Single Incision Laparoscopic Resection of a Giant Ovarian Mature Cystic Teratoma
Background: Ovarian tumors in the pediatric population are a rare occurrence, with a yearly incidence of 2.6 cases per 100,000 girls. Ovarian teratomas are germ cell tumors classified as either mature or immature. Mature cystic teratomas are the most common ovarian neoplasms and are typically benign, whereas immature teratomas are malignant. Patients frequently present with increasing abdominal girth and pain. Diagnosis is commonly made by ultrasound or CT scan. Normal alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (BHCG) are characteristic of benign mature teratoma. Historically, resection has been performed via laparotomy, though the laparoscopic and Single Incision Laparoscopic Surgery (SILS) approaches have been well documented in the literature. We present a video demonstrating the use of the SILS technique for removal of a giant ovarian mature cystic teratoma in a child. Methods: Case Report: A 13-year old girl presented with a one-year history of abdominal fullness and a significantly protuberant abdomen on examination. Ultrasonography and CT scan demonstrated a 32 x 15 x 27 cm fluid-filled cyst with calcifications, suggestive of a left ovarian mature cystic teratoma. Given the patient's normal tumor markers and low risk of malignancy, a single incision laparoscopic resection was undertaken. Upon entering the abdomen using a single umbilical incision, the teratoma was immediately encountered and 8 liters of fluid suctioned from within. Once the cystic mass was decompressed, the abdomen was insufflated and the ovarian teratoma resected from the left mesovarium and ovarian ligament using electrocautery. The umbilical fascial incision was opened and the mass removed. Examination of the mass demonstrated three teeth within its wall. The patient tolerated the procedure well and was discharged home on the first postoperative day. Pathology demonstrated an ovarian mature cystic teratoma. Discussion: Compared with laparotomy, the laparoscopic approach to adnexal mass resection offers advantages of decreased pain, decreased hospital length of stay, decreased incidence of adhesion formation, and improved cosmesis. In a review of 19 pediatric patients with ovarian masses, the SILS approach utilized by Lacher and colleagues demonstrated the safety and feasibility of this technique. There were no complications, conversions to open, or readmissions. Conclusion: In our patient, SILS resection was considered appropriate because the malignancy risk was very low due to the characteristic appearance on CT scan and negative tumor markers. This case is of particular interest given the impressive size of the cystic mass, and its successful resection via the SILS technique.