This video demonstrate the challenging aspect of this case was that the patient was a 19-year-old unmarried woman with bilateral mature cystic teratoma of the ovary. The whole of the left ovary was involved in the dermoid cyst without any normal ovarian tissue. An Ovarian dermoid cyst is a saclike growth that is present at birth. It contains structures such as hair, fluid, teeth, or skin glands that can be found on or in the skin.

A Bilateral Dermoid Cyst (also known as mature cystic teratoma) is a condition where both ovaries develop germ cell tumors. While "tumor" sounds frightening, these are almost always benign. They are unique because they develop from totipotent germ cells, meaning they can contain diverse tissues like hair, teeth, bone, and sebum (oil).

At World Laparoscopy Hospital (WLH), the management of bilateral dermoid cysts is a specialized task, focusing on the "Fertility Sparing" technique pioneered by experts like Dr. R.K. Mishra.

Dermoid cysts are bilateral in about 10–15% of cases. The primary surgical challenge is removing the cysts while preserving enough healthy ovarian tissue for future hormone production and fertility.

• Size Variation: Often, one side is much larger than the other.

• Weight: Because they contain heavy materials like bone or teeth, they increase the risk of Ovarian Torsion (the ovary twisting on its blood supply), which is a surgical emergency.

2. Laparoscopic Management at WLH

The gold standard for treatment is Laparoscopic Cystectomy. Unlike an oophorectomy (removing the whole ovary), a cystectomy "shells out" the cyst.

The "Boutique" Surgical Approach:

1. Cleavage Plane Identification: The surgeon identifies the thin layer between the cyst wall and the healthy ovarian cortex.

2. Hydrodissection: Injecting a saline solution under the cyst wall to lift it, making it easier to peel away without tearing.

3. Spillage Prevention: This is critical. If a dermoid cyst ruptures inside the abdomen, the greasy contents can cause "Chemical Peritonitis."

   • The WLH Protocol: Surgeons use an EndoBag (a sterile plastic pouch). The cyst is placed inside the bag before it is decompressed or removed from the body.

4. Ovarian Reconstruction: After the cysts are removed from both sides, the remaining ovarian tissue is folded and sometimes sutured (using fine, non-reactive sutures) to restore its natural shape.

3. Key Differences in the Bilateral Procedure

Feature	Unilateral Dermoid	Bilateral Dermoid
Surgical Time	Shorter (30–45 mins)	Longer (60–90 mins)
Fertility Concern	Low (other ovary is healthy)	High (both ovaries are operated on)
Approach	Standard Triangulation	Frequent table tilting to access both sides
Risk of Menopause	Negligible	Slight risk if ovarian reserve is low

4. Why the "Mishra Technique" Matters

In bilateral cases, traditional surgery often results in excessive use of cautery (heat) to stop bleeding. However, heat can destroy eggs (oocytes).

• Cold Scissors & Suturing: At WLH, the emphasis is on using "cold" dissection and precise suturing rather than heavy electrosurgery. This preserves the Anti-Müllerian Hormone (AMH) levels, which is a marker for a woman's remaining egg count.

• Thorough Wash: A massive saline irrigation (3–5 liters) is performed at the end of the procedure to ensure every trace of "dermoid oil" is removed, preventing post-operative adhesions.

5. Recovery and Follow-up

• Hospital Stay: Usually 24 hours.

• Follow-up Ultrasound: Performed at 3 and 6 months to ensure no recurrence (though recurrence is rare if the cyst wall is removed completely).

• Fertility Window: Patients are often advised they can try for pregnancy within 2–3 months post-surgery.

Conclusion

Bilateral dermoid cysts require a surgeon with high tactile sensitivity and advanced laparoscopic skills. The goal at World Laparoscopy Hospital is not just to remove the "teeth and hair" found in these cysts, but to leave the patient with two functioning, healthy ovaries