{"paper_id":"80d35781-2126-42c3-908d-824b55e990c1","body_text":"Review\nCopyright© 2025 The Author. Published by Galenos Publishing House on behalf of Turkish-German Gynecological Association. \nThis is an open access article under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND) International License.\nJ Turk Ger Gynecol Assoc \nAutoamputation of the ovary after missed diagnosis of \novarian dermoid cyst torsion: a case report and review \nof literature\n Ayşe Seyhan1,2,  İrem Usta Korkut1,  Bülent Urman1,3 \nAbstract\n1American Hospital, Women’s Health Center, İstanbul, Türkiye\n2Department of Obstetrics and Gynaecology, Atlas University Faculty of Medicine, İstanbul, Türkiye\n3Department of Obstetrics and Gynaecology, Koç University Faculty of Medicine, İstanbul, Türkiye\nTorsion is the most frequent complication of ov arian dermoid cysts. Adnexal torsion typically presents as a severe abdominal pain and is treated \nas an acute surgical emergency. However, if surgery is delayed or t he diagnosis is not made in a timely manner, autoamputation of the ovary \nis a very rare, but possible, complication. Herein, we report a case of  an autoamputated ovary with a dermoid cyst and review the literature. A \n33-year-old patient presented with pelvic pain lasting  three weeks and was scheduled for a laparoscopy due to the presence of bila teral ovarian \ncysts, with a dermoid cyst identified on the left ovary. During the pr ocedure, it was discovered that both the left fallopia n tube and ovary were \nabsent. The infundibulo-pelvic ligament appeared to termin ate ab ruptly at the pelvic brim. Moreover, an 8 cm pelvic m ass was found lodged \nin the cul-de-sac, which was extensively adherent to the bowel and the uterus, and was covered by vascular omen tal tissue. Histopathological \nanalysis revealed that this pelvic m ass was a dermoid cyst. The cyst con tained adipose tissue, hair, and microscopic ovarian stroma, con firming \nthe diagnosis. This case highlights the complexity of diagnosing and managing pelvic masses. Clinicians should main tain a high index of suspicion \nfor ovarian torsion and consider the possibility of autoamputation when an ovary is not found in its anatomical location, especially if  imaging \nsuggests the presence of a dermoid cyst. This case also underscores the importan ce of meticulous surgical dissection for the complete removal \nof such masses. [J Turk Ger Gynecol Assoc.  ]\nKeywords: Pelvic mass, autoamputation of ovary, dermoid cyst, ovarian torsion, spon taneous oophorectomy, teratoma\nReceived: 28 May, 2025  Accepted: 18 September, 2025 Epub: 14 Octob er, 2025\nIntroduction\nOvarian torsion is an infrequent yet consequential gynecologic \nemergency, characterized by the rotation of the ovary around \nits vascular pedicle, leading to compromised blood flow, \nischemia, and potential ovarian compromise. Incidence rates \nof ovarian torsion range from 2.7% to 15% in patients undergoing \nsurgical treatment for adnexal masses (1,2).  It has been \nobserved that ovarian torsion often occurs in cases involving \nmature cystic teratoma. However, their varied composition and \natypical presentation make the prompt and accurate diagnosis \nof ovarian torsion challenging. \nOvarian autoamputation is a rare complication of ovarian \ntorsion that may result in the formation of a parasitic \novarian teratoma (3,4). Reimplantation of the ovary after \nautoamputation is possible due to the phenomenon of \nneovascularization, which allows for the formation of new \nblood vessels and subsequent reperfusion. There have been \nrelatively few documented cases in the literature available \non this topic although reimplantation of the ovary following \nAddress for Correspondence: İrem Usta Korkut\ne-mail: iremusta@gmail.com  ORCID: orcid.org/0000-0001-7021-4600\nDOI: 10.4274/jtgga.galenos.2025.2025-1-10\nCite this article as: Seyhan A, Usta Korkut İ, Urman B. Autoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion: a case \nreport and review of literature.  J Turk Ger Gynecol Assoc.  [Epub Ahead of P rint]\n\n\nSeyhan et al.\nAutoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion\n \nautoamputation has been reported to the pouch of Douglas, \nomentum, sacrouterine ligaments, and the broad ligament (5-\n8). In this case report, we present a case of autoamputation of \nthe ovary resulting from a missed diagnosis of ovarian dermoid \ncyst torsion. \nCase\nA 33-year-old gravida 1, para 1 patient was referred to our \nclinic with a suspected ovarian tumor. Her medical and \nsurgical history was unremarkable, except for hospitalization \nthree weeks earlier for abdominal and pelvic pain ascribed \nto the presence of an ovarian cyst. The acute phase subsided \nwithin 24 hours, however intermittent cramping remined. At \nthe time of presentation to our clinic, the pain had worsened, \nnecessitating regular non-steroidal anti-inflammatory drugs for \nrelief.\nAbdominal examination revealed tenderness in the \nsuprapubic region and left iliac fossa. Transvaginal ultrasound \nexamination showed the presence of three ovarian cysts (Figure 1).  \nThe right ovary contained an anechoic unilocular cyst \nmeasuring 7x6x5 cm, while the left ovary contained a mixed \nechogenic cyst measuring 5x4x4 cm and an anechoic \nunilocular cyst measuring 3x3x4 cm in size. The cyst in the left \novary was consistent with a dermoid cyst located at the pouch \nof Douglas. Ultrasound with color Doppler demonstrated the \npresence of blood flow. A laparoscopy was scheduled because \nof the persistent pain.  \nAt laparoscopy there were extensive dense adhesions in the \npelvis precluding the visualization of the internal genitalia. \nFollowing lysis of adhesions, it was noted that the left fallopian \ntube and ovary were absent. The infundibulo-pelvic ligament \nabruptly terminated at the pelvic brim, while the utero-ovarian \nligament was identified as a rudimentary structure arising from \nthe posterolateral aspect of the uterus (Figure 2). A large pelvic \nmass, approximately 8 cm in size, was found lodged in the cul-\nde-sac and densely adherent to the bowel and the posterior \naspect of the uterus (Figure 3). The mass was covered by a \nthick and vascular layer of omentum. During careful dissection, \nthe left ureter, adherent to the mass, was identified and \ndissected meticulously, followed by freeing the mass from the \nFigure 1. Transvaginal ultrasound imaging showing A) a \nunilocular cyst with low level echogenity in the right ovary. \nB) two ovarian cysts: one is a unilocular cyst and the other \nexhibits hyperechoic lines and dots in the left ovary\nA\nB\nFigure 2. Illustrating the absence left ovary and fimrial \nportion of the fallopian tube in the fossa ovarica with \nabrupt end of left infundibulopelvic ligament \nFigure 3. Left ovarian mass and obliteration of Douglas \n\n\nSeyhan et al.\nAutoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion\n  \nunderlying bowel using the medial pararectal space. Upon full \nmobilization, two dermoid cysts were removed together with \nthe pelvic mass that had no connection with the right adnexa. \nThe right ovary, adherent to the right pelvic side wall, contained \na large cyst that was successfully excised. All specimens were \nremoved inside an endobag through a culdotomy incision. \nThe culdotomy incision was closed using a 3-0 V-Lock suture, \nand the removed specimens were sent to histopathology. The \nprocedure was terminated without complications, and the \npatient was discharged the next day.\nHistopathological evaluation of the excised specimens showed \nthat the mass removed from the cul-de-sac was a dermoid \ncyst and the one removed from the right ovary a mucinous \ncystadenoma. The parasitic mass that was identified as a \nteratoma contained adipose tissue, hair and also microscopic \novarian stroma (Figure 4).   \nDiscussion\nWhen torsion occurs, the ovary usually rotates around both \nthe infundibulo-pelvic and the utero-ovarian ligaments. \nThe rotation of the infundibulo-pelvic ligament leads to \ncompression of the ovarian vessels, compromising partial or \ncomplete obstruction of lymphatic and venous outflow as well \nas arterial inflow. Persistent arterial perfusion, coupled with \nblocked outflow, causes ovarian edema, resulting in significant \novarian enlargement and increased vascular compression. \nSubsequently, ovarian ischemia develops, potentially leading \nto ovarian necrosis and local hemorrhage.  The treatment of \novarian torsion is via prompt detorsion usually via laparoscopy. \nHowever, if the diagnosis is missed and the patient placed \non analgesics, the pain usually subsides within a few days \nand the affected tissues becomes necrotic and eventually \nundergoes atrophia.  In some rare cases, adnexal torsion may \nlead to autoamputation and subsequent reimplantation of the \namputated adnexal mass to the neighboring structures. This \nmay lead to the formation of a parasitic pelvic or abdominal \nmass, supported by new collateral blood flow (3,7,9-16). \nBased on earlier case reports, the autoamputated ovary, most \ncommonly harboring a teratoma, was found to be situated at \nthe omentum, pouch of Douglas, attached to the uterosacral \nligaments and even within an inguinal hernia. The majority were \ncovered by the omentum, which is unsurprising as omentum is \na very mobile organ that controls inflammation and promotes \nrevascularization due to its rich vascular supply. Doppler flow \nin a torsional ovary may be present, decreased, or absent. \nNormal Doppler flow does not rule out torsion, as preserved \nflow can result from incomplete occlusion, intermittent torsion, \nor collateral blood supply, as observed in our case, where the \nomentum provided the blood supply.\nThere are two possible hypotheses for parasitic teratomas; \none originating from an autoamputated dermoid cyst, as in the \npresented case, and the other originating from ectopic ovarian \ntissue (17-19). The absence of the ovary and the presence \nof a separate cyst in the pelvic or abdominal cavity covered \nby omentum supports the first cause. Histopathological \nobservation of ovarian tissue in the excised tumor adds further \nevidence to support this suggestion.  \nThe second hypothesis for supernumerary ovaries proposes \nthat if the migration of certain primitive germ cells is halted \nduring their journey to the gonadal ridges, their influence \non the surrounding epithelium can result in the formation of \nectopic ovarian tissue (20,21). Supernumerary ovaries are \novarian tissue that is completely separate from the normally \npositioned ovary. There is no ligamentous or direct connection \nwith the ovaries, broad ligament, utero-ovarian ligament, or \ninfundibulo-pelvic ligament, as it originates from a distinct \nFigure 4. Microscopic findings of the tumour: A) ovarian \ncyst wall with with hair shafts in the lumen B) ovarian cyst \nwall and ovarian stroma (hematoxyline & eosin staining, \noriginal magnification x40, x200)\nA\nB\n\nSeyhan et al.\nAutoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion\n \nprimordium. A supernumerary ovary is typically located in \nthe pelvic region, near structures such as the uterus, bladder, \npelvic wall, retroperitoneum, omentum, mesentery, and \ninguinal region (22-25). In rare cases, supernumerary ovaries \nhave been reported to be located in unusual areas, such as the \nhepatorenal space, near the right psoas major muscle, and at \nthe intrarenal pole (26,27).  \nA search was conducted in the PUBMED database to investigate \nthe incidence of reported cases concerning autoamputated \novarian dermoid cysts between 2000 and 2024. Table 1 presents \nthe clinical data for the 10 cases identified. The patients’ age \nranged from 14 to 77 years. Of these patients, three reported \nno abdominal pain, four had chronic abdominal pain and the \nremainder experienced acute abdominal pain. Notably, among \nthose with chronic pelvic pain, the duration of symptoms \nranged from 1 to 5 years. Size of the tumor varied between \n4 and 10 cm. Autoamputation due to torsion of the ovarian \ndermoid cyst did not show a preference for laterality. The \nlaterality of origin of the dermoid cyst was found to be similar \n(six from the left and four from the right ovary). In the majority \nof cases, preoperative diagnostic imaging was conducted \nusing ultrasound (n=9), followed by computed tomography \n(n=2) and magnetic resonance imaging (n=2). Preoperative \ndiagnosis was inaccurate in 30% and the presence of a dermoid \ncyst was confirmed in only half of the cases. Dermoid cyst was \nbilateral in 30% of cases.\nAutoamputation of the ovary is a rare phenomenon with \nvarious potential locations for implantation. The most common \nlocation was the pouch of Douglas (n=5), followed by the left \nadnexal region (n=1), peritoneal cavity (n=1), vesicouterine \nspace (n=1), right subhepatic region (n=1), and pelvic \nside wall (n=1). The unexpected intraoperative finding of \nthe absence of an ovary and the corresponding fallopian \ntube being blind-ended without fimbriae and infundibulum \nusually leads to the diagnosis of ovarian autoamputation. \nIn cases when bilateral dermoid cysts are present and one \novary has been autoamputated and migrated, misdiagnosis \nis quite common, resulting in incomplete removal of all cystic \ncomponents. In a 14 year-old girl, the initial intraoperative \ndiagnosis was right ovarian dermoid cyst and congenital \nabsence of left ovary. Following right ovarian cystectomy, \nthe 4 cm left dermoid cyst was successfully removed after a \nthorough pelvic exploration and meticulous dissection from \nthe surrounding omental adhesions. In another case, a 42-year-\nold patient was preoperatively diagnosed with an 8 cm right \novarian cyst, suggestive of cystadenoma, and a 2 cm echogenic \nleft ovarian cyst. Initially, the plan was to perform a bilateral \novarian cystectomy.\nHowever, due to technical difficulties encountered during \nsurgery, an adnexectomy for the right ovarian cystadenoma \nwas performed. Unexpectedly, the left ovary was not found \nin its usual location in the ovarian fossa; instead, it was \ndiscovered completely detached and located in the pouch \nof Douglas. Consequently, the patient underwent a bilateral \nadnexectomy, which inadvertently triggered the onset of \nmenopause. Meticulous localization of anatomical structures \ncan significantly influence surgical outcomes and patient well-\nbeing. It is important for the surgeon to have a high level of \nsuspicion, thorough preoperative evaluation, and intraoperative \nassessment to identify any migrated cysts and ensure complete \nremoval, especially in cases when ovary is not identified in its \nnormal anatomical location and there are pelvic adhesions \nenveloped by omentum.\nThe removal of adnexal specimens through an abdominal port \nsite or posterior culdotomy incision is a feasible and safe option \nfor pelvic specimen extraction. This approach can be tailored \nbased on the preferences of the patient and surgeon, as well \nas individual patient factors. Colpotomy negates the need to \nenlarge abdominal incisions or performing intracorporeal \nspecimen size reduction. We particularly prefer this method in \nobese patients to minimize the risk of port-site hernias and skin \ninfections. For closing the cul-de-sac incision, we favor the use \nTable 1. Articles about autoamputation of the ovary\nAuthor, year Age Symptom Size Preop diagnosis Location of AO\nDaccache et al. (9) 42 Aysmptomatic 80 mm Cystadenoma Douglas pouch\nGorginzadeh et al. (10) 14 Chronic pelvic pain 101x60 mm (RO) and \n40x25 mm (LO) Dermoid cyst Douglas pouch\nJohn (11) 32 Asymptomatic 60 mm Complex cyst Douglas pouch\nKim et al. (12) 34 Chronic pelvic pain 50x27 mm  Complex cyst Left adnexal region\nLee et al. (3) 77 Acute abdominal pain 143x140 mm, 90 mm Dermoid cyst Right subhepatic space\nKusaka and Mikuni (7) 24 Chronic pelvic pain 50x35 mm Dermoid cyst Douglas pouch\nOllapallil et al (13) 46 Acute abdominal pain 80x60x40 mm Complex cyst Peritoneal cavity\nPeitsidou et al. (14) 33 Asymptomatic Incidental finding NA Douglas pouch\nShah et al. (15) 26 Chronic pelvic pain 40x40 mm Dermoid cyst Vesicouterine space\nÜreyen et al. (16) 27 Acute abdominal pain 68x40 mm Complex cyst Pelvic side wall\n\nSeyhan et al.\nAutoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion\n  \nof a barbed suture material, which provides consistent tension \nalong the suture line without the need for knots. This feature \nis particularly advantageous in laparoscopic settings, where \nspace is limited and visibility can be challenging. This suture \ntype not only enhances the speed of closure but also improves \nthe overall security of the incision, thereby reducing the risk of \ncuff dehiscence.\nConclusion\nIt is important for the surgeon to have a high level of suspicion, \nthorough preoperative evaluation, and intraoperative \nassessment to identify any migrated cysts and ensure complete \nremoval, especially in cases when ovary is not identified in its \nnormal anatamical location and there are pelvic adhesions \nenveloped by omentum. \nFootnotes\nAuthor Contributions:  Surgical and Medical Practices: B.U., \nConcept: A.S., İ.U.K., Design: A.S., İ.U.K., Data Collection or \nProcessing: A.S., İ.U.K., Analysis or Interpretation: A.S., İ.U.K., \nLiterature Search: A.S., İ.U.K., Writing: A.S., İ.U.K., B.U.\nConflict of Interest:  No conflict of interest is declared by the \nauthors.\nFinancial Disclosure:  The authors declared that this study \nreceived no financial support.\nReferences\n1. 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