although neonatal ovarian cysts ( noc ) are increasingly diagnosed with routine antenatal ultrasound screening , their management is still controversial .
preserving the ovary is the key aim in the management of these apparently benign lesions .
we describe a technique of 2-port laparoscopic - assisted transumbilical ovarian cystectomy performed successfully in a neonate with a complex ovarian cyst .
this technique aids in the panoramic assessment of the abdomen and the pelvis in addition to accomplishing ovarian cystectomy with ease .
a full - term female neonate with a birth weight of 3.08 kg was prenatally diagnosed at 35 weeks gestation as having an abdominal cystic lesion .
postnatally , the child was asymptomatic , and the abdominal cystic mass was not palpable .
the ultrasound scan of the abdomen revealed a 2.02.63.0-cm cystic structure in the left hemipelvis , probably arising from the left ovary .
the computed tomographic scan of the pelvis confirmed the same findings , and the diagnosis of possible left ovarian dermoid cyst was considered .
the ultrasound examination performed 2 weeks later revealed that the size of the cyst had declined ( 2.21.40.9 cm ) but still contained the solid nodule measuring 1.01.51.0 cm . in view of the persistent complex nature of the cyst ,
laparoscopic ovarian cystectomy was contemplated . at surgery , after the insertion of a 5-mm umbilical camera port by the open hasson 's technique and creation of pneumoperitoneum up to 8 mm hg pressures , a yellowish left ovarian cystic lesion measuring 2.52.0 cm was noticed .
a second port of 3 mm in size was inserted into the left lumbar region .
the ovary with the cystic lesion was grasped with an atraumatic grasper passed through the working port .
the umbilical incision was extended vertically in the umbilical cicatrix and joined to a periumbilical smiling incision 4 mm in length on the inferior aspect of the umbilicus .
the cyst contained chocolate colored fluid suggestive of a hematoma that resulted in a solid appearance on the computed tomographic ( ct ) scan and ultrasound examination .
the ovary was reconstituted with continuous sutures of 6.0 polydiaxonone and placed back into the pelvic cavity ( figure 1 ) .
ovarian cysts are the rule , not the exception in the newborn infants . at birth ,
98% of female neonates have ovarian cysts on ultrasound examination , about 20% of which measure more than 9 mm in diameter .
they occur either due to hormonal stimulation during the intrauterine or perinatal period , or abnormal development of the primitive gonad , probably because of disruption of its vascularization .
a simple cyst is anechoic , with an imperceptible wall , no solid components , and no fluid debris level .
a complex or complicated cyst contains a fluid level , retracting clot , septa , or is completely filled with echoes producing a solid mass - like appearance .
ultrasound is the cornerstone in the diagnosis and delineation of the nature of the noc .
ultrasonogram and computed tomographic scans serve in differentiating other abdominal cystic lesions in a neonate , such as intestinal duplication cysts , hydronephrosis , lymphangioma , cystic meconium peritonitis , omental , mesenteric , omphalomesenteric , choledochal , hepatic , urachal , renal , or ureteral cysts , anterior myelomeningocele and hydrometrocolpos .
the treatment of noc is highly debated , and no universal consensus exists . a conservative approach with a wait and see policy and serial ultrasonography is advocated because noc is found to resolve with time , and the risk of malignancy is virtually nonexistent .
surgical intervention is recommended in cases of complex cysts and simple cysts larger than 4 cm to 5 cm in diameter to avoid the risk of ovarian torsion and other complications , such as compression on the bowel , ureter , or inferior vena cava ; rupture and peritonitis with hemoperitoneum ; or incarceration in the canal of nuck .
surgical intervention could theoretically reduce the risk of these complications along with the salvation of the ovary and also obviates long - term follow - up with serial ultrasonograms .
the histopathological examination of the ovarian cyst in our neonate revealed hemorrhagic and fibrous tissue along with hemosiderophages , suggesting previous torsion and detorsion or hemorrhage into the cyst .
these features may also suggest that although malignancy is virtually nonexistent in noc , smaller cysts are also at risk for torsion and ovarian loss .
the management options of noc vary from antenatal transuterine aspiration to postnatal intervention in the form of repeated ultrasound - guided needle aspiration , laparotomy , or laparoscopic oophorectomy or ovarian cystectomy .
recent advances in laparoscopy and neonatal anesthesia has opened new avenues for minimally invasive management of noc .
neonatal laparoscopy is tenable because neonates can sustain pneumoperitoneum up to the pressures of 8 mm hg .
laparoscopy aids in the delineation of the lesion , evaluation of the contralateral ovary , and sometimes management of other cystic lesions that mimic ovarian cysts .
laparoscopic oophorectomy for ovarian torsion , laparoscopic 2- or 3-port ovarian cystectomy , laparoscopic - assisted aspiration , and ovarian cystectomy through a suprapubic incision have been described in the literature .
minilaparotomy with an exteriorization - aspiration (  catch and suck  ) approach has also been described .
however , this technique has limitations , especially in cases of a mistaken diagnosis of abdominal cystic lesions in a neonate . in our patient , we contemplated surgical exploration because the second ultrasound examination revealed the persistence of the solid component within the cyst . to our knowledge , this is the first case report of transumbilical ovary - preserving ovarian cystectomy in a neonate , although a similar technique has been described by mahomed et al .
this technique is also an extrapolation of the procedure utilized for transumbilical extraction of the laparoscopically resected torted ovary .
the umbilicus is viewed as a window to the abdominal cavity that serves to safely execute minimal access procedures in children .
necessary access into the abdominal cavity can be safely obtained through a cosmetically acceptable and concealable incision . however , umbilical vessels in a neonate may be patent , and hence umbilical port insertions should be through an open hasson 's technique .
our technique of vertical umbilical incision with extension to a small infraumbilical smiling incision , allows wide exposure for ligating the patent umbilical vessels and atraumatic extracorpo - real delivery of the ovary with the cyst . the shallow neonatal pelvis and long ovarian pedicle allows transumbilical extraction of the ovary with ease .
this obviates spilling of the contents , reduces operative time , in addition to achieving a safe , effective , aesthetic outcome .
this procedure , which combines laparoscopy with conventional operative techniques , has the potential to be performed through a single umbilical incision with insertion of 2 coaxial ports or a single port with access for both the telescope and the grasper .
the cyst could be drawn up to the umbilical incision and aspirated with a purse - string suture in situ , avoiding spillage and contamination .
the decompressed ovary with the cyst wall can be delivered out of the umbilical incision , accomplishing extracorporeal cystectomy .
ovary - preserving ovarian cystectomy , although contentious , is indicated for complex cysts and simple cysts larger than 4 cm to 5 cm to avert the potential complications . saving
the ovary is the key , and this can be safely accomplished in neonates by laparoscopic - assisted transumbilical ovarian cystectomy .
 the occurrence of ovarian cysts in a neonate is common , but the management of the same is contentious . 
 we present a case of a prenatally diagnosed complex ovarian cyst in a neonate , which was successfully treated by a novel laparoscopic technique . 
 the literature was reviewed and the diagnosis , treatment options , and controversies in the management are discussed , highlighting the role of preservation of the ovary via the laparoscopic - assisted transumbilical ovarian cystectomy procedure . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION