What are the causes of fever post elective laparoscopic cystectomy (removal of dermoid cyst)?

Causes of Fever Post Elective Laparoscopic Cystectomy for Dermoid Cyst

Fever after laparoscopic dermoid cyst removal is most commonly due to benign inflammatory response in the first 48-72 hours, but chemical peritonitis from cyst spillage is a unique and serious complication specific to dermoid cysts that must be considered, particularly if fever persists beyond 72 hours or is accompanied by peritoneal signs. 1, 2

Timing-Based Differential Diagnosis

Early Fever (0-48 hours postoperatively)

• Benign systemic inflammatory response (SIR) is the most common cause, triggered by surgical tissue injury and typically self-limiting 1
• The magnitude of inflammatory response corresponds to the extent of surgical injury 1
• This early fever usually resolves spontaneously within 2-3 days without intervention 1
• Extensive workup is generally unnecessary for mild fever without other symptoms during this period 1

Intermediate Period (48-96 hours postoperatively)

• Chemical peritonitis from dermoid cyst spillage becomes a critical consideration unique to this surgery 2, 3
  • Spillage occurs in 62-88% of laparoscopic dermoid cyst removals 3, 4
  • Chemical peritonitis presents with low-grade fever, rebound tenderness, guarding, and markedly elevated white blood cell count 2
  • Typically manifests 3 days post-surgery with persistent fever and peritoneal signs 2
• Early surgical site infection (though rare in first 48 hours, exceptions include group A streptococcal or clostridial infections) 1

Late Fever (>96 hours postoperatively)

• Surgical site infection becomes equally likely as other causes by postoperative day 4 1
• Granulomatous peritonitis from retained dermoid cyst contents (sebum, hair, keratin) 5
  • Presents with persistent fever, degradation of general health, moderate abdominal pain 5
  • May show nodular inflammatory granuloma on imaging 5
• Urinary tract infection, especially if catheterization duration exceeded 72 hours 1
• Pulmonary complications including pneumonia or pulmonary embolism (particularly with risk factors: sedentary status, lower limb immobility, malignancy, oral contraceptive use) 1
• Intra-abdominal abscess from inadequate irrigation of spilled dermoid contents 6
• Deep venous thrombosis or pulmonary embolism 1

Dermoid Cyst-Specific Complications

Chemical Peritonitis Pathophysiology

• Spillage of sebaceous material, hair, and keratin triggers intense foreign body reaction 2, 5
• Despite copious irrigation during initial surgery, residual microscopic particles can cause delayed inflammatory response 2
• Presents with extensive filmy adhesions of bowel and omentum to peritoneal surfaces 2

Clinical Presentation Red Flags

• Rebound tenderness with guarding beyond expected postoperative discomfort 2
• Markedly elevated WBC count (>12,000/µL) 7
• Persistent fever beyond 72 hours with peritoneal signs 1, 2
• Nodular masses on imaging suggesting granuloma formation 5

Evaluation Algorithm

For Fever <72 Hours Without Peritoneal Signs

• Daily wound inspection only without extensive workup 1
• Chest radiograph not mandatory if fever is sole indication 1
• Urinalysis not mandatory unless specific urinary symptoms present 1
• Avoid unnecessary antibiotic use for non-infectious inflammatory fever 1

For Fever >72 Hours or With Peritoneal Signs

• Immediate wound inspection for purulent drainage, erythema >5 cm, induration, or necrosis 1, 7
• Complete blood count with differential to assess leukocytosis 6
• Abdominal CT scan with IV contrast as preferred imaging to identify intra-abdominal abscess or retained dermoid contents 6
• Blood cultures if temperature ≥38°C with systemic signs 1
• Consider diagnostic laparoscopy if chemical peritonitis suspected based on clinical presentation and imaging 2

Management Priorities

For Chemical Peritonitis

• Repeat laparoscopic surgery is the definitive treatment for removal of residual dermoid contents 2
• Copious peritoneal lavage and removal of all visible particles and adhesions 2
• Early recognition and prompt surgical intervention prevents progression to granulomatous peritonitis 2, 5

For Surgical Site Infection (Day 4+)

• Obtain Gram stain and culture of any purulent drainage 1
• Empiric antibiotics: cephalosporin + metronidazole, levofloxacin + metronidazole, or carbapenem for GI tract operations 1
• Add vancomycin if MRSA risk factors present 7

Critical Pitfalls to Avoid

• Do not dismiss persistent fever as "normal postoperative response" beyond 72 hours, especially with peritoneal signs 1, 2
• Do not delay imaging in patients with fever beyond 96 hours post-dermoid cyst removal 6
• Do not assume adequate irrigation during initial surgery eliminates risk of chemical peritonitis—microscopic particles can cause delayed reaction 2, 5
• Do not overlook thromboembolic disease in patients with risk factors (oral contraceptives commonly used in reproductive-age women undergoing ovarian surgery) 1
• Atelectasis should be diagnosis of exclusion, not first-line explanation for postoperative fever 1