Cystic duct cyst: Need for new classification ?

Aim-Background

Choledochal cysts are rare entities presenting as cystic dilatations of the biliary tree. Even though their origin is uncertain, they are usually referred for removal because of malfunction of the biliary tract as well as their association with developing malignancy. Traditionally, these choledochal cysts are classified under 5 main types. A condition that is even rarer, the cystic duct cyst, is not included in this classification. We describe such a case of a cyst of the cystic duct that was successfully removed via laparoscopy.

Material-Method

A 32-year-old patient is described who was admitted to the hospital complaining of symptoms consistent with acute cholecystitis and associated with signs of biliary tract obstruction. Following imaging investigation with MRI, a cystic duct malformation was revealed and further surgical treatment was planned.

Results-Conclusion

Our case shows that even though cystic duct cysts are extremely rare, they are a clinical entity that cannot be ignored and needs to be recognized. Given the existence of similar case reports in literature and the similarity of cystic duct cysts with other choledochal cysts, a new category in the Todani classification may be considered so that clinicians are prepared for this ‘Type VI’ cystic variant.     

Hepatobiliary rhabdomyosarcoma mimicking choledochal cyst: Lessons learned

INTRODUCTION

The differential diagnosis of hepatic cystic lesions is a challenging process especially in case of hepatic rhabdomyosarcoma (HRMS) presenting as hepatic cyst.

PRESENTATION OF CASE

We introduce our experience with a case of HRMS in a 3-year-old female patient who was misdiagnosed to have type IV-A choledochal cyst and definitive correct diagnosis was reached after the pathological and immunohistochemical examination of the surgically resected lesion. This case presentation is followed by important practical messages to hepatobiliary surgeons regarding HRMS.

DISCUSSION

HRMS is a rare pediatric tumor. Jaundice is the most common presentation of HRMS followed by abdominal pain and vomiting. Great effort is needed to differentiate the tumor from choledochal cyst and infectious hepatitis. Through evaluation using available imaging studies together with clinical anticipation is mandatory for establishing the correct diagnosis.

CONCLUSION

Differentiation of HRMs from choledochal cyst mandates through evaluation and clinical anticipation. HRMS should be suspected in any child with obstructive jaundice. Once diagnosis is established, multidisciplinary treatment is the best management strategy and it has proved better surgical outcome and long term survival.     

Aberrant Presentation of the Gallbladder During Laparoscopic Cholecystectomy

Background:

Aberrant gallbladder transposed to the left side is a rare congenital anomaly that has been seen in as many as 0.7% of the population. These gallbladders are situated under the left lobe of the liver between Segment III and IV and to the left of the falciform ligament. Many preoperative studies fail to identify the anomaly, causing confusion to the surgeon during laparoscopic resection. Selective use of intraoperative cholangiography and meticulous dissection can aid in safe resection.

Methods:

A 61-year-old female was admitted with ultra-sound confirmation of cholecystitis and subsequently taken to the operating room for a laparoscopic cholecystectomy.

Results:

Evaluation of the gallbladder under laparoscopic view revealed an inflamed left aberrant gallbladder. An intraoperative cholangiogram was obtained to delineate the biliary anatomy that showed the cystic duct entering the common hepatic duct on the right side.

Conclusion:

A left aberrant gallbladder is a rare presentation that requires awareness of biliary anatomy and selective use of intraoperative cholangiography to aid in the safe laparoscopic resection of the gallbladder.     

Thoracic Myelopathy Secondary to Intradural Extramedullary Bronchogenic Cyst

Background/Objective:

To report a case of thoracic myelopathy secondary to intradural extramedullary bronchogenic cyst.

Study Design:

Case report.

Methods/Findings:

A 20-year-old man presented to the emergency department with increasing back pain and lower-extremity weakness. Magnetic resonance imaging demonstrated a cystic lesion at the T4 level with mass effect on the spinal cord.

Results:

The lesion was resected, and histopathologic evaluation showed a cyst lined by respiratory-type epithelium consistent with a bronchogenic cyst.

Conclusions:

Intradural extramedullary bronchogenic cysts of the thoracic spine have been reported previously but are extremely rare. The treatment of choice is surgical resection.     

Villous Mucinous Cystadenoma of the Appendix in a Postmenopausal Woman

Objective:

To present the case of a postmenopausal woman, who was suspected of having an ovarian cyst. Instead, a cystadenoma of the appendix was discovered during laparoscopy.

Methods:

A 64-year-old postmenopausal nulliparous woman was admitted to our hospital because of a cystic lesion, which had been detected in the course of a routine gynecological examination. The patient underwent vaginal ultrasound, magnetic resonance tomography, and laparoscopy.

Results:

During vaginal ultrasound, a dumbbell-shaped anechogenic cystic structure 70 × 32 × 22 mm in diameter was found in the region of the right adnexa. Magnetic resonance tomography revealed no additional information. During diagnostic laparoscopy, the cystic lesion was found to be a distended appendix. A laparoscopic appendectomy was performed. Subsequent histological analysis revealed a villous mucinous cystadenoma of the appendix with low-grade intraepithelial neoplasia.

Conclusion:

Gynecologists should routinely consider this disease in the differential diagnosis of right lower dumbbell abdominal cysts. Eleven percent to 20% of mucoceles are caused by mucinous cystadenocarcinomas, which carry the risk of peritoneal tumor implantation caused by rupture or laparoscopic resection. Therefore, it should be mandatory that a general surgeon be involved in the laparoscopic procedure and the conversion to laparotomy for resection of the structure.     

Initial experience with complex laparoscopic biliary surgery in children: biliary atresia and choledochal cyst

Background

Laparoscopic approaches are possible for many pediatric surgical diseases, including complex biliary disorders. The authors describe their early experience with laparoscopic procedures for biliary atresia and choledochal cysts.

Methods

A retrospective review was performed with Institutional Review Board (IRB) approval of children undergoing laparoscopic Kasai portoenterostomy (n = 2) or laparoscopic excision of a choledochal cyst with Roux-en-y biliary reconstruction (n = 3). The authors report the operative technique for these procedures and present their initial results.

Results

All procedures were performed with 4 to 5 trocars using 3- and 5-mm ports. Excision of the fibrous biliary remnant (biliary atresia) or of the cyst (choledochal cysts) was performed laparoscopically in all cases. The Roux-en-y limb was created through a 1-cm extension of the umbilical port site. Laparoscopic biliary reconstruction was performed successfully in 4 of 5 patients. In one child, the proximal extent of the choledochal cyst was at the bifurcation of the hepatic duct, and the biliary reconstruction was performed via an open incision with separate anastomoses of the right and left ducts. The gallbladder was used as a handle for retraction of the liver for portal visualization, as in a cholecystectomy, and was resected at the end of the procedure. All children with choledochal cysts have normal bilirubin values. One of 2 children who underwent laparoscopic Kasai has a normal postoperative bilirubin level, whereas the other child did not drain bile and underwent a successful liver transplantation. Mean length of surgery was 338 minutes; mean length of stay was 5.5 days. There were no significant postoperative complications. Cosmesis was excellent in all cases.

Conclusions

Laparoscopic approaches for children with biliary atresia and choledochal cysts are possible. Excellent visualization of the portal structures can be achieved laparoscopically with adequate retraction of the liver. Further follow-up is needed to determine broader application.     

A giant adrenal cyst difficult to diagnose except by surgery

Introduction

Adrenal cysts represent rare clinical entities. Although surgical indications are well defined, pitfalls arise from the failure to establish an accurate preoperative diagnosis. Cystic lesions of other abdominal organs especially the pancreas complicate the diagnostic field.

Presentation of case

We present the case of a giant adrenal cyst in a young female causing diagnostic dilemma. Imaging studies revealed a large cystic lesion of uncertain origin located between the spleen and the tail of the pancreas. It was decided to perform a laparotomy which confirmed the presence of an adrenal cyst and enucleation of the cyst was performed. Examination at one year confirmed no complications.

Discussion

Adrenal cysts should always be included in the differential diagnosis of cystic abdominal lesions.

Conclusion

When the preoperative diagnosis is uncertain, surgical intervention can be both diagnostic and therapeutic.     

Total Laparoscopic Roux-en-Y Cholangiojejunostomy for the Treatment of Biliary Disease

Background and Objectives:

Roux-en-Y cholangiojejunostomy (RCJS) has been widely used in biliary bypass surgeries, but in most reported literature, an assisted mini-incision was needed, and studies reporting total laparoscopic Roux-en-Y cholangiojejunostomy (TLRCJS) are rare. The goal of this study was to investigate how to treat hepatic portal bile duct diseases and perform jejunojejunostomy and cholangiojejunostomy totally laparoscopically. We evaluated the feasibility of TLRCJS in treating biliary tract diseases.

Methods:

TLRCJS were performed in 103 patients from January 2000 to August 2011. There were 28 cases of recurrent choledocholithiasis combined with stricture of the common bile duct (CBD) after several stone extractions, 3 patients with iatrogenic bile duct injury, 24 patients with choledochal cyst, 36 patients with hepatic portal cholangiocarcinoma, and 12 patients with cancer of the pancreatic head and periampullary cancer. All surgeries were performed through 5 trocars. First, laparoscopic surgery on the CBD was performed according to the original disease. The CBD was opened and stones were extracted in choledocholithiasis patients. In iatrogenic injury patients, strictured CBD was resected and repaired. Dilated CBD or choledochal cyst with tumor was transected. In patients with malignant jaundice, the CBD was opened longitudinally. At the same time, the bile duct was prepared for cholangiojejunostomy. Second, the positions of the laparoscope and surgeons were altered. The jejunal mesentery and jejunum were transected, and side-to-side jejunojejunostomy (JJS) was performed. The laparoscope and surgeon positions were exchanged again; the Roux-en-Y biliary limb was lifted close to the residual bile duct; and side-to-side or end-to-side choledochojejunostomy (CJS) was performed. Finally, an abdominal drainage tube was placed.

Results:

All the surgeries were performed successfully. The diameter of the residual bile duct ranged from 0.4 to 3.2 cm (average, 0.9 cm). Three patients had postoperative bile leakage and were treated from 1 week to approximately 1 month with abdominal drainage. Postoperative intraperitoneal hemorrhage and stress ulcer of the stomach occurred in 2 patients with biliary tract injury combined with obstructive jaundice. One with intraperitoneal hemorrhage was cured by another laparoscopic surgery. The other patient was cured after 2 days of abdominal drainage, antacids, and hemostatic drug therapy. The follow-up duration of 95 patients was 4 to 93 months (average, 48.3 months). The follow-up rate was 92.2% (95/103). Patients with cancer died of metastasis or cachexia during 14-month follow-up with no postoperative complication. Reflux cholangitis occurred in 3 patients 2, 3, and 5 years after the operation, respectively. No anastomotic stricture or other complication was found in other patients during the follow-up.

Conclusions:

TLRCJS is the best and first choice for patients with biliary tract diseases that need biliary-jejunal anastomosis. But it is essential that the surgeon has proficiency in laparoscopic surgeries.     

Laparoscopic Spleen-Preserving Distal Pancreatectomy in a Solitary True Pancreatic Cyst

Background:

Solitary true pancreatic cysts (STPCs), or epithelial cysts, are benign lesions that are extremely rare in adult patients. Advances in radiographic techniques have improved the ability to identify pancreatic cystic lesions. We report a case of a large and symptomatic STPC in a 47-year-old female patient who was treated successfully with spleen-preserving laparoscopic distal pancreatectomy. We also review the clinical and pathologic features of all reported STPCs within the past 25 years.

Database:

To compose the review, we did a search of the international literature for STPCs that had occurred in adults. Fourteen related articles were found describing cases of STPCs. Clinical and pathologic information was collected for all of the reported pancreatic cysts, and a database was formed. STPCs are detected more frequently in women than in men. The mean age of occurrence is 43.2 years, and the mean cyst size is 5.6 cm. Fifty percent of true cysts are located in the head of the pancreas. Size and site are responsible for the symptoms caused, although 22.8% were asymptomatic. Diagnosis was made postoperatively in all cases by histopathologic studies. No case of malignancy was reported in any STPC.

Conclusions:

STPCs are rare and benign lesions commonly discovered incidentally during abdominal imaging. Surgical treatment is considered the appropriate therapy for large and symptomatic STPCs. The definitive diagnosis is established by histopathologic and immunohistochemical studies.     

Management of cervical thoracic duct cyst with cyst-venous anastomosis

INTRODUCTION

Cervical thoracic duct cyst (CTDC) is a rare cause of lateral neck mass. Surgical excision with ligation of the cervical thoracic duct is the current standard for definitive management with symptomatic patients. We report the first case of an alternative method of management performing a cyst venous anastomosis for decompression.

PRESENTATION OF CASE

A 77 year old female presented with a six month history of left arm pain, swelling and a left-sided cystic neck mass. She was treated with cyst-venous anastomosis between the cyst wall and the left internal jugular vein. At two year follow-up, she has had resolution of pain and no recurrence of the mass.

DISCUSSION

Many potential etiologies have been proposed for CTDC, though surgical management of this rare problem has consistently required cyst excision and thoracic duct ligation. Few innovative modes of therapy have been developed to address this problem in a less invasive manor. Maintaining a more natural thoracic duct anatomy decreases the likely of complications associated with duct ligation.

CONCLUSION

Cyst-venous anastomosis for the management of CTDC provides an effective, novel form of treatment which maintains the integrity of the thoracic duct and avoids potential complications associated with duct ligation.     

How to Build a Simple and Safe Laparoscopic Hydatid Evaluation System

Background:

One of the most common problems faced in laparoscopic treatment of hydatid cysts is the difficulty in evacuating the particulate contents (daughter cysts and laminated membrane). Although various instruments and laparoscopic techniques have been described to evacuate the contents of hydatid cysts, most are not available at many surgical centers.

Methods:

By assembling disposable, cheap, and available anesthesia equipment with common laparoscopic instruments, a laparoscopic system was made to evacuate the contents of a hydatid cyst. Ten patients with hepatic hydatid disease underwent laparoscopic surgery using this new hydatid system between June 2011 and January 2013.

Results:

The procedure was completely straightforward. Twelve hydatid cysts (2 patients had 2 separated cysts) were evacuated without any spillage. All patients were followed for at least 8 months, with no evidence of recurrence.

Conclusions:

This simple apparatus, which can be assembled anywhere, was safely used to evacuate the contents of hydatid cysts without causing any spillage.     

Laparoscopic correction of biliary duct stenosis in choledochal cyst

Background/Purposes

Laparoscopy has been widely accepted as a technique for the excision of choledochal cyst, but there has been little experience using it as a therapeutic modality for hepatic duct stenosis. The aim of this study is to present our experiences in laparoscopic excision of biliary stenosis and Roux-en-Y reconstruction for patients with choledochal cysts.

Methods

Eight patients, 3 boys and 5 girls (ranged from 6 months to 12 years; median age, 3.6 years), with hepatic duct stenosis underwent laparoscopic excision of the cyst and ductoplasty, with a Roux-en-Y hepaticoenterostomy between July 2001 and January 2005. Seven of the 8 patients had common hepatic duct stenosis with intrahepatic duct dilatation, and 1 had right hepatic duct stenosis with proximal dilatation.Four ports were inserted for instruments of 3- and 5-mm sizes. Each patient underwent a laparoscopic cholangiography. The gallbladder and dilated bile ducts were completely excised. The strictures of the hepatic ducts were treated by ductoplasty. The cut end of the duct was widened by incising along the anterior wall of the hepatic duct after excision of the narrow segment. By using intraoperative bile duct endoscopy, the optimal level of resection of the common hepatic duct was determined safely without endangering the orifices of the hepatic ducts or leaving any redundant duct, and the stone debris in the bile duct was identified and washed out. The Roux-en-Y jejunal loop was fashioned extracorporeally by exteriorizing the jejunum through the umbilical incision (1.0-1.5 cm) and passed up retrocolically followed by an end-to-side hepaticojejunostomy.

Results

The median duration of the operation was 4.3 hours (3.8-5.6 hours). Intraoperative bleeding was minimal, with no patients requiring blood transfusion. In 7 of the 8 cases, postoperative hospital stay ranged from 4 to 6 days; the other case had bile leak, which was cured by draining for 26 days without surgical intervention. All the patients had been followed up for 6 to 51 months. They stayed asymptomatic and well with no delayed complication.

Conclusions

Laparoscopically assisted hepatic ductoplasty is effective and safe for children with choledochal cyst. Bile duct endoscopy proved to be a valuable instrument in showing detailed variations of the biliary system and allowed a safe hepatic hilum exploration and accurate placed hepaticojejunal anastomosis.     

Solitary liver cysts in children: not always so simple

Aim

Liver cysts in children are uncommon. Many are simple and solitary and do not require intervention. However, this series demonstrates a broad range of potential pathologies, some of which are life-threatening.

Methods

All children referred to our unit during an 8-year period (1998-2005) and found to have a solitary liver cyst were prospectively recorded. Clinical, radiologic, and pathologic features were analyzed. Children with an isolated extrahepatic choledochal cyst and polycystic disease were excluded.

Results

Twenty-one children with a liver cyst were identified. Two had undergone unsuccessful surgical intervention before referral. There were 11 prenatally detected cysts. Median gestational age at detection was 22 weeks (19-35 weeks); only 1 was specifically characterized as a liver cyst prenatally. Six of these required surgery: 2 large simple cysts, 2 intrahepatic choledochal cysts, 1 giant complex biliary cyst causing respiratory distress, and 1 ciliated hepatic foregut cyst. Of the 5 cysts remaining under ultrasound surveillance, 4 decreased in size or resolved. In 10 children presenting between birth and 15.8 years, a liver cyst was diagnosed postnatally: 3 huge cystic mesenchymal hamartomas, 1 type V choledochal cyst, 1 hydatid cyst, and 5 simple cysts. Four of these required surgical resection. Simple cysts tended to be small and could be distinguished from other pathologies using a combination of imaging techniques (ultrasound, magnetic resonance imaging/magnetic resonance cholangiopancreatography [MRCP], radionuclide scan). Only 2 of 12 children with “simple” cysts required surgery for symptoms. However, a wide range of other cyst pathologies were found in 9 children, and although none was malignant, some were life-threatening and 7 required resection.

Conclusions

Simple solitary nonparasitic liver cysts rarely cause symptoms or require surgery, but the pediatric surgeon should be aware of the wide range of other types of liver cyst in children to ensure appropriate treatment.     

Paraovarian Cysts of Neoplastic Origin Are Underreported

Introduction:

We suspected that paraovarian cysts of neoplastic origin may be underreported. This study was designed to evaluate our data on the pathologic characteristics of cystic lesions located in the paraovarian area and compare them with previous studies that claimed the vast majority of these lesions were simple paraovarian cysts and only few (1.69% to 5%) were neoplastic ones.

Methods:

This is a retrospective analysis of the clinical, surgical, ultrasonographic, and pathologic features of 59 women operated on for cystic paraovarian lesions at our institution from January 2002 to April 2006.

Results:

Forty-four women (74.6%) had simple paraovarian cysts, and 15 (25.4%) had benign neoplastic paraovarian cysts (7 cystadenomas and 8 cystadenofibromas). There were no cases of malignant tumor. There was no difference in the clinical presentation of the women with either type of cyst. Preoperative ultrasound examinations (n=50) demonstrated more complex cysts with internal papillary projections in the group with neoplastic paraovarian cysts (41.7% compared with 7.9%, P=0.01). The macroscopic pathologic examinations revealed a significantly increased percentage of gross papillary excrescences in the group of neoplastic paraovarian cysts (10/ 15, 66.7%) compared with the group with simple paraovarian cysts (3/44, 6.8%, P<0.01). Other pathologic features did not differ between the 2 study groups.

Discussion:

Our analysis revealed a higher percentage of paraovarian cysts of neoplastic origin (∼25%) than the figures quoted in most previous reports.

Conclusion:

Intraoperative inspection for diagnosing the cyst type and more frequent use of endobag devices to avoid spillage of cystic fluid are recommended.     

Laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in symptomatic neonates

Purpose

Choledochal cysts require surgical excision, preferably before the onset of cholangitis. Recently, it has become feasible to accomplish the excision laparoscopically in adults and older children. Yet, whether laparoscopic excision of choledochal cyst can be performed safely in symptomatic neonates with choledochal cyst is unclear. We herewith reviewed our experience of laparoscopic excision of choledochal cysts in neonates.

Methods

We managed 9 neonates with choledochal cysts between April 2003 and February 2007. The choledochal cysts were excised laparoscopically. The Roux-en-Y hepaticojejunostomy was fashioned extracorporeally by exteriorizing the jejunum through the extended umbilical port site. End-to-side anastomosis between the common hepatic duct stump and Roux loop was carried out intracorporeally. The patients were followed up for an average of 26 months.

Results

The patients presented with jaundice, pale stool, and deranged liver function tests. The diagnosis was confirmed with ultrasonography postnatally. The median operation time was 3.6 hours. There was no operative complication and no conversion. The blood loss was minimal. The recovery was uneventful, and the median hospital stay was 6 days. The liver function tests normalized 3 to 16 weeks postoperatively. No complication was detected at the follow-up visits.

Conclusions

Our preliminary results show that laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in neonates is both feasible and safe. It curtails further complication of the cysts and reverses the derangement of liver function. In addition, the laparoscopic approach minimizes surgical trauma.     

Giant chylolymphatic mesenteric cyst and its successful enucleation: A case report

INTRODUCTION

Cysts of the mesentery are among surgical rarities. The clinical presentation is not characteristic and in addition, the preoperative imaging although suggestive is not diagnostic in this case ultrasound and CTscan was consistent with giant mesenteric cyst. In most cases, the diagnosis is confirmed after surgical exploration.

PRESENTATION OF CASE

A 42 yrs old male patient on exploratory laparotomy had a 14cm×10cm×10 cm cysts which was seen arising from the mesentery ofdistal jejunum 80cm from the duodeno jejunal flexure. The cyst was enucleated successfully from themesentery without entailing resection. The cyst contained milky white fluid consistent with a chylolymphatic cyst. The diagnosis was confirmed on histopathology which revealed a cyst wall with lymphoidaggregates. After 3 years of follow-up, the patient is doing well and there is no evidence of recurrence.

DISCUSSION

The cysts may be asymptomatic or maymanifest with abdominal pain, distension lump or intestinal obstruction. Our patient was symptomatic with mild and long standing abdominal pain. The definitive diagnosis of these lesions is difficult prior to surgical exploration as there are no pathognomonic symptoms or characteristic imaging findings.

CONCLUSION

Cysts of the mesentery are among surgical rarities. In most of the cases the diagnosis is confirmed after surgical exploration and removal of thecyst. We would like to emphasize the importance of successful enucleation of the cyst irrespective of its size due to its independent blood supply as opposed to enterogenous cyst which requires bowel resection and anastomosis.     

Laparoscopic removal of a large ovarian mass utilizing planned trocar puncture

Background:

Large cystic ovarian masses pose technical challenges to the laparoscopic surgeon. Removing large, potentially malignant specimens must be done with care to avoid the leakage of cyst fluid into the abdominal cavity.

Case:

We present the case of a large ovarian cystic mass treated laparoscopically with intentional trocar puncture of the mass to drain and remove the mass.

Discussion:

Large cystic ovarian masses can be removed laparoscopically with intentional trocar puncture of the mass to facilitate removal without leakage of cyst fluid.     

Pandora's box and retrorectal tumors in laparoscopy: A case report and review of the literature

INTRODUCTION

Retrorectal tumors are uncommon and the etiology diverse. Literature to define the preoperative diagnosis and plan the intraoperative management are uncommon.

PRESENTATION OF CASE

We describe a case of a 44 year old patient with a laparoscopic approach for the removal of a retrorectal tumor and emphasize on the preoperative diagnostics and the intraoperative, minimal invasive approach.

DISCUSSION

Especially because these tumors are rare and often an incidental finding in gynecologic surgery, it is important to know the various differential diagnoses and its consequences with the laparoscopic approach.

CONCLUSION

We suggest the laparoscopic approach in cases of retroperitoneal cysts of unknown origin is ideal also because anatomic structures, mostly nerves, can be easily spared.     

Laparoscopic management of chemical peritonitis caused by dermoid cyst spillage

Background:

Dermoid cyst is the most frequent benign ovarian tumor. Spillage of cyst contents during surgery is common and can rarely lead to chemical peritonitis.

Case Report:

A patient presented 3 days after attempted laparoscopic removal of bilateral dermoid cysts. On examination, she had a low-grade fever, rebound tenderness with guarding, and a markedly elevated white blood cell count. A decision was made to proceed with laparoscopy with the presumptive diagnosis of chemical peritonitis. Laparoscopic findings included residual dermoid cyst contents and extensive filmy adhesions of the bowel and omentum to the peritoneal surface. The chemical peritonitis resolved after laparoscopic removal of residual dermoid cyst content including bilateral salpingo-oophorectomy and copious irrigation.

Conclusion:

Early recognition and prompt treatment by repeat laparoscopic surgery with removal of the remaining cyst contents and peritoneal lavage can be a successful method for treating chemical peritonitis.