Minimally invasive, fertility-sparing surgical management of multiple bilateral ovarian dermoid cysts

To study a fertility-sparing, minimally invasive surgical approach to numerous bilateral ovarian dermoid cysts, emphasizing techniques that preserve ovarian tissue and minimize electrosurgical injury.

Surgical video demonstration.

A 25-year-old nulligravid woman presented with pelvic pain. Pelvic ultrasound demonstrated multiple, bilateral heterogeneous cystic ovarian masses. Magnetic resonance imaging was obtained for surgical planning. The patient included in this video provided consent for publication of the video and posting of the video online. including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and so forth.) and other applicable sites. Institutional review board approval was not required for this case report per institutional policy; patient consent was obtained as noted above. Preoperative anti-Müllerian hormone was discussed but not obtained preoperatively. Given the bilateral and numerous dermoid burden, the patient is planning oocyte cryopreservation, at which time ovarian reserve will be assessed.

Robot-assisted bilateral ovarian cystectomy. The robotic platform was selected to leverage tremor filtration and articulated instrumentation for delicate dissection in a case with multiple large teratomas; the techniques described remain applicable toconventional laparoscopy.

N/A RESULTS: This video outlines key surgical steps, including strategic robotic port placement for optimal access and identification of the cyst-ovarian interface. Vasoconstrictive infiltration with dilute vasopressin (20 units in 400 mL normal saline) was performed to facilitate hydrodissection of tissue planes and reduce intraoperative bleeding. Blunt dissection was used to develop the correct plane (primarily using cold scissors) with brief, targeted monopolar cut current reserved for vascular tissue to minimize lateral thermal spread. With traction-countertraction techniques facilitated enucleation followed by prompt containment and irrigation in event of spillage. Meticulous hemostasis was achieved using short, targeted applications of monopolar energy with a fine instrument tip to minimize hematoma or fluid collection that could obscure postoperative imaging. The ovarian cortex then was reapproximated with selective suturing. All cysts were excised successfully. The procedure was completed without complication. Pathology confirmed bilateral mature cystic teratomas. The postoperative course was uncomplicated. Postoperative imaging demonstrated normal ovarian morphology, adhesion barriers were not used as the peritoneum remained intact with no exposed raw ovarian surfaces, and the patient was counseled regarding an approximate 5% recurrence risk.

Extensive bilateral dermoid disease does not preclude minimally invasive, fertility-sparing surgery. Even in cases of large and numerous cysts, careful adherence to tissue-preserving principles allows restoration of functional ovarian anatomy. Key strategies include use of vasoconstrictive agents to reduce bleeding and facilitate tissue-plane dissection, prioritizing blunt and hydrodissection, selective suturing for hemostasis, and rapid management of spillage. This approach offers a reproducible framework for reproductive surgeons managing complex bilateral ovarian pathology in patients desiring future fertility.