Eddy Hartono, Edmoon Liwan
Obstetrics and Gynecology Department
The Faculty of Medicine of the University of Hasanuddin
ABSTRACT
Objective : To report the success use of medical plastic bag as a replacement for endobag in the laparoscopic procedure of ovarian dermoid cyst.
Location : Dr. Wahidin Sudirohusodo General Hospital, Makassar
Study design : Case-report
Method : women, 39 years old, PIIIA0, with a preoperative diagnosis of ovarian cyst, a diagnostic laparoscopic was performed, we found a right ovarian dermoid cyst and endometriosis stage I, then we performed right salpingooforectomy through operative laparoscopic, as a replacement for endobag we used medical plastic bag (Zipack®). For the endometriosis stage I, we did bipolar coagulation. Sterilization was performed using bipolar destruction method.
Result : The use of medical plastic bag as a replacement for endobag in the laparoscopic procedure of ovarian dermoid cyst was quite effective in preventing spill of the cyst content to abdominal cavity.
Key words : laparoscopy, ovarian dermoid cyst.
I. INTRODUCTION
There were two types of ovarian tumors; neoplastic and non-neoplastic (e.g. tumors caused by inflammation and functional ones). As for neoplastic tumor, it was divided as benign and malignant, in a cystic or solid forms. Dudley (1992) stated the forms of ovarian cyst were:
1. Teratoma-dermoid 40%
2. Functional cyst 30%
3. Epithelial tumor 20%
4. Paraovarial tumor 6%
5. Endometrioma 5%
6. Malignant ovarian tumor 2%
One of the study of ovarian tumor found dermoid cysts in 62% of all ovarian neoplasm in young women aged less than 40 years old. Malignant transformation occurs in less than 2% of all dermoid cysts, and usually in post menopausal women. The risk of torsion of dermoid cyst was around 15%.3,4
The surgical management of ovarian dermoid cyst can be performed through laparotomy or laparoscopy procedure.5,6
Laparoscopy procedure was recommended for ovarian cyst management, if the cyst sized more than 5 cm, it contained a solid part, persistent of worsening symptoms, it was found in more than 2 or 3 menstrual cycles.5
In laparoscopic procedure of ovarian dermoid cyst, in order to prevent spilling of the cyst content when we take the cyst out from the abdominal cavity, we could use endobag, however this function of endobag may be replaced with the use of medical plastic bag.
II. CASE
A woman, PIIIA0, aged 36 years old, referred from a gynecologist with lower abdominal mass which has been diagnosed since one month ago and a complaint of lower abdominal discomfort which has been experienced since one year ago.
She had regular menstruation, without dysmenorrheal. From physical examination, we palpated a mass in the right hypochondriac area, sized 8 x 5 cm2, sharp demarcation, mobile, no tenderness. From vaginal touché, we found no abnormalities in the vulva, vagina, nor portio, closed internal and external ostia of the uterus which was anteflexed and normal in size, at right adnexal area we palpated a cyst mass sized 8 x 6 x 5 cm3, sharp demarcation, regular surface, mobile, no tenderness.
The results of laboratory examination of urine and blood were within normal limit. Pregnancy test negative. Abdominal ultrasonography found a normal size uterus, a hipoechoic mass in the adnexal sized 8,3 cm x 6,8 cm, with a conclusion of adnexal tumor.
Patient was diagnosed with adnexal tumor, she was planned to underdo diagnostic laparoscopic procedure followed by operative laparoscopic. After counseling this 36 year old woman on contraception and the fact that she has already had enough offspring, we also planned a laparoscopic sterilization.
Figure 1 : Abdominal USG
After we completed preoperative evaluation, laparoscopy was performed on December 12th 2007 at 10:30-12:00 PM. We performed asepsis and antisepsis to the whole operation field, continued by uterine manipulator insertion. Insert verres neddle to the umbilicus and flow carbon dioxide until a pressure of 25 mmHg than insert a 10-mm optical trocar. Insert a 5-mm trocar to left and right abdominal wall for instruments used. Sustained carbon dioxide pressure at 10-12 mmHg.
After we explored the abdominal cavity, we found omental adhesion to the peritoneum which was then lysed, it was followed by observation for futher bleeding.
From identification of the uterus and bilateral adnexa, we found that they were within normal limit. In the right adnexal, we found a cystic mass sized 8 x 6 x 5 cm, having greyish border, regular surface, free of adhesion, giving the impression of right ovarian dermoid cyst (Figure 2).
Figure 2 : Right ovarian dermoid cyst
In the sacrouterine area, there is a endometriosis patch stage I, we performed a bipolar coagulation, which was continued by unilateral tubal sterilization per laparoscopic (Figure 3).
Figure 3 : endometriosis patch stage I and laparoscopic tubal sterilization
This was followed by right salpingooforectomy, and hemmorhage control (Figure 4) and reducing cyst through vacuum aspiration so that we got smaller mass which could be put in the medical plastic bag (Zipack®). It was pull out from the abdominal cavity through a 3 cm insision at 2 fingers above pubical symphisis (Figure 5).
Figure 4 : right salpingooforectomy
Figure 5 : right ovarian dermoid cyst inside medical plastic bag
Afterward, we performed bleeding control, and it was ascertained that no bleeding (Figure 6). Operation done, samples was taken to the histopathological examination. We gave post operative antibiotic and analgetik.
Figure 6 : right salpingooforectomy, without bleeding complication
III. RESULT
The use of medical plastic bag as a replacement to endobag in laparoscopic prosedure of dermoid cyst of the ovaries was quite effective in preventing spilling of the cyst content to the abdominal cavity. In the first day post laparoscopic, patient went home with a good general condition, the histopatological result showed ovarian dermoid cyst (Histopathological examination was performed at Wahidin Sudirohusodo General Hospital Registration number 1.07.P.0702).
IV. DISCUSSION
Dermoid cyst was a benign cystic teratoma in which ectodermal structures were completely differentiated, such as dermal epithelium, hair, tooth, and sebasea gland product which was yellowish resembling fat were more dominant than entodermal and mesodermal elements. Transformation to malignancy of all dermoid cysts was less than 2% and it usually happened to post menopausal women.2-6
Similar to the other ovarian tumors, dermoid cysts gave unspecific signs and symptoms, i.e. abdominal distention, abdominal pain or discomfort, pressure sensation on the lower abdomen, urinary and gastrointestinal symptoms.2,5-7
In this case, patient with dermoid cyst also gave unspecific symptoms i.e. discomfort in the lower abdomen since 1 year ago, this complaint makes the patient visit a gynecologist. After history taking, physical examination, and vaginal toucher, we got the impression of anteflexed uterus with normal size, we also palpated a cystic mass sized 8 x 6 x 5 cm, with distinct border, reguler surface, mobile, with no tenderness. From laboratory and abdominal ultrasound examination, we obtained a diagnosis of adnexal tumor.
Patel et.al. showed that the use of ultrasound to support a diagnosis of ovarian dermoid cyst has a positive predictive value of 98% and a sensitivity of 85%. Mais et.al. stated that transvaginal ultrasound has a sensitivity and specificity of 84.6% and 98.2%.6
From abdominal ultrasound, we identify a normal uterus with a hypoechoic mass sized 8.3 x 6.8 cm, giving the impression of adnexal tumor. Not giving an impression of ovarian dermoid cyst. In this case, the content of ovarian dermoid cyst was a prosuct of sebacea glands and hair, therefore we only found a hipoechoic image; if there were any mesodermal elements such as bone, cartilage, etc, it may gave a mixed echogenicity image; with this ultrasound, we can temporarily diagnose this as an ovarian dermoid cyst.
Diagnosis of dermoid cyst was confirm after diagnostic laparoscopy, we observe a grayish cystic mass with thin wall (Figure 2).
The management of ovarian dermoid cyst can be performed through laparotomy and laparoscopy.5,6
From a study comparing laparoscopy and laparotomy procedure for ovarian dermoid cyst by Benezra V et.al., it was concluded that laparoscopic gave less bleeding, shorter hospital stay, and minimal complications. Therefore, laparoscopic procedure for dermoid cyst was quite safe.8
Surgical management of ovarian dermoid cyst may easily caused complications such as chemical peritonitis or wide spread infection and these were main complications of laparoscopic procedure. The incidence of chemical peritonitis in the laparoscopic procedure performed for ovarian dermoid cyst was 0.2%.7
The uptake of cyst using endobag will significantly reduce the operation time nor cyst’s content spill, however a spill which was well controlled will not increase morbidity as long as we wash the abdominal cavity thoroughly.9
The use of medical plastic bag as a replacement for endobag with the consideration that it was more economical and easier to be obtained compared to endobag, however the possibility of rupture during the uptake was higher than that of endobag.
The management of dermoid cyst in this case, using laparoscopy, was by performing a right salpingectomy (Figure 4) continued with cyst fluid aspiration. Cyst mass was inserted to the medical plastic bag (Figure 5), that it was taken out through a 3-cm insisional wound above the level of symphisis of pubic. If there is a spill of the cyst content, this may caused complication such as chemical peritonitis.
Before usage, the medical plastic bag will be rinsed for 20 minutes in glutaraldehyde solution (Cidex ®).
Figure 7 : Medical plastic bag (Zipack®)
Figure 8 : Endobag
Endometriosis is confirmed using laparoscopy, through laparoscopy, all types of endometriosis lesions can be seen including the minimal ones. To all lesions which were easily reached and seen, not near the ureter or bowel, a coagulation may be performed.10
In this patient, we observe an endometriosis lesion in the left sacrouterine area (Figure 3), since it was a minimal one, there were no sign or symptoms and the management was only bipolar coagulation of the lesion.
Considering the patient’s age and parity, a counseling on family planning, followed by tubal sterilization through laparoscopy using bipolar destruction method (Figure 3) were performed.
V. CONCLUSION
Similar to the other ovarian tumor, dermoid cyst gave unspecific sign and symptoms. Further diagnostic examination such as ultrasonography was needed.
The use of medical plastic bag as a replacement for endobag was quite effective in preventing spilling of the dermoid cyst content to the abdominal cavity.
Laparoscopic surgery on an ovarian dermoid cyst was a safe procedure with less bleeding, shorter hospital stay, and minimal complication.
REFERENCE
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8. Victor Benezra UV, R. wayne Whitted. Comparison of laparoscopy versus laparotomy for the surgical treatment of ovarian dermoid cysts. Miami, USA: Departmen of Obstertics and Gynecology, Jackson Memorial Hospital; 2004.
9. Campo S GN. Laparoscopic conservative excision of ovarian dermoid cysts with and without an endobag. J Am Assoc Gynecol Laparosc 1998;2:165-70.
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