Treatment Options for Mature Cystic Teratoma (Dermoid Cysts), and Treatment with Laparoscopic Surgery

Dermoid cysts (Mature Cystic Teratomas) are treated with surgery, and I’m sorry but “onion juice” does not work unfortunately, like it is useless in other types of cysts.
It is useful to give a detail at this point because there is a question that you, the patients, ask: “Can we wait?”. Yes, it can be postponed. In fact, the expression “Come on, you should be operated immediately” is not quite right. For example, in a study, the average waiting time was given as 12.6 months; and 1/3 of patients had to have a medical operation, although the complication risk was very low in that process (1). Yes, abdominal pain, etc. developed in some of them but the most important reason for surgery it the patient’s request.

Knowing that a cyst containing fat and hair grows inside with an average velocity of 1.67 cm per year (1) is not good for anyone’s psychology :-). On the other hand, rotation of a cyst around its own axis together with the ovary is a complication seen at a rate of 10%. Therefore, it is really important for you to have an elective, i.e. planned and programmed surgery.
Now, let’s get to the question that you are dying to know: “How will I have surgery?”.
In fact, what you the patients try to ask is intended for knowing whether it will be an open (laparotomy) surgery or a closed (laparoscopic) surgery.
Let’s answer in order

1. Will it be an open surgery? Or will it be a closed surgery? (Laparotomy or laparoscopy ??)
Laparotomy, i.e. open surgery is a surgery method that we often recommend when the cyst is larger than certain sizes. We often do not want to perform the surgery laparoscopically for cysts larger than 10cm. Among the things told to patients, there is a confusing assertion that the cyst’s content would be discharged into the abdomen, and therefore, the surgery should definitely be an open surgery. I will give you literature information on the subject but for now, let me tell you only that the assertion is not true.

Laparotomy (Open Surgery) is done often with an incision similar to cesarean section. If the cyst is large or the tumor markers (for example, CA 19.9) are high, the patient must be operated with a different incision but this is a way that we rarely use in casesof dermoid cysts. Patients are often discharged from the hospital 2 days after laparotomy. On the other hand, exceptions don’t break the rule.

Base on the example that I give our patients, you would be home Sunday evening if you have the surgery on Friday.

Laparoscopic surgery is a surgical technique that we perform with a camera by means of surgical instruments inserted through 3 small incisions on your abdomen. Sentences such as “Check your instruments before the surgery, and if there is any instrument out of order, do not take risk unnecessarily” are the sentences emphasized the most when the instruments used during surgery are introduced at the beginning of the books about laparoscopy.

As you know, there is a saying that “A car can only be as good as its tires.” Similarly, in laparoscopic surgery a surgeon can only be as good as the instruments that he/she uses. If there are problems in the instruments and if they do not work, it is pointless to insist on laparoscopic surgery.

On the other hand, there are serious advantages that laparoscopic surgery provides, such as a shorter duration of hospital stay, less blood loss, and almost no wound infection.

Laparoscopic surger has serious advantages, and these advantages are applicable for not only dermoid cyst surgeries but also for all gynecologic surgeries. For example, laparoscopic surgery or minimally invasive surgery must always be the first choice in (for example) uterine cancer surgeries.

After laparoscopic surgery, patients are often discharged the next day unless there are certain exceptions (for example, the patient suffered a blood loss that required a blood replacement etc.)

A meta-analysis published in Cohrane Database is one of the best academic studies about the subject i.e. that compare open and closed surgeries (2).

2. The allegation that “The cyst’s content is discharged into the abdomen in laparoscopy, and this leads to peritoneal inflammation”.

In the study involving the comparison of laparoscopic and laparotomic surgeries done for benign ovarian tumors, the prevalence of postoperative fever, urethritis, wound infection, and pain was shown to be far less (2).
We have some colleagues, who say that laparoscopic surgery should not be done because dermoid cysts lead to serious complications when they are discharged into the abdomen during a laparoscopic surgery; and consequently, a chemical peritoneal inflammation (peritonitis) may develop.

That’s true, laparoscopy is more likely to cause the cyst’s content to be discharged into the abdomen; however, it has been academically proven that laparoscopy does not cause such a problem as long as you properly wash the abdomen and remove that content.

In the study publised by Remorgida at al. in 1998 (3), it was asserted that dermoid cysts could be removed laparoscopically but its content may be discharged into the abdomen during the operation; however, this is an extremely low possibility if the operation is done by surgeons who have a good surgical techniques.

In the study published by Laberge et al in 2006 (4), laparoscopy and laparotomy in dermoid cysts were compared, and it was shown that the surgeons preferred open surgery when the cyst diameter increased and when there were cysts at the both sides. Laberge et al emphasized the importance of surgical experience, as well. Blood loss, complications and duration of hospital stay were less and shorter in the series of laparoscopic surgeries, compared to open surgeries.
In the same series (4), the prevalence of the discharge of the cyst’s content into the abdomen was reported to be 18% and 1% in closed and open surgeries, respectively; however, it is shown that the discharge of the cyst content into the abdomen did not cause any postoperative chemical peritonitis.

Another study containing very well data was published on Human Reproduction by Templeman et al (5). In the study on girls under 18 years of age diagnosed with dermoid cyst, the cyst’s content was discharged into the abdomen of 52% of the patients during laparoscopy, but any chemical peritonitis did not develop in any of the patients. And more importantly, a significant part of these patients got pregnant during the follow-up process.

In our own experience, we have never encountered any chemical peritonitis in the patients, whose cyst’s contents were discharged into their abdomens during the laparoscopy. We think this could be achieved because we always wash the abdomen many times and always took the cyst out when it is in a bag. But unfortunately, conducting academic studies that could academically support this idea is ethically impossible.

3. Does Dermoid Cyst Recur After Surgery?

Another question is about whether it will recur. Patients and especially mothers of young girls always ask this question in a rational way; and surely, they are right to ask this. Let me first have a look at what the literature says, and then let me tell you about our experience not based on evidence.
For example, in Laberge’s series (4), the recurrence frequency is 7.6% in 2 years in the laparoscopy group.

But the largest series on the subject was published in Canada again. In the study on young girls and children diagnosed with dermoid cyst, published by Rogers et al (6), dermoid cyst recurred or persisted in 11% of the operated patients, during their follow up process.

Frankly, we discussed this publication at the platfom in Istanbul Faculty of Medicine. 11% is a very high figure indeed. Likewise, 7.6% is very high as well! The opinions that I will express now are my humble evaluations but I think I have a right to make some judgments without restraint, as a person who have done dermoid cyst surgeries for years.

My answer to the question “Does dermoid cyst recur?” is mostly as follows: “When we remove the cyst, its recurrence in the ovary is almost impossible but it may recur in the other ovary after a certain time, with a possibility rate of 15%.” However, a rate of 10% is mentioned for the same ovary in these series. In other words, saying “if nothing was detected in the other ovary during the surgery, it might be detected in the future” is an expression different from saying “the cyst may recur in the operated ovary with a possibility rate of 10%”. During the discussion between us, we thought that this is caused by the diagnostic method.

Although the research done by Rogers et al (6) was published in 2014, the diagnosis was made by means of ultrasonography. However, fat-suppressed MRI is a method that gives much better results. Since any MRI was not obtained, a small nucleus in the operated ovary (if any) was overlooked, and it created the recurrence rate of 10%. This is a matter required to be investigated academically.


4. Is an ovary removed if it rotataes around its own axis and becomes torsioned?

Another matter to be discussed is the removal of an ovary in case of its torsion. No matter what happens, even if it rotates around its own axis (even if it becomes torsioned) and becomes discolored (even if it   appears like “rooten”, as they told you) as a result, the ovary should not be removed.
In the most recent study on this subject published in India in 2014, torsioned benign cysts of children were brought to their normal positions and then were left intact. Consequently, they were saved (7).

The only exceptions to this are the ovarian torsions that occur in the newborn period. Unfortunately, since the tissue is very weak in 1 to 6-month-old baby girls, an autoamputation develops in the torsioned ovary; in short, the ovary comes off by itself and cannot be saved (7).

In conclusion, laparoscopic surgery is a great option in experienced hands, in terms of the surgical treatment of dermoid cysts (mature cystic teratomas). In cases where the cyst is larger than 10 cm, the patient should be operated with laparoscopic surgery; except for cases where a lot of bone structures exist (in such a case, it is difficult to strip the cyst) and tumor markers are high.
Note: In the website, you can find many videos and images about the subject. You can watch the relevant videos in the videos section for especially the questions such as “How to remove the cyst when it is in the bag?” and “What to do when the cyst’s content is discharged into the abdomen?”

1. Hoo WL, Yazbek J, Holland T, Mavrelos D, Tong EN, Jurkovic D. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome? Ultrasound Obstet Gynecol. 2010; 36(2):235-240
2. Medeiros LR, Stein AT, Fachel J, Garry R, Furness S. Laparoscopy versus laparotomy for benign ovarian tumor: a systematic review and meta-analysis. Int J Gynecol Cancer. 2008; 18(3):387-399.
3. Remorgida V, Magnasco A, Pizzorno V et. al. Four year experience in laparoscopic dissection of intact ovarian dermoid cysts. J. Am. Coll. Surg. 1998; 187(5):519-521.
4. Laberge PY, Levesque S. Short-term morbidity and long-term recurrence rate of ovarian dermoid cysts treated by laparoscopy versus laparotomy. J. Obstet. Gynaecol. Can. 2006; 28(9):789-793.
5. Templeman CL, Hertweck SP, Scheetz JP et al. The management of mature cystic teratomas in children and adolescents: a retrospective analysis. Hum Reprod. 2000; 15(12):2669-2672.
6. Rogers E.M., Allen L., Kives S. The recurrence rate of ovarian dermoid cysts in pediatric and adolescent girls. J. Pediatr. Adolesc. Gynecol. 2014; 27(4):222-226.
7. Agarwal P, Agarwal P, Bagdi R. Et al. Ovarian preservation in children for adenexal pathology, current trends in laparoscopic management and our experience. J. Indian Assoc Pediatr Surg. 2014; 19(2):65-69.