The Ovary-Sparing Laparoscopic Excision of a Benign Teratoma

Abstract

Purpose: We demonstrate complete excision of a benign ovarian teratoma and combine the benefits of laparoscopy with ovary preservation and avoidance of tumor spillage. Case History: A 9-year-old female presented with 2 months of intermittent right lower quadrant abdominal pain. Physical examination was unremarkable with no palpable abdominal mass. Pelvic ultrasonography revealed an enlarged right ovary with no evidence of torsion on duplex scan. MRI revealed a calcified, 3.5 cm mass within the right ovary, consistent with a teratoma. Tumor marker blood studies, including beta-HCG, alpha-fetoprotein, and CA-125, were negative. Procedure: General anesthesia was administered. The patient was placed in Trendelenburg position with the monitor at the foot of the bed. Three 5-mm laparoscopic ports were placed, one for the 5-mm, 30° camera at the umbilicus and one each in the lower quadrants for dissection instruments. A 12-mm port was placed in the skin crease, directly above the ovary, for the endocatch bag. The abdomen was insufflated with carbon dioxide to 13-mm Hg pressure. Initial inspection revealed a normal-appearing abdomen, a normal contralateral ovary, and the serosa of the enlarged right ovary appeared intact. The dissection began at the pelvic edge by dividing the peritoneal attachments between the adnexal structures and the pelvic side wall with the harmonic scalpel. It proceeded toward the point between the bladder and the epigastric vessels. The ovarian and iliac vessels and ureter were avoided. The dissection extended under the adnexa. The ovary reached the 12-mm port without tension. It was placed in an endocatch bag to prevent spillage in case of rupture and carefully pulled through the 12-mm port site. The hydroplane technique of saline injection with a 30-gauge needle under the ovary serosa allowed dissection of the teratoma from normal ovarian tissue. The serosa was opened and the teratoma circumferentially excised.1,2 The preserved ovary serosa was closed with running suture of 3–0 chromic catgut. The adnexa were replaced in the abdominal cavity in the correct orientation. The abdomen was desufflated and port sites were closed. Results: The pathology analysis revealed a benign 3.0 cm teratoma, completely excised with intact margins and no immature elements. No complications occurred. The operative time was 70 minutes. The patient was discharged on postoperative day 2. Conclusion: We demonstrate complete excision of a benign ovarian teratoma and combine the benefits of laparoscopy with ovary preservation and avoidance of tumor spillage.3 For patients with negative tumor markers, an MRI with a teratoma contained in the ovary and a tumor diameter less than 5 cm are appropriate. The distance between bladder and epigastric vessels may limit the size of lesion that can be brought through the abdominal wall along the suprapubic skin crease. The hydroplane technique reveals a consistent plane between teratoma and normal ovary. However, this technique is also suitable for lesions where malignancy is suspected. The risk of suspicious histology, tumor rupture, and spillage increases with tumor diameter. In general, these risks increase with lesions more than 5 cm in diameter.4 Therefore, we promote the use of the endocatch bag. No competing financial interests exist. Runtime of video: 4 mins 55 secs