Copy of case report today.docx 1 SUBMITTED 16 NOV 22 1 REVISION REQ. 16 JAN 23; REVISION RECD. 13 FEB 23 2 ACCEPTED 7 MAR 23 3 ONLINE-FIRST: MARCH 2023 4 DOI: https://doi.org/10.18295/squmj.3.2023.019 5 6 Protracted Chemical Peritonitis Following Laparoscopy for Dermoid Cyst 7 A management dilemma 8 Miriam G. Fenn,1 Sreedharan V. Koliyadan,2 Lovina Machado,1 Shahila Sheik,2 9 *Nihal Al Riyami3 10 11 Departments of 1Obstetrics & Gynecology and 2Surgery, Sultan Qaboos University Hospital, Muscat, 12 Oman; 3Department of Obstetrics & Gynecology, College of Medicine and Health Sciences, Sultan 13 Qaboos University, Muscat, Oman 14 *Corresponding Author’s e-mail: drriyami@hotmail.com 15 16 Abstract 17 Dermoid cysts are common benign ovarian tumors arising from totipotent germ cells. We report a 18 rare case of chemical peritonitis and prolonged fever following laparoscopic salpingo-19 oophorectomy for torsion of a large ovarian dermoid and discuss the management of this patient 20 with prolonged hospital stay, antibiotics and anti-inflammatory use, repeated drainage of the 21 collection as well as re-laparotomy. The occurrence of this rare condition can be extremely 22 distressing for the patient and treating surgeon alike, as the recommendations for management are 23 limited. The management of chemical peritonitis may require one or more surgical procedures 24 along with prolonged anti-inflammatory therapy. 25 Keywords: peritonitis, dermoid cyst, laparoscopy 26 27 Introduction 28 Dermoid cysts are common benign ovarian tumors arising from totipotent germ cells.1,2 The 29 contents are therefore, very diverse and commonly include sebum, hair, teeth, bone, cartilage, and 30 thyroid tissue. The high fat content causes them to float freely in the abdominal cavity, promoting 31 mailto:drriyami@hotmail.com 2 torsion in 15% of dermoid cysts. Intraperitoneal rupture of a dermoid cyst may lead to chemical 32 peritonitis. Although spillage of cyst contents is fairly common at laparoscopy (66-88%), 3,4 33 chemical peritonitis is very rare (0.2%). 5,6 The occurrence of this rare condition can be extremely 34 distressing for the patient and treating surgeon alike, as the recommendations for management are 35 limited. The management of chemical peritonitis may require one or more surgical procedures 36 along with prolonged anti-inflammatory therapy. 37 38 Case Report 39 A 31-year-old woman, para1living1, who underwent a caesarean section two and half months 40 before presented to the emergency department at Sultan Qaboos University Hospital, Muscat, 41 Oman, in 2021 with two days history of abdominal pain, vomiting and diarrhea. On imaging, she 42 was found to have bilateral dermoid cysts measuring 75.07mm x 59.69mm (figure1), with the right 43 ovary showing evidence of torsion. Preoperative CRP was 4 mg/L. Emergency laparoscopy was 44 performed. Intraoperatively, the right ovary was 80 mm in size and gangrenous, and left ovary had 45 a smaller dermoid of 40 mm. The large dermoid was punctured with the trocar, to suck out the 46 contents and enable retrieval of the specimen. Inadvertent intraperitoneal spillage of contents 47 occurred, and the specimen (Right tube and ovary) were retrieved through Endobag. Left dermoid 48 cystectomy was performed as well. In view of the peritoneal spill, thorough, repeated peritoneal 49 lavage was done using three liters of saline. As the instilled saline was sucked out, no drain was 50 inserted. Patient was discharged after 24 hours as there were no immediate complications. 51 Histopathology was reported as mature cystic teratoma with hemorrhagic infarction. 52 53 The patient was re-admitted three days later with a history of high-grade fever and diarrhea of 1 54 day duration. On examination, she was dehydrated temperature 38.50C, heart rate of 110 beats/min 55 and blood pressure of 110/70 mm Hg. The abdomen was soft, with no clinical signs of peritonitis. 56 Septic work revealed, C-reactive protein (CRP) of 380mg/L, total white blood cell 57 count16.8X109/L, COVID-19 RTPCR negative, no growth on blood and urine cultures. CT 58 abdomen and pelvis revealed evidence of diffuse intraperitoneal inflammation, fat stranding of 59 mesentery and enlarged mesenteric nodes, with no evidence of intraperitoneal or pelvic collection 60 and no pneumoperitoneum to suggest injury of hollow viscous (figure 2). Mild bilateral pleural 61 effusion was noted with minimal atelectasis of right lower lobe. It was decided to manage her 62 conservatively with antibiotics (Tazocin 4.5 mg IV bid) and intravenous paracetamol only. 63 3 64 The diarrhea subsided over the next week, but high-grade fever persisted. Repeat CT abdomen four 65 days after initiating antibiotics revealed a small sub-hepatic collection and slight worsening of the 66 inflammatory process. The sub-hepatic collection was drained under ultrasound guidance, the 67 aspirate was straw colored and sterile. The blood, urine and stool cultures were sterile. 68 Inflammatory markers, CRP-373mg/L. 69 70 Ten days after re admission, patient developed chest pain in addition to persistent high-grade fever. 71 Chest X-ray and CT chest revealed moderate pleural effusion with right lobe atelectasis. A pleural 72 tap was done and a COVID test was repeated. About 580 ml of straw-colored fluid was drained and 73 a pig- tail catheter was left in situ. The pleural fluid was also sterile and negative for acid fast 74 bacilli. Fever persisted and she began to complain o f generalized abdominal pain. On 75 examination, a vague tender mass was palpable around the umbilicus. 76 77 A decision was taken for exploratory laparotomy and a thorough peritoneal lavage, after counseling 78 the patient that the procedure may not assure complete resolution of symptoms. She underwent a 79 laparotomy 20 days after admission. Intraoperatively, inflamed, thickened omentum was found, 80 dense bowel adhesions were encountered which were separated with difficulty. Dermoid contents 81 of hair and sebum were seen between bowel loops. The contents were cleared as much as safely 82 permissible. The upper abdomen could not be accessed due to dense adhesions. During 83 adhesiolysis, a small jejunal injury occurred, which was closed with vicryl no.3-0. Entire peritoneal 84 cavity and bowel loops were inflamed and edematous. Uterus left tube and ovary were normal. 85 Thorough peritoneal lavage was done with six liters of normal saline and intraperitoneal drain was 86 inserted. Histopathology showed omentum with fat necrosis, microabscess formation and 87 granulomatous inflammation around the content of dermoid. 88 89 She remained afebrile for 48 hours after the procedure. Total parenteral nutrition was started as her 90 serum albumin was low (22gm/L) and her oral intake for the last 3 weeks was minimal. Two days 91 post laparotomy, high spikes of fever returned reaching 39°C. Repeat imaging of the chest and 92 abdomen showed a slight worsening of the right lower lobe atelectasis. No intra-abdominal 93 collection or pneumoperitoneum was seen. She began tolerating orally and moved her bowel, the 94 surgical wound was well healed, but the fever persisted. Systemic anti-inflammatory Diclofenac, 95 4 was given for four days post laparotomy as her renal parameters were normal. Fever gradually 96 reduced but continued with a maximum temperature of 37.4°C. She was discharged on day 41 of 97 admission, on regular oral paracetamol. 98 99 Eight weeks after discharge, she remained afebrile, but complained of nausea and occasional 100 vomiting. She reported a weight loss of 10 kg over the last two months. Blood investigations as well 101 as repeat CT abdomen and pelvis was ordered. Counts, liver function tests and CRP were normal. 102 CT scan revealed multiple nodular deposits in the entire abdomen - mesentery, para colic gutters 103 and sub-diaphragm. Radiologist suggested that disseminated carcinomatosis has to be ruled out, 104 other possibilities being granulomatous peritonitis (inflammatory response to dermoid contents) or 105 tuberculosis abdomen. Ultrasound guided biopsy revealed granulomatous inflammation. Systemic 106 steroids were considered in case patient was not better symptomatically but fortunately she did not 107 require it. 108 109 Patient consent was obtained for publication purpose. 110 111 Discussion 112 Dermoid cysts are common benign tumors of the ovary. 15% of dermoid cysts undergo torsion. 113 Rupture of dermoids either spontaneous or iatrogenic may occur. The contents of dermoid, sebum 114 and hair can be highly irritant to peritoneum, resulting in chemical peritonitis. Hence all attempts 115 must be made to avoid or minimize spillage of contents. This may be difficult with large dermoids 116 especially when laparoscopic retrieval is attempted. Studies have been directed to compare the 117 outcomes of laparoscopy versus laparotomy, with regard to avoiding spillage in large dermoids. 118 Laparoscopy is associated with a higher incidence of spillage, up to 88% with large dermoids, 4 but 119 chemical peritonitis is rare. 120 121 A lot of factors may influence the development of this rare complication in certain individuals. The 122 more likely ones being an exaggerated inflammatory response to the irritant contents, the volume of 123 spillage and the thoroughness of the peritoneal lavage. Despite thorough peritoneal lavage at 124 laparoscopy, after spillage of contents, our patient had a prolonged severe inflammatory response 125 due to the spillage of the large dermoid content and her exaggerated inflammatory response causing 126 dilemmas in management. Our initial strategy was to adopt a conservative approach, with broad 127 5 spectrum antibiotics and anti-inflammatory medications. As a thorough lavage was done at primary 128 surgery, imaging not revealing any collection and no clinical signs of peritonitis, on initial 129 presentation with post-operative fever. 130 131 We hoped that the fever would settle, after the paracentesis and pleural tap, but as high-grade fever 132 continued into the 3rd week, and patient started having diffuse abdominal pain, and a tender vague 133 mass became palpable around that umbilicus, laparotomy and thorough peritoneal lavage was 134 considered. As anticipated, entry into the abdomen was extremely challenging and dense 135 inflammatory adhesions were encountered. No intra- abdominal collection was found and on 136 separating bowel adhesions with difficulty, some hair and sebum were found between bowel loops. 137 138 Post operatively patient was started on diclofenac. She remained afebrile for 48 hours, subsequently 139 it was interesting to know that the spikes of fever would occur just prior to the scheduled time of 140 next dose of diclofenac. This prompted us to continue the drug for 8 days, after which anti-141 inflammatory drug was downgraded to paracetamol, and she gradually improved. Systemic steroids 142 were not given since the role is controversial and the patient had pneumonia. 143 144 The case was reviewed by the morbidity committee in the department and agreed that laparoscopy 145 will continue to be the standard of care even for a large dermoid. This case was operated by a 146 skilled consultant with adequate experience. Thorough peritoneal lavage was done and the 147 specimen was retrieved by an endo-bag, as is the recommendation. Prophylactic single dose of 148 antibiotics and was not continued as the was no evidence of infectious process. The committee 149 suggested an earlier re-laparoscopy and lavage within 48 hours of her presentation could have 150 reduced the duration of her morbidity. Why a decision for immediate laparoscopy and lavage was 151 not taken as, it was thought that a thorough lavage was done at primary surgery and going back in 152 might increase morbidity due to adhesions. Howevere, in hindsight immediate relaparoscopy and 153 relavage might be a good option before dense adhesions set in. As there is insufficient literature to 154 support or refute early relaparoscopy. 155 156 Laparoscopic approach is preferred to laparotomy, considering the overall reduction in operative 157 morbidity, post op pain, analgesic requirement and hospital stay, with satisfactory scar.7,8 To 158 minimize the occurrence of intra operative spillage and ensuing peritonitis, measures recommended 159 6 include puncture of a large dermoid with trocar, retrieval of the specimen via endobag, 9 and 160 thorough peritoneal lavage. Abundant saline lavage has been proven to reduce inflammation and 161 adhesions significantly in an experimental study.10 Retrieval of specimen via colpotomy also 162 lessens spillage as compared to laparoscopic port site retrieval.11 Systemic steroids have also been 163 tried with one group reporting success.12 164 165 Conclusion 166 Chemical peritonitis following spillage of dermoid contents poses a management dilemma. Though 167 fortunately rare, when it does occur it is extremely distressing for the patient and the treating 168 surgeon alike. S epsis was ruled out in our patient, thus conservative management with antibiotics 169 therapy formed was tried and as the patient was not responding, laparomty and thorough peritoneal 170 lavage was resorted too but the procedure was technically challenging. Strong multi- disciplinary 171 input along with timely surgical intervention as when required, is the key to successful 172 management of this agonizing complication. 173 Acute inflammation was the consistent finding both at imaging and at laparotomy. Role of powerful 174 anti-inflammatory agents like steroids need to be studied further. 175 176 Authors’ Contribution 177 MGF wrote the whole manuscript. SVK, LM and SS reviewed the manuscript. NAR assisted in the 178 writing and revision of the manuscript. All authors approved the final version of the manuscript. 179 180 References 181 1. Watrowski R, Kostov S, Alkatout I. Complications in laparoscopic and robotic-assisted 182 surgery: definitions, classifications, incidence and risk factors – an up-to-date review. 183 Videosurgery Miniinvasive Tech. 2021 Sep;16(3):501–25. https://doi: 184 10.5114/wiitm.2021.108800. 185 2. Shamshirsaz AA, Shamshirsaz AA, Vibhakar JL, Broadwell C, Van Voorhis BJ. 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