceberg” sign) and cystic-solid structures.

MRI/CT scan: Useful in complex cases, providing detailed tissue characterization.

Tumor markers (CA-125, AFP, β-hCG, LDH): Generally normal in benign teratomas but checked to exclude germ cell malignancies.

Indications for Surgery

While small, asymptomatic teratomas may be observed, surgical removal is indicated when:

The cyst is symptomatic (pain, pressure).

Size exceeds 5–6 cm, increasing risk of torsion or rupture.

Complications such as torsion or rupture occur.

Malignancy cannot be excluded.

The patient desires fertility preservation and reassurance.

Role of Laparoscopy

Laparoscopy is now the gold standard for the management of ovarian teratomas. It provides:

Accurate diagnosis and complete excision.

Minimal postoperative pain.

Shorter hospital stay and faster recovery.

Excellent cosmetic outcomes.

Fertility-preserving management in young women.

Surgical Technique

1. Patient Preparation and Positioning

General anesthesia is administered.

The patient is positioned in lithotomy with Trendelenburg tilt.

Prophylactic antibiotics are given.

Port Placement

Typically, a three-port technique is used:

Umbilical port for the camera.

Two accessory ports for instruments in the lower quadrants.

Exploration

The pelvis and abdomen are inspected for ovarian pathology, adhesions, or evidence of complications like torsion.

Cystectomy (Preferred Approach)

The ovarian cortex overlying the teratoma is incised with monopolar scissors or harmonic scalpel.

The cyst wall is carefully stripped from normal ovarian tissue using traction and counter-traction.

Care is taken to minimize use of energy devices to preserve ovarian reserve.

Specimen Retrieval

The teratoma is placed in an endobag before removal to prevent spillage of sebaceous material and hair.

If spillage occurs, copious irrigation with warm saline is performed to reduce the risk of chemical peritonitis.

Hemostasis and Ovarian Reconstruction

Bleeding points are secured with bipolar coagulation or fine suturing.

The ovarian capsule is approximated to restore anatomy and minimize adhesions.

Oophorectomy (When Required)

In cases where the ovary is severely damaged, very large cysts occupy the entire ovary, or in postmenopausal women, laparoscopic oophorectomy may be performed.

Postoperative Care

Most patients recover rapidly, resuming oral intake within hours.

Hospital stay is typically less than 48 hours.

Analgesics and antibiotics are prescribed as needed.

Follow-up includes histopathological confirmation and periodic ultrasound monitoring in cases with bilateral disease or recurrence risk.

Advantages of Laparoscopic Management

Fertility preservation: Ovarian tissue is conserved in young women.

Minimal invasiveness: Smaller incisions, less pain, and faster recovery.

Reduced adhesion formation: Better reproductive outcomes.

Cosmetic benefit: Virtually scarless surgery compared to laparotomy.

Better visualization: Enhanced precision in dissection and specimen retrieval.

Challenges and Risks

Spillage: Sebaceous material and hair can spill into the peritoneal cavity, causing chemical peritonitis. Prevented with endobag use and thorough irrigation.

Recurrence: Though rare, residual tissue may lead to recurrence if cystectomy is incomplete.

Bilateral disease: Requires careful surgical planning to balance complete excision with ovarian preservation.

Malignant potential: Malignant transformation occurs in less than 2% of cases, necessitating histopathological confirmation.

Conclusion

Ovarian teratomas, though benign, can cause significant complications if untreated. Laparoscopic management has revolutionized the approach, combining diagnostic accuracy with therapeutic efficiency. Through cystectomy with ovarian preservation, careful specimen retrieval, and meticulous surgical technique, laparoscopy ensures excellent clinical outcomes, rapid recovery, and preserved fertility. Today, laparoscopy is the gold standard for managing ovarian teratomas, offering women the benefits of minimally invasive surgery with the assurance of safety and effectiveness.