Recurrent bilateral ovarian dermoids, co-occurring with multiple large benign cystadenomas, and a functional cyst; managed by minimally invasive surgery - A rare case report

INTRODUCTION

Benign ovarian cysts comprise 80% of all ovarian masses presenting in women of reproductive age group. Most common ovarian neoplasms are surface epithelial tumors and amongst them, the most common are benign cystadenomas, of which 75% are serous cystadenomas and 25% are mucinous cystadenomas.^[1]

Dermoid cysts account for 20-35% of total benign ovarian cysts. These are tumors arising from totipotent germ cells in ovary, a presentation commonly seen in young girls. Bilateral presentation can be seen in 10–15% of cases of dermoid cysts.^[2] Recurrence of ovarian dermoid is believed to be rare. Incidence of recurrence of ovarian dermoid is 2.5%.^[3] Recurrence is also attributed to incomplete excision of the cyst during primary surgery.

There have been reports of synchronous occurrence of a mucinous cystadenoma and a serous cyst present one in each ovary from patients presented to gynecological OPD.^[4-6] The presence of multiple large benign cysts of different pathogenesis in one ovary is an extremely rare presentation.^[4,7]

We present a case of dermoid cyst, mucinous cystadenoma, multiple serous cysts, and corpus luteal cyst-all in the right ovary along with a dermoid cyst in the left ovary as well. The patient underwent successful enucleation of these cysts laparoscopically. We also describe the challenges in such surgery and implications of various surgical techniques.

CASE REPORT

A 22-year-old unmarried lady presented with a dull aching, intermittent lower abdominal pain. Menstrual cycles were regular and there was no dysmenorrhea. She had undergone laparoscopic excision of a right ovarian dermoid cyst 5 years back. Abdominal examination revealed mild tenderness in the right iliac fossa. Per vaginal examination was not performed.

Pelvic ultrasound revealed a right ovarian dermoid cyst measuring 6.8 × 5.4 × 4.5 cm and left ovarian dermoid cyst measuring 3.0 × 2.5 × 2.5 cm. Routine investigations were normal and CA - 125 was 55 IU and normal. Anti mullerian hormone (AMH) 3.8 was also normal.

Laparoscopic surgery was performed after complete pre-anesthetic check-up and detailed written and informed consent.

Laparoscopic cystectomies was achieved with complete enucleation of all the cysts and retrieval of the cyst walls.

Figure 1 shows bilateral ovarian dermoid cyst.

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Figure 1:

(a) Initial picture of the pelvis on entry by laparoscope, showing large ovarian mass on right side, (b) Left-sided ovarian dermoid cyst, (c) Right ovarian mass in Toto.

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Figure 2 shows multiple right ovarian cysts of various pathologies. There were total seven cysts, enucleated from the right ovary.

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Figure 2:

(a) Use of suction cannula for dissection and enucleation, (b) complete enucleation of dermoid cyst (1), (c) mucinous cystadenoma (2), (d) Multiple serous cystadenomas (3,4,5), (e) Serous cyst (6), (f) Corpus luteal cyst (7).

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Figure 3 shows all the enucleated cysts and laparoscopic suturing and closing the dead space.

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Figure 3:

(a) Complete picture of all the cysts on completing cystectomies, including left dermoid cyst. (b) Laparoscopic suturing.

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The findings of all the cysts removed serially were confirmed on histopathology.

DISCUSSION

Diagnosis on imaging techniques, especially ultrasonography is largely technology and personnel dependent. It is not uncommon that the type, sizes, and numbers of ovarian cysts are misdiagnosed.

There are numerous case reports of bilateral presentations and multiple dermoid cysts.^[2] Comerci et al. reviewed a large number of cases of mature cystic teratoma of ovaries, (dermoid tumors) and found that 10.8% were bilateral.^[3]

A case report by Baradwan et al. from Saudi Arabia and two case reports from India, Mondal et al. and Sethi et al. demonstrated the synchronous presence of benign cystadenomas of different types in each ovary from the patient.^[4,5,7]

Co-occurrence of multiple benign cystadenomas, dermoid cyst, and a functional cyst together in an ovary is an extremely rare phenomenon. This was seen in the present case.

In this case, “multiple cysts in the right ovary” were observed during surgery. As pre-operative ultrasonography had suggested solitary right-sided dermoid cyst, we had challenges of enucleation of many cysts and of different types. We also noted the fibrotic and adherent nature of cyst walls over the ovarian cortex, probably attributable to scarred ovarian surfaces due to ovarian surgery the past.

We suggest the use of a laparoscopic suction cannula, as an effective tool for dissection among cysts and from ovarian surfaces, instead of the conventional and routine practices of dissection by plain or toothed laparoscopic graspers followed by peeling of the cyst wall after rupturing the cysts, or sharp dissection by electrocautery or cold scissors.

The use of a suction cannula promotes complete enucleation of the cysts without rupturing them which is of utmost importance in dermoid cyst surgery. Avoidance of electrocautery over ovarian surfaces also helps us to preserve the so-called “ovarian reserve.”

Meticulous and thoughtful efforts during surgery will prevent the recurrence of the cysts and, hence, will prevent repeat ovarian surgery, on this young and fertile woman.

CONCLUSION

Occurrence of multiple ovarian cystadenomas is a rare phenomenon. A detailed pre-operative work-up is of utmost importance. A laparoscopic approach is preferred but the use of electrocautery on the ovary should be discouraged in young patients in view of fertility preservation.