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J Ped Surg Case Reports 3 (2015) 239e241

Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports .com

Minimal laparotomy management of a giant ovarian cystic teratomain adolescence

Toshihiro Yasui a,*, Tatsuya Suzuki a, Fujio Hara a, Shunsuke Watanabe a,Hirokazu Tomishige b, Naoko Uga a, Atsuki Naoe a

aDepartment of Pediatric Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 4701192, JapanbDepartment of Surgery, Banbuntane Houtokukai Hospital, Fujita Health University School of Medicine, 3-6-10 Otobashi Nakagawa-ku, Nagoya, Aichi4548509, Japan

a r t i c l e i n f o

Article history:Received 2 February 2015Received in revised form14 April 2015Accepted 14 April 2015

Key words:AdolescenceGiant ovarian tumorMinimal laparotomy

* Corresponding author. Tel.: þ81 562 93 9247; fax:E-mail address: t-yasui@fujita-hu.ac.jp (T. Yasui).

2213-5766/� 2015 The Authors. Published by Elsevierhttp://dx.doi.org/10.1016/j.epsc.2015.04.006

a b s t r a c t

Giant ovarian cysts in adolescents are very rare. Those treatment by laparotomy or laparoscopic surgeryis discussed with gynecologists and pediatric surgeons because its limited working space and risk ofrupture and malignancy. We present a case of minimal laparotomy management of a giant ovarian cysticteratoma in adolescent. A 13-year-old girl presented with abdominal pain and constipation. A CT scanshowed a giant simple ovarian cystic tumor in her abdomen measuring 29 � 13 � 24 cm. We made a 3-cm Pfannenstiel incision and inserted an Alexis wound retractor XS. The cyst was completely aspiratedwithout spillage in the intraperitoneal space. In total, 6L of murky brown fluid was aspirated from thecyst. There was no ovarian tissue visible on the cyst wall. The left tube and right ovary and tube wereintact. The cyst wall and left ovary tube were dissected free by using a LigaSure. Postoperative recoverywas uneventful. Pathological assessment revealed a mature cystic teratoma. The ovarian tissue wasincluded in the part of the cyst wall. We were able to safely performwith minimal laparotomy. Therefore,we consider the for cases of giant ovarian tumors, minimal laparotomy surgery is useful from the safetyand cosmetic perspective.� 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND

license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Giant ovarian cysts, which are over 15 cm or occupy the entireperitoneal cavity in adolescents, are very rare. Its incidence is 2.6per 100,000 [1]. Whether such cysts should be treated by lapa-rotomy or laparoscopic surgery is currently discussed with gyne-cologists and pediatric surgeons because of limited working spaceand the risk of rupture and malignancy. We present a case of agiant ovarian mature teratoma treated by minimal laparotomywithout any complications.

1. Case report

A 13-year-old girl presented with abdominal pain and con-stipation. An abdominal X-ray showed an abnormal gas pattern,and she was referred to our hospital. Abdominal ultrasound

þ81 562 93 1951.

Inc. This is an open access article u

showed cystic mass and abdominal computed tomography (CT)scan showed a giant simple ovarian cystic tumor in her abdomenmeasuring 29 � 13 � 24 cm. The same findings were observed oncontrasted CT scan (Fig. 1a and b) and magnetic resonance im-aging (MRI). The tumor markers alpha-fetoprotein (AFP) was1.1 ng/mL, beta-human chorionic gonadotropin (b-hCG) was lessthan 0.1 mg/mL, and carbohydrate antigen 19-9 (CA19-9) was35.1 U/mL. They were almost normal except for CA125 (120.5 U/mL). Given that the tumor surface was smooth and other ma-lignancy risks of invasion and lymph node metastasis were notpresent, we consider that the tumor was benign and planed anoperation (Fig. 2).

We made a 3-cm Pfannenstiel incision and inserted an Alexiswound retractor XS (Applied medical systems, USA). We locatedthe cyst wall and directly punctured it with a 19-G elaster needle(Hakko, Japan). After the content of the cyst was shortlyaspirated, a horizontal mattress suture was placed and a14Fr Foley catheter was inserted. The cyst was completely aspi-rated without spillage in the intraperitoneal space. In total, 6L of

nder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Fig. 1. (a) Contrasted CT scan image. Most of the tumor occupy with cyst in part of calcification (*). (b) Tumor occupy her peritoneal cavity.

T. Yasui et al. / J Ped Surg Case Reports 3 (2015) 239e241240

murky brown fluid was aspirated from the cyst. The cyst wasextracted from the intraperitoneal space. We noted that the cystarose from the left ovary; however, there was no ovarian tissuevisible on the cyst wall. The left tube and right ovary and tubewere intact. The cyst wall and left ovary tube were dissectedfree by using a LigaSure (Covidien Surgical Solution, Japan)(Fig. 3a and b).

The operative time was 207 min and blood loss was 65 g. Therewas no complication.

Postoperative recovery was uneventful and the patient wasdischarged on the fifth postoperative days without any problem.Pathological assessment revealed a maturecystic teratoma con-taining the thyroid gland, bone and lipid (Fig. 4a and b). The ovariantissue was included in the part of the cyst wall. No problems weredetected at the 6-month postoperative follow-up visits (Fig. 5),CA125 levels had normalized (6.9 U/mL) and her menstruation wasregular.

Fig. 2. Patient on operating room table.

2. Discussion

A giant intraabdominal cyst in pediatrics and adolescentpatients is derived from ovarian, gastrointestinal, urological andlymphatic tissue. A giant ovarian cyst is a very rare occurrence, withan incidence of 2.6 per 100,000 among individuals aged less than 15years [1e6]. However some reports have described giant ovariancysts over 15 cm, while another report has indicated that the cystcould occupy the entire peritoneal cavity [1]. Some author hasdefined it as reaching above the level of the umbilicus [7].

Laparoscopic surgery is the golden standard for the manage-ment of benign ovarian tumors [8,9]. However, this is still underdiscussion because laparoscopic surgery of giant ovarian tumors foradolescents has to be performed in a limited space within theperitoneal cavity and there is a risk of rupture and spillage [10]. Inaddition, the risks of malignancy can be ruled out on the basis ofhistory, laboratory data, and images data before performing lapa-roscopic surgery [11]. In our case, we considered that the risk ofmalignancy was very low on the basis of the findings of CT imagesand tumor markers except for CA125.

For the management of giant ovarian cysts, it is necessary toabsorb the liquid contents. In laparotomy and laparoscopic surgery,care should be taken to avoid rupture and spillage. In recent years,some researchers reported they performed this safely using ultra-sonography [2,5,6]. Most of the cases were removed tumor fromminimal laparotomy or umbilical incision [1,2,5,6] and Murawskiand Kilincaslan et al. used preserving bag [5,6]. In this case, weopted for minimal laparotomy. Because it was necessary to removethe giant tumor out from the intraabdominal cavity, the size ofwound was needed and we didn’t need any other port incisions toovariectomy. It should have been very difficult to put the largetumor into the preserving bag. The use of the wound retractorenabled this and there was only on incisional scar, which isadvantageous from the cosmetic perspective.

To ensure fertility, it is appropriate to perform tumor enucleationinpediatric andadolescent patients.However, in this case, theovariantissue was part of the cyst wall. I guessed operative rapid pathologicdiagnosis method was one of the ways to avoid an ovariectomy. Butthis could be left the ovary tissue, this might leave other tumor tissueon the other hand: thus, tumor enucleation was very difficult.

Fig. 3. (a) The giant cyst was drained and taken out from the abdomen through the Pfannenstiel incision. (b) Appearance of the giant ovarian cyst inflated with water after itsremoval.

Fig. 4. (a) A picture of the pathology. Thyloid (*), lipid (※) and glandular tissue (＃) have been seen. (b) A graafian follicle was included in the part of the cyst wall.

Fig. 5. The operative wound 6 months after surgery (4 cm).

T. Yasui et al. / J Ped Surg Case Reports 3 (2015) 239e241 241

3. Conclusion

We were able to safely perform with minimal laparotomy.Therefore, we consider the cases of giant ovarian tumors, minimallaparotomy surgery is useful from the safety and cosmeticperspective.

References

[1] Dolan MS, Boulanger SC, Salameh JR. Laparoscopic management of giantovarian cyst. JSLS 2006;10(4):548e9.

[2] Ates O, Karakaya E, Hakguder G, Olguner M, Secil M, Akgur FM. Laparoscopicexcision of giant ovarian cyst after ultrasound-guided drainage. J Pediatr Surg2006;41(10):E9e11.

[3] Shapiro EY, Kaye JD, Palmer LS. Laparoscopic ovarian cyst in children. Urology2009;73(3):526e8.

[4] Coccia ME, Rizzello F, Bracco GL, Scarselli G. Seven-liter ovarian cyst in anadolescent treated by minimal access surgery: laparoscopy and open cys-tectomy. J Pediatr Surg 2009;44(6):E5e8.

[5] Murawski M, Golebiewski A, Sroka M, Czauderna P. Laparoscopic managementof giant ovarian cysts in adolescents. Wideochir Inne Tech Malo Inwazyine2012;7(2):111e3.

[6] Kilincaslan H, Cipe G, Aydogdu I, Sarac F, Toprak H, Ari E. Pure laparoscopicmanagement of a giant ovarian cyst in an adolescent. Am J Case Rep 2014 Jan7;15:4e6.

[7] Eltabbakh GH, Charboneau AM, Eltabbakh NG. Laparoscopic surgery for largebenign ovarian cysts. Gynecol Oncol 2008;108(1):72e6.

[8] Shawki O, El Sadek M, Soliman I, Bahnassy A, Ebrashy A. Laparoscopicmanagement of ovarian dermoid cysts. Middle East Fertil Soc J 2004;9(1):58e65.

[9] Kocak M, Dilbaz B, Ozturk N, Dede S, Altay M, Dibaz S, et al. Laparoscopicmanagement of ovarian dermoid cysts: a review of 47 cases. Ann Saudi Med2004;24(5):357e60.

[10] Ye LY, Wang JJ, Liu DR, Ding GP, Cao LP. Management of giant ovarian tera-toma: a case series and review of the literature. Oncol Lett 2012;4(4):672e6.

[11] Chapron C, Dubuisson JB, Fritel X, Rambaund D. Diagnosis and management oforganic ovarian cysts: indications and procedures for laparoscopy. HumReprod Update 1996;2(5):435e46.