ORIGINAL ARTICLE: REPRODUCTIVE SURGERY

Mesial side ovarian incision forlaparoscopic dermoid cystectomy:a safe and ovariantissue-preserving technique

Michele Morelli, M.D., Ph.D., Rita Mocciaro, M.D., Roberta Venturella, M.D., Alberto Imperatore, M.D., Ph.D.,Daniela Lico, M.D., and Fulvio Zullo, M.D., Ph.D.

Department of Obstetrics and Gynecology, University ‘‘Magna Graecia’’ of Catanzaro, Catanzaro, Italy

Objective: To evaluate safety and efficacy, in terms of spillage risk and ovarian tissue preservation, of mesial incision for laparoscopicdermoid cystectomy.Design: Randomized controlled trial.Setting: University.Patient(s): Sixty-seven women with dermoid cysts.Intervention(s): Laparoscopic dermoid cystectomy performed by mesial incision (33 patients, study group) or antimesial incision(34 patients, control group).Main OutcomeMeasure(s): Spillage of intracystic content rate, operative times, chemical peritonitis rate, and intraoperative blood loss(DHb) as primary outcomes. Postoperative ovarian reserve (DFSH levels, basal antral follicle number, mean ovarian diameter, and peaksystolic velocity at 3 and 12 months after surgery) as secondary outcome.Result(s): Spillage of intracystic content rate and operative time were significantly lower in the study than in the control group. Nonedeveloped chemical peritonitis.DHb was higher in the study group but not significantly. During the follow-up, median FSH values weresignificantly lower in the study group, with no differences in the E2 levels. Moreover, median basal antral follicle number, medianovarian diameter, and median peak systolic velocity were significantly higher in the study group.

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Conclusion(s): Ovarian mesial-side incision appears to be a safe as well as tissue-sparingtechnique.Clinical Trial Registration Number: NCT01590030. (Fertil Steril� 2012;-:-–-. �2012 byAmerican Society for Reproductive Medicine.)Key Words: Mesial incision, dermoid cyst, spillage risk, ovarian reserve

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D ermoid cysts, also calledmaturecysts teratomas, represent 21%of all ovarian tumors (1) and

are the most common germ cell tumors,with an incidence of 95% (2). This be-nign tumor afflicts principally womanof reproductive age (3) and in 10%–

15% of cases is bilateral (4). Malignancyoccurs in less than 3% and is most fre-quent in postmenopausal women (5).

Received May 2, 2012; revised and accepted July 13,M.M. has nothing to disclose. R.M. has nothing to dis

ing to disclose. D.L. has nothing to disclose. F.ZReprint requests: Fulvio Zullo, M.D., Ph.D., Viale E

(E-mail: zullo@unicz.it).

Fertility and Sterility® Vol. -, No. -, - 2012 0015-Copyright ©2012 American Society for Reproductivehttp://dx.doi.org/10.1016/j.fertnstert.2012.07.1112

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Laparoscopy is considered the goldstandard treatment for dermoid cysts.This approach is associated with a re-duction in fever, urinary tract infection,postoperative complications and pain,hospitalization time, and total costs (6).

Although the standard procedureto enucleate dermoid cysts is repre-sented by an antimesial incision (7),a spillage rate is documented (8–10),

2012.close. R.V. has nothing to disclose. A.I. has noth-. has nothing to disclose.uropa, loc. Germaneto 88100, Catanzaro, Italy

0282/$36.00Medicine, Published by Elsevier Inc.

and it can be as high as 80% (11).After spillage, a chemical peritonitisrate of 0.2% is reported (12).

The identification of an alternativetechnique could be helpful to reducethe spillage risk. According to our expe-rience, considering the greater ovariancortical thickness at the mesial side, in-cision in this area can provide a betteridentification of the cleavage planethus allowing a safer cystectomy. Infact, the greater thickness of the cortexmakes it easier to discriminate the ovar-ian parenchyma from the cystic wall.Moreover, by suspending the wholeovary from its mesial side, the dermoidenucleation is enhanced, thanks to

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ORIGINAL ARTICLE: REPRODUCTIVE SURGERY

gravity and the weight of the cyst itself. In this way, cyst rup-ture and operative times are both reduced in our practice.

Our awareness was related to the close proximity of thesite of incision to the ovarian hilum and to the risk of bipolarcoagulation of larger vessels, even if the need for ovarian cor-tex electrocauterization was globally reduced.

Therefore, the aim of our study was to compare, in a ran-domized fashion, the standard antimesial incision techniquewith mesial incision in laparoscopic dermoid cystectomy interms of surgical outcomes and sparing of ovarian reserve.

MATERIALS AND METHODSThe procedures used during the study were in accordance withthe guidelines of the Declaration of Helsinki on human exper-imentation and of the Good Clinical Practice. The study pro-tocol was approved by the Ethical Committee of theDepartment of Gynecology and Obstetrics, University ‘‘Ma-gna Graecia’’ of Catanzaro, and submitted on the websitefor clinical trial (www.clinicaltrials.gov, identifier number:NCT01590030). The purpose of the protocol was carefully ex-plained to each woman, and a written consent was obtainedfrom them before beginning the study.

Between September 2004 and December 2009, 67 womenwith dermoid cysts underwent laparoscopic cystectomy at theDepartment of Obstetrics and Gynecology of the University‘‘Magna Graecia’’ of Catanzaro, Italy. Five women had bilat-eral dermoid cysts.

Inclusion criteria were reproductive age (18–45 years),preoperative ultrasound findings strongly suggestive forovarian dermoid cyst according to Caspi's diagnostic criteria,and regular menstrual cycles at least 6 months before surgery.Exclusion criteria were previous pelvic surgery, known endo-crine disease, and estrogen-progestin use before surgery.

All patients preoperatively underwent to Ca125 antigenevaluation, FSH and E2 level dosage on day 3 of menstrual cy-cle, and transvaginal ultrasound.

Patients were randomized in two groups, in a 1:1 alloca-tion ratio: 33 underwent laparoscopic cystectomy by mesialincision (study group) and 34 by antimesial incision (controlgroup) on the basis of lists that were created with randomizedpermuted blocks to ensure that, at any point in the trial,roughly equal numbers of participants were allocated to twocomparison groups. The blocks were created by an indepen-dent statistician with a computerized random number gener-ator, containing unique trial numbers. The random allocationsequencewas concealed until the interventions were assigned.

Laparoscopy was performed by pneumoperitoneum withCO2; laparoscopic access was performed with a 10-mm trocarthrough the umbilicus and two lateral ancillary ports, on theleft side by 10-mm trocar and on the right side by 5-mm tro-car. A complete pelvic examination was performed to excludemalignant disease. Ovarian capsule was incised by scissors onthe mesial side in the study group (Fig. 1) and the antimesialside (Fig. 2) in the control group. Particularly, the mesial sideis defined as the anterior, hilar margin of the ovary, where thetubal fimbria is closely applied to the tubal pole of the ovary(Fig. 1A–1C). After cleavage plane identification, the cystenucleation was completed by atraumatic dissection

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(Fig. 1D). Control of hemostasis was achieved using bipolarforceps (40 W), coagulating only the site of bleeding. Thecyst was removed from the abdomen by endo-bag. All surgi-cal procedures were performed by the same surgeon (F.Z.).

In cases of spillage of intracystic content during dissec-tion, a peritoneal washing with lactated Ringer's solutionwas performed, and corticosteroids were administered IV toreduce the risk of chemical peritonitis.

After laparoscopy, all patients were included in a fol-low-up program consisting of a third and twelfth monthassessment of ovarian reserve. Particularly, on days 1–3 ofmenstrual cycles, FSH and E2 dosage was performed. In caseof E2 levels >60 pg/mL, the dosage was repeated 2 monthslater. Then a transvaginal ultrasound examination to assessbasal antral follicle number (all ovarian follicles measuring3–10 mm on the operated ovary were counted), mean ovariandiameter (measured in the largest cross-sectional sagittal viewof the ovary, evaluating the two perpendicular diameters), andpeak systolic velocity (measured by color Doppler ultrasound,on stromal blood vessels away from the ovarian capsuleand utero-ovarian ligament) were performed by the sameblinded experienced ultrasonographer.

For each surgical procedure, operative time, spillage ofintracyst contents, chemical peritonitis rate, and variationof hemoglobin level (DHb) were recorded as primary out-comes. Then ovarian reserve (variation of FSH levels, basalantral follicle number, mean ovarian diameter, and peak sys-tolic velocity) was evaluated as secondary outcome.

Statistical Analysis

The SPSS 19 (Statistical Package for the Social Science; SPSSInc.) statistical program for Microsoft Windows was used forstatistical calculations. For comparing quantitative variablesbetween the study groups, Kruskal-Wallis analysis of ranksand the median test were used for independent samples non-normally distributed. Comparison of categorical data was per-formed using the c2-test. The Yates correction equation wasused instead, when the expected frequency was less than 5.P< .05 was considered statistically significant.

Owing to the lack of published literature about the surgi-cal outcome of our technique, a pilot study was conducted todefine the sample size needed. It was estimated that inclusionof 33 patients in each group was sufficient to consider as sta-tistically significant a difference of at least 20% in spillagerate, with a power of 80% and an a ¼ 0.05. We expectedthat the dropout rate would be 10%; therefore 36 patientswere included in each group.

RESULTSPatients Characteristics

A total of 75patientswere assessed for eligibility. Eight patientswere excluded from the study: five did not meet the inclusioncriteria, two did meet the exclusion criteria, and one refusedthe randomization. At the end, a total of 67 patientswere foundto be eligible and underwent the surgical procedure.

Baseline patients characteristics are presented in Table 1.Therewasno significant difference in any variables considered.

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FIGURE 1

(A and B) In the study group, the ovarian capsule is grasped by two Manhes forceps on the mesial side, defined as the anterior, hilar margin of theovary, where the tubal fimbria is closely applied to the tubal pole of the ovary. (C) The capsule is then incised by scissors. (D) Cyst enucleation iscompleted by atraumatic dissection; by suspending the whole ovary from its mesial side, the dermoid enucleation is enhanced, thanks togravity and the weight of the cyst itself.Morelli. Safety and efficacy of dermoid mesial incision. Fertil Steril 2012.

FIGURE 2

Fertility and Sterility®

All patients had basal FSH levels consistentwith their age.Withrespect to preoperative cysts evaluation, Ca125 assay waswithin the normal range (<35 U/mL) in all patients, and cystdiameter size was homogeneous between groups.

During the follow-up period, six patients dropped out be-cause they had started hormonal contraception, so 31 patientsin the study group and 30 in the control group concludedfollow-up evaluations. Of the six patients lost to follow up,only surgical outcomes were evaluated.

Surgical Outcomes

In all cases the laparoscopic procedure was successfully com-pleted. All surgical outcomes are presented in Table 2. Globaloperative time was statistically (P< .001) shorter in the studygroup than in the control group (48 vs. 76 minutes), as we ex-pected. TheDHbwas slightly higher in the study group than inthe control group (1 vs. 0.8 g/dL), but this difference was nei-ther clinically nor statistically significant.

The overall spillage of intracyst content rate was 11.9%,and it was significantly lower in the study group than inthe control group (3% vs. 20.6%, P< .05). No chemical perito-nitis was developed in case of spillage.

In the control group, the ovarian capsule is incised by forceps on theantimesial side.Morelli. Safety and efficacy of dermoid mesial incision. Fertil Steril 2012.

Ovarian Reserve Evaluations

The median FSH value was significantly lower in the studythan in control group, at the third and twelfth month

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TABLE 1

Basal patient characteristics.

CharacteristicMesial incision(study group)

Antimesial incision(control group)

Pvalue

n 33 34 NSDropout 2 4 NSAge (y) 27 (18–44) 26 (18–45) NSCyst size (mm) 75 (45–140) 81 (32–141) NSCa 125 levels (IU/mL) 12 (3.0–30.2) 11.8 (3.0–34.9) NSBasal FSH levels (IU/L) 6 (3.6–17.9) 6 (3.9–18.8) NSBasal E2 levels (pg/mL) 39 (15–49) 38.7 (21.4–51) NSNote: Data expressed as median (minimum–maximum values) and analyzed using theKruskal-Wallis analysis of ranks. NS ¼ not statistically significant.

Morelli. Safety and efficacy of dermoid mesial incision. Fertil Steril 2012.

ORIGINAL ARTICLE: REPRODUCTIVE SURGERY

follow-up, while there was no significant difference in the E2level (Supplemental Table 1, available online). Particularly,the variation of FSH level was calculated for each patientsby deducting the FSH value of the third month dosage fromthe preoperative one (DFSH 3rd) and by deducting the FSHvalue of the twelfth month dosage from the preoperativeone (DFSH 12th). At the third and twelfth month follow-upvisits, DFSH was significantly lower in the study than in thecontrol group (1.10 vs. 2.86 IU/L, P< .001; and 0.18 vs.2.30, P< .001 at the third and twelfth month for study andcontrol groups, respectively).

Results from ultrasound evaluation about ovarian reserveare reported in Table 2. At the third and twelfth monthfollow-up visits, median basal antral follicle number, medianovarian diameter, and median peak systolic velocity of theoperated ovary were significantly higher in the study groupthan in the control group (Supplemental Table 1).

DISCUSSIONA common complication arising during laparoscopic dissec-tion of ovarian dermoid cysts is the spillage of intracystic con-tent, with a median incidence of 54% (15) and a chemicalperitonitis rate of 0.6% (16). The procedure to reduce the onsetof chemical peritonitis consequent to spillage is the irrigationof the abdominal cavity with lactated Ringer's solution andthe removal of all particles of cyst content. However, the riskof chemical peritonitis is still present and surgical times areincreased.

For the first time, we suggest a technique for dermoid cys-tectomy based on a better identification of the cleavage plane

TABLE 2

Surgical outcomes.

Mesial incision(study group)

Antimesial incision(control group) P value

Operative time (min) 48 (34–90) 76 (35–120) < .001Spillage rate (%) 3 20.6 < .05DHb (g/dL) 1 (0.5–2.0) 0.8 (0.4–1.3) NSNote: Data expressed as number (percentage) and analyzed with the Pearson c2 test, or asmedian (minimum–maximum values) and analyzed using the Kruskal-Wallis analysis of ranks.NS ¼ not statistically significant.

Morelli. Safety and efficacy of dermoid mesial incision. Fertil Steril 2012.

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by ovarian mesial incision. According to our experience, themain advantage of this technique is the reduction in the spill-age rate. The greater ovarian cortical thickness at the mesialside allows a better and easier cleavage plane identification,thus providing a reduced risk of cyst rupture and reducedrisk of bleeding by small vessels of the ovarian wall, eventu-ally requiring minimal electrocauterization. Moreover, de-spite our suspicions to the contrary, this technical proceduredoes prevent ovarian volume reduction due to coincidentaltissue removal and large electrosurgical coagulation, so thatovarian reserve is not compromised in spite of the closenessof the site of incision to the ovarian hilum.

Few studies in the literature discuss the dermoid cystenucleation procedure. Among those, Candiani et al. (13) re-ported a significant reduction in ovarian volume at the ultra-sound assessment after 3 months from laparoscopic standardcystectomy (median percentage of reduction 33%). As re-ported, this result was not related to a reduction in antral fol-licle count and stromal blood flow but could probably beexplained by the short follow-up period (3 months) and bythe high dropout rate (35%) of their study (13). Moreover,in accordance with our hypothesis, Candiani et al. also con-cluded that the main factor responsible for ovarian tissue re-duction was the damage to ovarian stroma. Indeed, Li et al.(14) demonstrated significant reduction in ovarian reserve,expressed by a significant increase in mean FSH value andsignificant decreases in basal antral follicle count, meanovarian diameter, and peak systolic velocity caused byelectocauterization.

Furthermore, the ovarian mesial incision technique,thanks to a faster identification of the cleavage plane, easierenucleation of the cyst, and reduced hemostasis of ovarianparenchyma required, leads to a significant reduction inoperative time.

Nevertheless, the only disadvantage of the proposed tech-nique, which is related to the closeness of the incision to theovarian hilum, could potentially be the increased risk ofbleeding. In our experience, however, DHb was only slightlyhigher in the mesial incision group than in the controlgroup, and neither statistical nor clinical significance wasdemonstrated.

In conclusion, the laparoscopic cystectomy of ovariandermoid by ovarian mesial-side incision is a safe, effective,and ovarian tissue–preserving technique. Therefore,reproductive-age women affected by ovarian dermoid cystsshould be treated with this technique.

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in an adolescent. J Am Board Fam Pract 2002;5:164.2. Tsikouras P, Liberis V, Galazios G, Savidis A, Teichmann AT, Vogiatzaki T,

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3. Kaminski P, GajewskaM,WielgosM, Szymusik I. Laparoscopic managementof dermoid cysts in patients of reproductive age. Neuro Endocrinol Len2006;27:818.

4. Mecke H, Sawas V. Laparoscopic surgery of dermoid cysts intraopera-tive spillage and complications. Eur J Obstet Gynecol Reprod Biol2001;96:80.

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5. Chistopherson WA, Councell RB. Malignant degeneration of a mature ovar-ian teratoma. Int J Gynaecol Obstet 1989;30:379–84.

6. Medeiros LR, Rosa DD, Bozzetti MC, Fachel JM, Furness S, Garry R, et al. Lap-aroscopy versus laparotomy for benign ovarian tumour. Cochrane DatabaseSyst Rev 2009;15(2):CD004751.

7. Eltabbakh GH, Charboneau AM, Eltabbakh NG. Laparoscopic surgery forlarge benign ovarian cysts. Gynecol Oncol 2008;108:72–6.

8. Lin PL, Falcone T, Tulindi T. Excision of ovarian dermoid cyst by laparoscopyand by laparotomy. Am J Obstet Gynecol 1995;173:769–71.

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10. Hessami SH, Kohanim B, Grazi RV. Laparoscopic excision of benign dermoidcysts with controlled intraoperative spillage. J Am Assoc Gynecol Laparosc1995;2:479–81.

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12. Nezhat CR, Kalyoncu S, Nezhat CH, Johnson E, Berlanda N, Nezhat F. Lap-aroscopic management of ovarian dermoid cysts: ten years' experience.JSLS 1999;3:179.

13. Candiani M, Barbieri M, Bottani B, Bertulessi C, Vignali M, Agnoli B, et al.Ovarian recovery after laparoscopic enucleation of ovarian cysts: Insightsfrom echographic short-term postsurgical follow-up. J Min Invasive Gynecol2005;12:409–14.

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SUPPLEMENTAL TABLE 1

Ovarian reserve: postoperative ultrasound evaluation, FSH and E2 levels.

Time Characteristic Mesial incision (study group) Antimesial incision (control group) P value

3-mo follow-up n 31 30 NSBasal antral follicle (n) 6 (4–8) 4 (2–7) < .01Peak systolic velocity (cm/s) 10.1 (8.0–13.2) 8.55 (6.4–11.4) < .01Mean ovarian diameter (mm) 29 (22–35) 25.5 (20–34) < .01FSH levels (IU/L) 7.1 (4.0–18.4) 9.0 (6.0–20.1) < .05E2 levels (pg/mL) 37.5 (21–45.2) 38 (27.3–43) NS

12-mo follow-up n 31 30 NSBasal antral follicle (n) 7 (4–8) 6 (3–8) < .01Peak systolic velocity (cm/s) 10.6 (7.9–13.2) 9.00 (7.4–12.3) < .01Mean ovarian diameter (mm) 28 (21–34) 23.5 (18–32) < .01FSH levels (IU/L) 6.1 (3.7–18.0) 8.45 (5.0–19.5) < .05E2 levels (pg/mL) 37.4 (23–50) 39 (24–51) NS

Note: Data expressed as median (minimum–maximum values) and analyzed using the Kruskal-Wallis analysis of ranks. NS ¼ not statistically significant.

Morelli. Safety and efficacy of dermoid mesial incision. Fertil Steril 2012.

ORIGINAL ARTICLE: REPRODUCTIVE SURGERY

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