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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 92-96

Review of laparoscopic management of mature cystic teratoma of ovaries in children

1 Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster NHS Foundation Trust, Imperial College London, London, United Kingdom; Department of Pediatric Surgery, Clinic for Pediatric Surgery and Orthopedic Nis, Clinical Centre of Nis, Nis, Serbia
2 Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster NHS Foundation Trust, Imperial College London, London, United Kingdom

Date of Web Publication1-Mar-2019

Correspondence Address:
Dr. Maja Raicevic
Department of Pediatric Surgery, Clinic for Pediatric Surgery and Orthopedics, Clinical Centre of Nis, Nis 128000

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.JIAPS_246_17

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Ovarian cystic mature teratomas (OCMTs) are the most frequent ovarian tumors in childhood. This review aimed to determine the feasibility and safety of laparoscopic management of OCMT. Literature was searched for terms “mature,” “ovarian,” “teratomas,” and “laparoscopy.” Primary endpoints were age at surgery, laparoscopic and surgical technique, intraoperative complications, postoperative morbidity, and associated pathology. Literature search revealed 11 articles published between 1998 and 2014 that met the inclusion criteria. There were 105 (n = 95 unilateral; n = 10 bilateral) patients for this analysis, with mean age at surgery being 13 years. Four laparoscopic approaches were opted: gasless transumbilical laparoendoscopic single-site (LESS) surgery (n = 19), gasless multiport surgery (n = 24), single-incision laparoscopic surgery (SILS) (n = 3), and pneumoperitoneum multiport laparoscopy (n = 59). The 10 patients with bilateral OCMT underwent ovary-sparing surgery: LESS-assisted extracorporeal bilateral cystectomy in which tumors were punctured by a balloon catheter (n = 2), intracorporeal cystectomy for gasless multiport laparoscopy (n = 5) with use of endobags to prevent spillage, and transperitoneal multiport laparoscopy (n = 3). OCMT was associated with ipsilateral and unilateral ovarian torsion in five and bilateral ovarian torsion in one patient with bilateral OCMT. In four patients with unilateral OCMT, salpingo-oophorectomy was performed. Intraoperative complications were laceration of utero-ovarian ligament and bladder injury during a suprapubic port placement. The mean follow-up was 31.9 months. Patients with unilateral or bilateral OCMT can be offered ovarian-sparing surgery laparoscopically with one of the following techniques: LESS, SILS or multiport laparoscopy with pneumoperitoneal or gasless. Long-term follow-up of these techniques has shown no recurrence with low postoperative morbidity and low intraoperative complications.

Keywords: Laparoscopy, mature, ovarian, pediatric, teratomas

How to cite this article:
Raicevic M, Saxena AK. Review of laparoscopic management of mature cystic teratoma of ovaries in children. J Indian Assoc Pediatr Surg 2019;24:92-6

How to cite this URL:
Raicevic M, Saxena AK. Review of laparoscopic management of mature cystic teratoma of ovaries in children. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2021 May 14];24:92-6. Available from: https://www.jiaps.com/text.asp?2019/24/2/92/253339

   Introduction Top

Teratomas are the most common germ cell tumors in children and are classified as mature, immature, and malignant. Ovarian tumors constitute only 1% of all childhood tumors. Germ cell tumors constitute 47%–87.7% of tumors, of which 95% are benign mature teratomas.[1],[2] Within the group of benign mature teratomas, mature cystic teratoma, often referred to as dermoid cysts, comprises 25% of all the ovarian tumors.[1],[2],[3] Ovarian cystic mature teratomas (OCMTs) can be bilateral in 10%–15% of the patients and more than one-fifth of the children with ovarian mature teratoma could manifest with metachronous tumor of the contralateral ovary.[4],[5] Mature ovarian teratomas are more frequent than immature and they are mostly of cystic-solid composition with calcification in 40% of cases.[1],[2],[4]

Mature cystic teratomas may present with palpable abdominal mass, pelvic pain, or clinical findings of acute emergencies such as torsion or rupture. Adnexal torsion is the main complication of mature ovarian teratomas. Ultrasound is the primary imaging technique in 95% of cases.[2],[6],[7]

At present, laparoscopy is widely used in pediatric surgery as the advantages of minimally invasive techniques are well known such as excellent cosmetic results, less pain, decreased demand for analgesics, quicker recovery, and shorter hospital stay. In pediatric patients, the safety of laparoscopic excision of benign ovarian tumors has been reported by various reports as an effective and safe method for diagnosis as well as definitive therapy.[2],[8],[9],[10] Various laparoscopic and operative techniques for OCMT in children have been reported during the last two decades, and the outcomes of these procedures are the basis for present analysis.

   Materials and Methods Top

The literature was reviewed for terms “mature,” “ovarian,” “teratomas,” and “laparoscopy.” Primary endpoints were the age at surgery, type of performed laparoscopic and surgical technique, intraoperative complications, postoperative morbidity, and associated pathology with mature cystic ovary teratomas in children. The search revealed 11 articles published between 1998 and 2014 that met the inclusion criteria and offered 105 patients for this analysis, of which 95 had unilateral OCMT and 10 had bilateral [Table 1].
Table 1: Articles that met the inclusion criteria showing the number of patients, laparoscopic approach, and type of performed surgery

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   Results Top

Four different laparoscopic techniques were identified that were applied in the management of pediatric OCMT. The most common technique was pneumoperitoneum multiport laparoscopy (n = 59), followed by gasless transumbilical laparoendoscopic single-site surgery (LESS) (n = 19), gasless multiport laparoscopy (n = 24), and single-incision laparoscopic surgery (SILS) (n = 3). With regard to the port sizes and special instruments used, 5-mm ports were preferred in all patients, and the Alexis Wound Retractor was utilized for LESS [Figure 1].
Figure 1: Laparoscopic management of ovarian mature cystic teratoma is approached with four different techniques. This graph represents the distribution of the 105 patients according to the techniques employed

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Ovary-sparing surgery was the preferred approach for most of the surgeons as it was performed in 101°CMT patients, with 4 undergoing unilateral salpingo-oophorectomy [Figure 2].
Figure 2: Laparoscopic management of ovarian mature cystic teratoma showing the overwhelming preference for the ovarian-sparing approach

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In the two patients who underwent LESS-assisted extracorporeal bilateral cystectomy with ovary tissue preservation, tumors were punctured using a SAND balloon catheter. In patients with bilateral OCMT, gasless multiport laparoscopy technique was used in 5 and pneumoperitoneum multiport in 3, with intracorporeal cystectomy and endobags to prevent spillage.

With regard to the 13 years (range: 4 months–19 years) mean age of patients at the time of surgery; a mean age of 13.4 years (4 months–19 years) was observed in pneumoperitoneum multiport approach which was markedly lower than that observed using the LESS (17.5 years; range: 6–19 years) or the gasless multiport (17 years; range: 9–19 years) approach. SILS was however offered at a mean age of 12.5 years (3.5–17 years) and not used in the analysis due to small sample size.

The mean operative time was 73.5 min (range 28–152 min) for gasless techniques LESS and multiport, 41.5 min (21–97 min) for SILS, and 73.3 min (22–141 min) for pneumoperitoneum multiport laparoscopy. Average tumor size was 9.58 cm (2–27 cm). Regarding intraoperative complications, there was 1 laceration of utero-ovarian ligament during LESS, 2 bladder injuries at the time of suprapubic port placement during multiport laparoscopy, and 2 wound infections.

The mean follow-up was 31.9 months (0.4–96 months). Postoperative morbidity included one necrotizing fascitis after multiport laparoscopy. Bilateral OCMT was associated with bilateral torsion in one patient and with perforated appendicitis in another one. Torsion of unilateral OCMT was reported in five patients, and in one patient, a hemorrhagic cyst was found on the contralateral ovary. In one patient with OCMT, there was also an association with inflamed appendicitis.

   Discussion Top

Laparoscopic surgery is considered to be the gold standard for the management of benign ovarian masses in children and adults. To date, four different laparoscopic techniques have been described for management of OCMT in the pediatric population. Multiport pneumoperitoneum laparoscopy was the most common technique, being used in 56.1% of cases. The possible explanation for this would be that majority of the surgeons are the most familiar with multiport laparoscopy, probably as it is the oldest minimally invasive technique and it is suitable for use in the wide patient size range of the pediatric age group.

The age of patients undergoing multiport laparoscopic surgery with pneumoperitoneum was lower than those where surgery was performed by gasless LESS and gasless multiport techniques. Most surgeons prefer to perform standard multiport pneumoperitoneum cyst excision in younger girls as it may be technically easier in a smaller space, whereas other techniques with single-site accesses could be more suitable for older girls where the size of the umbilicus is larger to conceal the incision and more abdominal space to perform the manipulations.

Ovarian-sparing procedures have found precedence, especially since the incidence of bilateral metachronous ovary torsion (OT) is found to be as high as 12%.[11] In the present analysis, bilateral and unilateral OTs caused as a result of OCMT were found to be 7.4%. In a 9-year-old girl, bilateral torsion was reported, although adnexal torsion occurring in a premenarchal girl is an extremely rare disorder and bilateral adnexal torsion is even a rarer event.[12]

Some of the advantages of LESS surgery over multiport laparoscopic surgery are (a) access to the pelvic cavity through a single large umbilical incision, (b) safer approach to the abdominal cavity by an open procedure, (c) potentially less incisional morbidity by reducing the number of abdominal incisions, (d) easier retrieval of the bulky masses such as ovarian dermoid cyst containing teeth or cartilage components, and (e) favorable cosmetic results obtained from a single surgical wound eventually concealed with umbilicus. However, a significant disadvantage in LESS surgery is the difficulty in intra-abdominal manipulation with the surgical instruments due to the lack of triangulation and lack of sufficient working space.[13]

Although SILS was implemented by gynecologists, it is yet to be widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. The most significant contribution of SILS procedure is only the cosmetic result after the procedure, as postoperative pain and length of hospital stay have not shown advantages with SILS.[14],[15] However, when considering operating times, although mean operating time was equal for gasless techniques and pneumoperitoneum multiport laparoscopy (73.5 vs. 73.3 min), the advantage of shorter operating time in SILS in this analysis (41.5 min) was obvious.

For years, the classic treatment for mature teratomas was oophorectomy either by the open or by the laparoscopic approach. However, ovary-sparing surgery is being successfully performed in recent years. The present analysis has shown that ovary-sparing surgery during childhood has become a standard for many centers, as unilateral salpingo-oophorectomy was performed in only 4 of 105 patients. Ovary-sparing surgery with preservation of gonadal function in the pediatric population is important for the development of normal puberty and future fertility. Conservative surgery might be considered only in patients whose Alfa-fetoprotein and beta-human chorionic gonadotropin levels are within normal range, so that malignancy can be excluded, as appropriate management of this tumor is of concern to surgeons caring for patients in this age group.[2],[7],[11],[16]

With regard to the size of OCMT, the average tumor size was found to be 9.58 cm in diameter. Three cases of giant OCMT were reported, with the largest diameter being 27 cm. Giant ovarian cysts in adolescents, especially in premenarchal girls, are very rare. Laparoscopic surgery of giant ovarian cysts may be difficult because of the risk of cyst rupture and limited working space within the abdomen. Thus, in children, it is better to compare the size of the cyst to the size of the peritoneal cavity when such procedures are planned.[8]

Although the metastatic potential is uncertain, the importance of rupture prevention and spillage risk is of paramount importance.[1],[2] Spillage of ovarian cyst fluid during surgery is associated with a number of risks that include chemical peritonitis, gliomatosis peritonei, pseudomyxoma peritonei, tumor recurrence, and possible dissemination of malignant cells if the workup was not conclusive.[17] To prevent spillage, endobags are used for multiport surgery and SAND balloon catheters in LESS. Watanabe et al. described a surgical technique to prevent spillage of cyst fluid during operation of cystic ovarian tumors in the pediatric population. For this, the tumor mass is placed just under the wound, and a sterilized surgical sheet is attached to the cyst using a special quick-drying tissue glue. After the sheet is glued, the cyst is punctured with a suction tube, and the cyst fluid is aspirated, following which the tumor is brought outside of the body for resection.[17]

This analysis determined the overall intraoperative complication rate in OCMT laparoscopic management to be low 2.9%. Postoperatively, only two wound infections and one postoperative necrotizing fasciitis were associated with multiport surgery. The mean follow-up of these patients was 31.9 months and no recurrences were reported. The estimated growth rate of OCMT is slow; therefore, an annual ultrasound follow-up is needed for these patients up to potential pregnancy to enable early diagnosis, ovary preserving surgery, and maintenance of fertility in the case of the metachronous tumor.[1],[5] A 3-year follow-up which is suggested for teratoma at any site was not followed according to this analysis.

The main symptom in OCMT patients is lower abdominal pain. Because the symptom is nonspecific, the clinical features can be confusing, especially in emergency cases. Laparoscopy is used to diagnose cases of sudden pelvic pain. In addition to the diagnostic role, now laparoscopy allows most treatments to be carried out in ovaries with torsion (detorsion with or without oophoropexy, transparietal cystectomy), including procedures those for associated lesions such as appendicectomy.[18],[19],[20],[21],[22] However, laparoscopy should be performed only after a careful preoperative workup has confirmed a nonmalignant tumor. In case of an emergency, laparoscopy should be employed to relieve the torsion; resection using laparoscopy should be performed in the second session if the lesion is confirmed to be benign.

Based on this analysis, it can be concluded that data are scarce in the literature on laparoscopic management of OCMT, although laparoscopic treatment of adnexal masses is the standard approach in pediatric surgical centers. Patients with unilateral or bilateral OCMT can be offered ovarian-sparing surgery laparoscopically with variants such as LESS, SILS, or gasless laparoscopy. Long-term follow-up shows that there were no recurrences, and postoperative morbidity and intraoperative complications were low in the laparoscopic approach to OCMT in girls. The literature also showed that there was correct patient selection for laparoscopic approach after malignancy was ruled out.

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Conflicts of interest

There are no conflicts of interest.

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