Management of 6.2 cm Ovarian Dermoid in Reproductive-Age Women
Laparoscopic cystectomy is the recommended treatment for a 6.2 cm ovarian dermoid in a woman of reproductive age, as this size exceeds the threshold for conservative management and warrants surgical removal to prevent complications while preserving fertility. 1, 2
Why Surgery is Indicated
Dermoid cysts >5 cm require surgical intervention rather than observation, as larger cysts have increased risk of torsion, rupture, and are more difficult to characterize completely on imaging. 1
The 6.2 cm size places this dermoid above the conservative management threshold, where simple observation with annual ultrasound would be appropriate only for dermoids <5 cm in premenopausal women. 1, 2
While dermoid cysts have an extremely low malignancy risk (1-2% undergo malignant transformation, typically in postmenopausal women), surgical removal allows definitive histologic diagnosis and prevents future complications. 1, 3
Recommended Surgical Approach
Laparoscopic ovarian cystectomy with ovarian preservation is the gold standard, offering multiple advantages over laparotomy:
Shorter operative time (mean 64.6 minutes), reduced blood loss, less postoperative pain, and shorter hospital stay (mean 1.6 days vs. 3.5 days with laparotomy). 4, 5, 6
Better fertility outcomes, with 58% spontaneous pregnancy rate in infertile patients following laparoscopic dermoid removal. 5
Fewer postoperative adhesions compared to open surgery, which is critical for preserving future fertility. 4
Excellent cosmetic results with faster recovery and return to normal activities. 4
Critical Technical Considerations to Prevent Spillage
The main concern with laparoscopic dermoid removal is intraperitoneal spillage of cyst contents, which occurs in 28-88% of cases. 5, 6 However, this can be minimized:
Use the "enucleation in a bag" technique: Place the entire ovary inside an endobag at the beginning of the procedure before cyst enucleation, which reduces evident peritoneal contamination to only 5.7% even when cyst rupture occurs. 5
Aspirate cyst contents before removal to reduce spillage volume, then remove the cyst through the endobag via a 10-mm trocar. 6
Perform copious peritoneal lavage during and at the end of the procedure if any spillage occurs. 6
Avoid culdotomy for cyst removal, as this increases contamination risk. 6
Important Caveats
Postoperative fever occurs in approximately 6% of cases with spillage but does not indicate peritonitis and resolves spontaneously. 6
Chemical peritonitis from spillage is rare when proper technique is used, with no cases of clinical peritonitis reported in large series using the bag technique. 5, 6
Surgeon experience matters: This procedure should be performed by gynecologists with considerable experience in advanced laparoscopic surgery to minimize complications. 4
Preoperative Workup
Before surgery, confirm the diagnosis with:
Transvaginal ultrasound with color Doppler showing classic dermoid features: echogenic components (hair, fat, teeth), posterior acoustic shadowing, and absence of internal vascularity. 1, 2
Tumor markers are not routinely needed for classic dermoid appearance in reproductive-age women, but CA-125 may be considered if any atypical features are present. 1
Postoperative Management
Annual ultrasound surveillance is not required after complete surgical removal, unlike dermoids managed conservatively. 1, 2
Histopathologic confirmation of mature cystic teratoma should be obtained, with careful examination to exclude the rare malignant transformation (squamous cell carcinoma in 1-2% of cases). 1