Laparoscopic Resection of a Torted Ovarian Dermoid Cyst

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  Torsion or rupture of an ovarian cyst may present as an acute abdomen. A case is presented where the diagnosis was made at laparoscopy and laparoscopic resection was done. Controlled aspiration of the cyst contents allowed the cyst to be easily removed from the abdomen.  Ovarian dermoid cysts may present as an emergency after torsion or rupture and from time to time general surgeons will encounter such a case. Laparoscopic management is beneficial and preservation of ovarian tissue and the fallopian tube is usually possible. We would recommend placing the cyst into a bag and externalizing it prior to the aspiration to avoid any risk of contamination.  For more information please contact:  https://www.laparoscopyhospital.com/admission.php  World Laparoscopy Hospital  Cyber City, Gurugram, NCR DELHI  INDIA 122002  Phone & WhatsApp: +919811416838, + 91 9999677788

Transcript

00:00Hello friends, this is a case of torqued ovarian cyst.

00:06This patient has a large dermoid cyst and it got torqued and she had a severe pain in

00:14the right iliac fossa and it was inflamed and this was that much size of the ovarian

00:21cyst.

00:23So we will do the surgery that is laparoscopic ovarian cystectomy.

00:29And this is our cystic area, we should be careful.

00:35And this ovarian cyst is a large dermoid cyst, the cent is unmarried so we will keep it in

00:40the supine position, we are not using any uterine manipulator or any lithotomy position.

00:48Now we will enter for safety initially with the palmer's point and later we will transfer

00:56the telescope to the supra-amblycal area.

01:01So pneumo-pitonium is completed and now the trocar has been introduced to the palmer's

01:06point.

01:08So we will enter inside and then other ports, this we will do ipsilateral port and one contralateral

01:27also will be required to use one endobag and one supra-amblycal will be used.

01:37For later we will transfer the telescope there.

01:40So we can see here this is an ovarian cyst and due to the torsion it was completely inflamed

01:50and omentum is trying to arrest it, trying to cover it.

01:54So we have to remove the omentum from there although it is all the adhesions due to the

01:59inflammation.

02:03But these adhesions are not very mature adhesions and you can separate all the omentum from there.

02:15Once the omentum is separated after that you can do the examination of the pedicle and this

02:25is a right ovarian cyst and it was torsion because it is becoming little fragile here at this axis.

02:36It was torqued but the problem is detorsion is not possible at this moment of time because

02:43of the inflammation and the size.

02:46So this is an endobag.

02:49You can introduce an endobag that is a commercially available endobag, it is a size C endobag.

02:55And then the ovary with the cyst will be brought inside this endobag so that if any espilage

03:06happen then it should be controlled espilage.

03:12It is impossible in laparoscopy that you can 100% guarantee that there will be no contamination

03:19but controlled espilage is okay.

03:22This is aspiration needle and slowly with the suction we are aspirating initially with the

03:28needle and then with the suction the entire fatty content of the cyst is aspirated out.

03:37of course it is dermoid so you have a thick cheesy material together with the hair together with

03:50the nail or bone may be there.

03:53So aspiration needle will not aspirate everything, suction will necessary.

04:09Once the entire aspiration as much as it is possible and it is debulk as we can see if any

04:15spillage is there that spillage is going into the endobag.

04:22There may be some time septate one or two pockets in those situations you can take both

04:30pockets separately.

04:40Once it is over after that you can try to do in those cases of the torted ovarian cyst first

04:48we should try to do detorsion.

04:52So that it will be easy to do the ovarian cystectomy.

05:00Now almost all the suction is complete and here we can see at the level of the IP ligament

05:07the torsion of the ovary and tube is visible.

05:13Once it is okay then you can start doing detorsion.

05:30So now this is detorsion which we are using doing it and this is first time.

05:52Now this is second turn and here it is third detorsion and now one more.

06:14Now it is okay.

06:15This is fimbrial end of the tube what we are seeing is and now it is fine.

06:27I think one more time.

06:31One more detorsion is required and now it is okay.

06:39So after detorsion this entire cyst will be separated from the ovary.

06:43Luckily ovary was near the ovarian ligament and it was some of the ovarian tissue can be

06:50preserved otherwise in those cases you might have to do the entire ofectomy but here we

06:56are preserving some of the ovarian tissue and with the harmonic scalpel we will separate

07:02the cyst from the ovary.

07:05In those cases the traditional enucleation of the cystic wall is not possible so you have

07:13to cut the cystic wall and then you can separate the ovarian cyst from the ovary.

07:22Now this is slowly slowly with the harmonic it is separated partial ofectomy and here remaining

07:31ovary and that much even if the 40-60% of the tissue is remaining it will work.

07:39It will do some ovary and these are cortex this is fine.

07:46You can check for any bleeding and after that this entire cyst will be kept in the endobag

07:56and then we can close the purse string of the endobag.

08:12And now this endobag mouth of the endobag will be pulled into the cannula and then everything

08:19will be pulled together.

08:24This patient has previous appendicectomy done by opane so you can see some adhesion there.

08:35And now this mouth of the endobag will be taken out and then immediate lavage should be performed

08:43for any spilled content and irrigation and suction to the curl.

08:50This is the remaining ovary of the right side and multiple time irrigation and suction should

08:56be performed so that there should not be any remnant of the spilled dermoid content.

09:08Copious lavage should be done and all the fluid will be aspirated out.

09:23In those situations it is recommended by many surgeons that open the mouth of the endobag

09:30and use it as a wound protector and slowly with the ovum forceps you should take the ovary

09:37and cystic content out.

09:40And slowly by the zig-zag fashion you can take the endobag together with the ovary cysts.

09:46So we can see here this cystic wall is coming out and you can hold with one to another artery

09:52forceps and take it out.

09:55And then again final thorough lavage will be performed.

10:00So that there should not be any residual dermoid content.

10:06So this way sometime if the dermoid cyst is ignored there may be torsion that is an emergency condition

10:14and it has a lot of you know the pain you can see on the right side of the bladder and

10:21the right side of the medial umbilical ligament still there are inflammation because at this

10:28area was completely adhered.

10:31So posterior cul-de-sac, anterior cul-de-sac and again proper irrigation and suction and

10:37thorough lavage will be performed.

10:40Any drain was not required in this case because there was no any bleeding and everything is

10:44fine.

10:46So thank you very much for watching this video, this was a simple case of torted ovarian dermoid.

10:53So thank you very much.

11:00Thank you very much.

11:09And thank you very much for joining us today.

11:12Thank you very much.

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