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Keywords:

  • Benign cystic teratoma;
  • dermoid cyst;
  • laparoscopy;
  • spillage

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Please cite this paper as: Kondo W, Bourdel N, Cotte B, Tran X, Botchorishvili R, Jardon K, Rabischong B, Pouly J, Mage G, Canis M. Does prevention of intraperitoneal spillage when removing a dermoid cyst prevent granulomatous peritonitis? BJOG 2010;117:1027–1030.

In this retrospective study of 314 patients undergoing surgery for ovarian dermoid cysts, conducted over a 20-year period, we evaluated the impact of the routine use of laparoscopic surgery without recourse to laparotomy to retrieve the specimen, using an endoscopic retrieval bag placed under the cyst to prevent intraperitoneal spillage of cyst contents, and subsequent postoperative granulomatous peritonitis. Accidental cyst rupture was more frequent when a total laparoscopic approach was used (26/174 or 15% versus 39/140 or 28%; = 0.005), but there were no cases of intraperitoneal spillage when an endoscopic bag was used. Two cases of granulomatous peritonitis developed out of 26 women with intraperitoneal spillage of cyst contents (8%). We conclude that the risk of granulomatous peritonitis can be minimised by undertaking laparoscopic removal of dermoid cysts with the routine intraoperative use of an endoscopic retrieval bag to prevent intraperitoneal spillage of cyst contents.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Dermoid cysts, or benign cystic teratomas, are the most common benign ovarian neoplasms occurring in the childbearing years.1 Ovarian cystectomy or oophorectomy is usually undertaken to treat the associated pain symptoms, to exclude malignancy and to avoid potential complications such as torsion and spontaneous rupture with subsequent chemical peritonitis. Less invasive laparoscopic treatment of dermoid cysts has become routine, replacing traditional laparotomic approaches.2 However, despite the advantages of laparoscopic treatment,3 there is an increased risk of intraperitoneal spillage of the cyst contents that can potentially result in chemical peritonitis.3,4 Shawki et al.1 reviewed 496 laparoscopic dermoid cystectomies, and spillage occurred in 324 cases (65.3%). Despite this high incidence of spillage, chronic granulomatous peritonitis developed in only one patient (0.2%). The use of an endoscopic bag during surgery can avoid or reduce any leakage of cyst material into the peritoneal cavity.

The aim of this study was to evaluate if the prevention of intraperitoneal spillage of cyst contents can prevent postoperative chemical peritonitis.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

A retrospective study was conducted of all women undergoing surgical treatment of ovarian cysts, confirmed as benign cystic teratomas following histological examination of the removed specimen, between January 1982 and December 2003 at the Polyclinique de l’Hôtel Dieu, Clermont-Ferrand, France. Demographic data, operative technique and details of peri- and postoperative complications were obtained from an electronic database of surgical procedures and medical records. The study was approved by the Inter-regional Ethics Committee of the Rhône-Alpes-Auvergne Clinical Investigation Centre, Grenoble, France, on 14 January 2010 (IRB number 5044).

Three different surgical approaches for cystectomy or adnexectomy were used over the study period: (i) laparotomy, (ii) laparoscopy with mini-laparotomy for exteriorisation of the ovary, or (iii) pure laparoscopy. The laparoscopic technique with mini-laparotomy involved opening the abdominal wall to facilitate the evacuation of the cystic contents under laparoscopic guidance. The whole ovary was then exteriorised through this abdominal incision, and cystectomy or oophorectomy was performed.

The laparoscopic operative techniques were standardised and applied by all surgeons: eight staff surgeons or senior residents under supervision. In short, the standard laparoscopic procedure involved the use of four port sites, obtaining peritoneal cytology, mobilisation of the cyst if required and dissection of the ovary to enucleate the cyst. Prior to the availability of endoscopic bags in our department, the surgical specimen was retrieved from the abdominal cavity either through the trocar, via a mini-laparotomy, or culdotomy. In 1992, endoscopic retrieval bags were introduced (Medical Technical Promotion, Tuttlingen, Germany). The laparoscopic technique was changed to include the placement of the open bag under the dermoid cyst with the aim of minimising the risk of abdominal spillage of intracystic material. Depending on the size of the cyst and the preference of the surgeon, the cyst was punctured before starting the laparoscopic intraperitoneal cystectomy or oophorectomy. At the end of the procedure, the abdominal cavity is checked for any bleeding. In cases of spillage of intracystic contents during dissection, the abdominal cavity was washed using Lactated Ringer’s solution. In cases in which the cyst was removed intact, removal of the specimen from the abdominal cavity was achieved by puncturing and evacuating the cyst within the endobag.

Data were analysed by dividing women into two groups according to whether an endoscopic bag was employed. Group 1 included patients in whom endoscopic bags were not used (1983–1992), and group 2 included patients in whom endoscopic bags were used (1992–2003). The primary statistical endpoint was the rate of postoperative chemical peritonitis in each group. Other parameters evaluated included operating time, estimated blood loss, conversion to laparotomy, length of hospital stay, and complications of surgery. A Student’s t-test and Fisher’s exact test were performed to compare groups when needed, with < 0.05 considered as statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Three hundred and fourteen patients with a histological diagnosis of ovarian dermoid cyst were treated during the 20-year study period. The mean patient age was 37 years (range 13–76 years), and the mean parity was 1 (range 0–9). They were classified according to reproductive stage, as follows: one in pre-puberty (0.3%), seven pregnant (2.2%), 282 of reproductive age (89.9%), and 24 post-menopausal (7.3%). The chief presenting complaint was chronic pelvic pain in 76 women (24.2%), abnormal uterine bleeding in 18 women (5.7%), acute abdominal pain in 14 women (4.5%), and progressive abdominal distension in two women (0.6%). Two hundred and four women (65%) were asymptomatic, having their cysts discovered incidentally either on ultrasound or at the time of surgery for another indication. Ovarian cysts were bilateral in 22 patients (7%), and the mean diameter of the adnexal mass from radiological imaging was 62.7 ± 31.4 mm (ranging from 15 to 350 mm). Table 1 shows the surgical approaches used and complications of surgery stratified by routine use of an endoscopic retrieval bag.

Table 1.   Comparison between both groups*
 Group 1 (n = 174)Group 2 (n = 140)P value
  1. *Values are given as median (minimum–maximum) or number (%).

  2. **Including 19 patients who underwent primary laparotomy and 17 cases of conversion to laparotomy.

  3. ***No patient required blood transfusion. Both cases occurred when hysterectomy was also performed.

  4. ****Mini-laparotomy performed after the laparoscopic procedure, solely to remove the cyst or ovary.

  5. *****Patients who underwent surgery with preoperative indication of hysterectomy.

  6. ******Patients who underwent laparoscopy with mini-laparotomy.

Age37.3 ± 11.736.3 ± 11.70.99
Diameter66.2 ± 35.258.3 ± 25.20.03
Surgical approach
Cystectomy by laparoscopy with mini-laparotomy34 (19.5%)0 
Adnexectomy by laparoscopy with mini-laparotomy10 (5.8%)0 
Intraperitoneal cystectomy77 (44.2%)104 (74.3%) 
Intraperitoneal adnexectomy17 (9.8%)36 (25.7%) 
Cystectomy by laparotomy**10 (5.8%)0 
Adnexectomy by laparotomy**26 (14.9%)0 
Intraoperative complications5 (2.9%)2 (1.4%)0.39
Subcutaneous emphysema2 (1.15%)1 (0.7%) 
Uterine perforation1 (0.6%)1 (0.7%) 
Bleeding >500 ml***2 (1.15%)0 
Extraction techniques
Laparotomy36 (20.7%)0 
Trocar80 (46%)0 
Endoscopic bag0140 (100%) 
Mini-laparotomy****6 (3.4%)0 
Vaginal*****8 (4.6%)0 
Transparietal******44 (25.3%)0 
Postoperative complications8 (4.6%)2 (1.4%)0.11
Surgical site haematoma3 (1.7%)1 (0.7%) 
Surgical site infection2 (1.15%)0 
Urinary tract infection1 (0.6%)1 (0.7%) 
Granulomatous peritonitis2 (1.15%)00.20

We did not demonstrate any difference in operating time (92.4 versus 78.6 minutes; = 0.10), nor in the incidence of intraoperative complications (2.9 versus 1.4%; = 0.39), between the two groups. An intraoperative blood loss of >100 ml was more prevalent in group 1 compared with group 2 (7.5 versus 0.7%; = 0.004), as was the use of laparotomy (20.7%), either as a primary procedure or subsequent conversion during laparoscopy. The overall accidental rupture rate was 20.7% (65 out of 314), and was significantly less in group 1 compared with group 2 (26/174 or 15% versus 39/140 or 28%; = 0.005), reflecting the greater use of laparotomy in group 1. However, in group 1 accidental rupture resulted in intraperitoneal spillage of cyst contents, whereas in group 2 there were no cases of intraperitoneal spillage because the accidental rupture occurred within the endoscopic retrieval bag. The conversion rate of laparoscopy to subsequent laparotomy was higher in group 1 compared with group 2 (11 versus 0%; < 0.001).

There was no difference in the rate of postoperative complications comparing both groups (4.6 versus 1.4%; = 0.11). Two cases (0.6%) of granulomatous peritonitis developed in our series, and both occurred in group 1. One patient was discharged from our hospital on postoperative day 2, and was admitted to another hospital in the fourth postoperative day complaining of abdominal pain, fever, and vomiting. She underwent a second-look surgery for complete cure of the granulomatous peritonitis. The other patient had an uneventful immediate postoperative course. Two years after the procedure, she presented abdominal pain, low-grade fever, anaemia, nausea, and vomiting. She underwent a diagnostic laparoscopy with the intraoperative finding of a small number of ascites and omental thickening. Histology of the removed omental tissue revealed a granulomatous inflammatory process consistent with foreign body reaction. Other etiologies were excluded, including tuberculosis, peritoneal carcinomatosis, other infections, and peritonitis induced by talc. In both cases spillage of cyst contents occurred during laparoscopic surgery. No patient underwent surgery for recurrent ovarian dermoid cysts.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Accidental rupture during dissection of an ovarian dermoid cyst is common, and granulomatous peritonitis can develop in cases of intraperitoneal spillage of irritative cyst contents. Laparoscopic surgery has replaced laparotomy as the preferred surgical approach, but the incidence of inadvertent rupture and subsequent chemical peritonitis is higher. Our series demonstrated that the use of laparotomy or laparoscopic surgery with mini-laparotomy to exteriorise the cyst results in a lower incidence of accidental cyst rupture, compared with laparoscopy alone. However, the routine use of an endoscopic bag placed during surgery underneath the ovarian cyst eradicated the intraperitoneal spillage of cyst contents. Reassuringly, the incidence of granulomatous peritonitis was low, with only two cases reported in the whole series of 314 women. There were 26 cases of intraperitoneal spillage of cyst contents, and so the incidence of granulomatous peritonitis in our series following intraperitoneal spillage was 8%. Thus, given the significant risk of inadvertent cyst rupture (28% in the current series), we recommend placing an endoscopic retrieval bag beneath a dermoid cyst during laparoscopic surgery to prevent granulomatous peritonitis.

Spillage rates in laparoscopic surgery range from 15 to 100%,3,4 compared with only 4–13% via laparotomy.5,6 In our series we identified two patients (0.6%) with postoperative granulomatous peritonitis. Intrabdominal spillage into the peritoneal cavity occurred in 26 patients, giving an incidence of chemical peritonitis of 8% in this group of patients. This incidence is much higher than that reported by Shawki et al.1 They found only one case of chronic granulomatous peritonitis among the 324 laparoscopic dermoid cystectomies where spillage occurred (0.3%). They stated that the gold standard to avoid complications in cases of pelvic spillage during laparoscopic surgery is irrigation of the abdominal cavity with copious quantities of fluid, removing even microscopic particles of cyst content. This was performed in all of our patients with intraoperative spillage, but even so we observed two cases of postoperative chemical peritonitis. The differences in incidence of granulomatous peritonitis may reflect length and completeness of follow up, and difficulties with diagnosis.

To the best of our knowledge, this is largest experience on the surgical management of ovarian dermoid cysts in a single teaching centre. Although the study is retrospective, the laparoscopic operative techniques were standardised and prospectively applied by all surgeons of our department. The surgical technique adopted is simple and generalisable, given that senior residents (under supervision) were able to successfully perform the procedure. Group 2, where an endoscopic retrieval bag was used, was benefited from technological evolution (instruments and optical systems), and the learning curve of laparoscopic surgery acquired from the group-1 procedures. It is therefore not surprising that the need for laparotomy was negated over the time of the series.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Accidental rupture during dissection of an ovarian dermoid cyst is common, and granulomatous peritonitis can develop in cases of intraperitoneal spillage. The use of an endoscopic bag is useful to avoid intraperitoneal spillage of cyst contents.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Conception and design: WK, NB, and MC. Acquisition of data: WK and BC. Analysis and interpretation of data: WK, NB, and MC. Drafting the article or revising it critically for important intellectual content: WK, NB, BC, XT, RB, KJ, BR, JLP, GM, and MC. Final approval of the version to be published: WK, NB, BC, XT, RB, KJ, BR, JLP, GM, and MC.

Details of ethics approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

The study was approved by the Inter-regional Ethics Committee of the Rhône-Alpes-Auvergne Clinical Investigation Centre, Grenoble, France, on 14 January 2010 (IRB number 5044).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References
  • 1
    Shawki O, Ramadan A, Askalany A, Bahnassi A. Laparoscopic management of ovarian dermoid cysts: potential fear of dermoid spill, myths and facts. Gynecol Surg 2007;4:25560.
  • 2
    Chaparro JC, Vera H, Cognet A, Mage G, Pouly JL, Manhes H, et al. Traitement coelioscopique des kystes de l’ovaire. Gynecologie 1986;37:3105.
  • 3
    Nezhat C, Winer WK, Nezhat F. Laparoscopic removal of dermoid cysts. Obstet Gynecol 1989;73:27881.
  • 4
    Chapron C, Dubuisson JB, Samouh N, Foulot H, Aubriot FX, Amsquer Y, et al. Treatment of ovarian dermoid cysts. Place and modalities of operative laparoscopy. Surg Endosc 1994;8:10925.
  • 5
    Lin P, Falcone T, Tulandi T. Excision of ovarian dermoid cyst by laparoscopy and by laparotomy. Am J Obstet Gynecol 1995;173:76971.
  • 6
    Howard FM. Surgical management of benign cystic teratoma. Laparoscopy vs. laparotomy. J Reprod Med 1995;40:4959.