"Saving Two: Laparoscopic Approach to a Large, Twisted Ovarian Dermoid Cyst in Pregnancy"

Objective: 

This case is reported due to the rarity and complexity of managing a large, twisted ovarian dermoid cyst during pregnancy, where both maternal and fetal well-being must be carefully balanced. Ovarian torsion is a surgical emergency, and its occurrence in pregnancy poses significant diagnostic and therapeutic challenges. This case highlights the successful use of laparoscopic surgery in the second trimester, demonstrating its feasibility, safety, and advantages over open surgery in reducing postoperative morbidity and ensuring favorable maternal and fetal outcomes. By sharing this experience, we aim to raise awareness, discuss optimal management strategies, and contribute to the growing body of evidence supporting minimally invasive surgery for ovarian torsion in pregnancy.

Case Report:

A 28-year-old primigravida at 18 weeks of gestation was admitted to the antenatal ward with severe lower abdominal pain, progressive abdominal distension, and an inability to sit. The pain was unrelenting and did not respond to analgesia.

An urgent abdominal ultrasound revealed a large ovarian dermoid cyst, approximately 20 cm in size, with evidence of torsion. Given the acute presentation and the risk of compromised ovarian blood supply, the patient was taken for emergency laparoscopy for ovarian cystectomy or oophorectomy.

Intraoperative Findings and Management

During laparoscopy, attempts were made to remove the cyst using an endobag; however, due to its large size, manipulation led to cyst rupture. Generous peritoneal lavage with saline was performed to minimize the risk of chemical peritonitis.

Postoperative Course and Complications

Despite extensive peritoneal irrigation, the patient developed severe peritonitis with intestinal obstruction on the second postoperative day. The surgical team was consulted, and an emergency laparotomy was performed to manage the obstruction. She was subsequently transferred to ITU for postoperative care. She was discharged home in good health after one week.

Discussion:

Large dermoid cysts pose a high risk of rupture during manipulation, especially in a laparoscopic setting. Spillage of sebaceous material can lead to severe chemical peritonitis, as seen in this case. To minimize this risk, preoperative planning should include consideration of controlled cyst decompression or alternative surgical techniques to ensure safe removal. While maternal recovery in this case was ultimately uneventful, surgical complications in pregnancy can increase the risk of preterm labor, fetal distress, and maternal morbidity.

Conclusion:

This case highlights the challenges associated with laparoscopic management of large, twisted ovarian dermoid cysts during pregnancy, particularly the risk of cyst rupture and chemical peritonitis.