Endoscopic Excision of Angular Dermoid in a Pediatric Patient: a Case Report
Article Notes and Dates
Journal of Minimally Invasive Surgical Sciences: ,
; e11389.Published Online: February 28, 2014
Article Type: Case Report; Received : April 4, 2013; Accepted : July 2, 2013
To Cite :
R K, Gupta
K K, Mudkhedkar
K. et al. Endoscopic Excision of Angular Dermoid in a Pediatric Patient: a Case Report,
J Minim Invasive Surg Sci.
Online ahead of Print
Subcutaneous swellings of the scalp, forehead and neck are commonly managed by an incision on the skin within the swelling (and along skin creases to hide the incision scar). No matter how fine surgical skills are, scarring is inevitable and becomes a cosmetically matter of concern for patients and parents (particularly scars over exposed parts of the body, such as face and neck) (
1, 2). These concerns can be resolved by shifting the site of incision from an exposed location to a hidden area of the body, such as behind hairline for scalp swellings and axilla for neck swellings. This approach is also known as stealth surgery, as they allow us to perform relatively invasive procedures without leaving any obvious scar of an operation. There are few reports of using these approaches by plastic ( 3, 4), ENT ( 5) and maxillofacial surgeons ( 6). In this report, we have described using this approach for excision of an angular dermoid cyst.
2. Case Presentation
A 10 year old boy presented with swelling on the temporal side of the left eyebrow since birth (
Figure 1a). On examination, the swelling was 2 × 1.5 cm, cystic and mobile. He had no history of trauma. The result of skull X-ray was normal. With the diagnosis of angular dermoid, we decided to treat it by subcutaneous endoscopic excision. Patient’s skull was shaved just above the hairline. The procedure was performed under general anesthesia and endotracheal intubation. 500 mg Cefazolin was administered intravenously for preoperative wound infection prophylaxis. Patient’s head was kept in lateral position. A 1.5 cm incision was made on the left temporal region just above the hairline. A plane was created subcutaneously with an artery forceps ( Figure 1b). Foley’s catheter no. 8 was used as a dissection tool to carefully expand the subcutaneous space, aided by insufflations of ballon ( Figure 1c). With the initial surgical field created, 3mm 300 telescope was inserted directly after manually lifting the eyebrow. The dissection was done with a 3 mm Maryland dissector and 3 mm hook electrode ( Figure 1d). The dissection was straightforward, as this space is largely avascular ( Figure 2a). Finger palpation on the skin was helpful to guide the dissection. Electro-cautery usage was avoided near skin. The most important aspect of stealth surgery is to create single large subcutaneous space rather than creating multiple tunnels. This makes instruments exchange and movements easier. The dermoid was removed intact ( Figure 2b). The incision was closed using 5-0 subcuticular suture. Postoperative compression dressing was given. It was removed in the evening and he was discharged on the same day with prescription of 300 mg acetaminophen twice a day for two days . On follow at day 7, he was absolutely alright ( Figure 2c). Histopathology was suggestive of angular dermoid.
Figure 1. A) Angular dermoid over left side of eyebrow, B) Creation of subcutaneous plane with artery forceps, C) Expansion of subcutaneous space, aided by insufflations of balloon, D) Telescope with working ports
Figure 2. A)Showing dissecton of dermoid, B) Post excision dermoid bed, C) Postoperative healed wound behind hairline
Dermoid cyst is most commonly located along the line of embryonic fusion (Outer third of the fronto-orbital region) (
7). Conventionally, dermoid cysts are managed by making an incision on the skin overlying the swelling, which leads to formation of visible scar and disfiguration, along with long term psychosocial consequences. . In the literature, a new method for the excision of these cysts was described, in which one or two small incisions are made behind the forehead hairline and swelling was excised with endoscopic instruments. . This is known as stealth approach and its advantages over conventional open approach are as follows: 1) a small hidden incision; 2) Avoiding injury to important structures by endoscopic assisted magnified view and 3) No disfigurement ( 7).
The stealth approach has the advantages of better visualization, finer dissection, and avoidance of disfiguration. The only disadvantage is the longer learning curve for surgeons than the open approach. However, it should be noted that just like any other operative technique -open, laparoscopic or stealth approach- excellence can be obtained after acquiring experience by operating few cases.