Wonder of the wandering dermoid cyst

Germ cell tumours (GCT) account for 15-20% of all ovarian tumours in children and the young female population. Mature cystic teratoma, commonly known as dermoid cyst, is the most common type of GCT. In this report, we are presenting a rare case of a totally detached mature cystic teratoma located in the pouch of Douglas, which posed a diagnostic challenge and was a wonder intraoperatively. A 41 year old woman, P2L2, came with a one year history of pain in the lower abdomen and distension of abdomen. Her initial ultrasound at an outside hospital showed uterine fibroids and features suggestive of bilateral endometrioma and underwent conservative management. However, her symptoms continued and she came to our hospital for further evaluation after 9 months. Repeat ultrasound showed multiple uterine fibroids and left endometriotic cyst, whereas CECT showed multiple fibroids and left dermoid cyst. She underwent laparotomy. Intraoperatively, the uterus showed serosal fibroids and a detached grape-like cystic mass approximately measuring 9 x 4 x 2cm lying in the pouch of Douglas and thus underwent total abdominal hysterectomy and bilateral salpingectomy along with en bloc removal of the cystic mass. Histopathology of the mass was suggestive of dermoid cyst. In our present case, a diagnostic dilemma arose as the ultrasound imaging was reported as ovarian endometriosis, but she did not have symptoms suggestive of it. There are fewer reports regarding the detachment of the ovarian dermoid and its positioning in the pouch of Douglas. Thus, the explanatory theory behind it is an enigma. Increased awareness among gynaecologists regarding such masses, coupled with thorough preoperative evaluation and intraoperative decisions, would provide proper justification for the patient’s management.