Laparoscopic Diagnosis Of A Mesenteric Cyst Confused With Ovarian Endometrioma

We present the case of a 40-year-old woman with persistent pelvic pain and an abdominal ultrasound aspect of a right ovarian cyst. The medical history of the patient comprised a total hysterectomy for severe bleeding (placenta accreta) after vaginal birth (at 27 years old) and a cystectomy for a right ovarian mature teratoma (at 37 years of age). Both procedures were performed via open laparotomy using a vertical subumbilical incision; the latest one was converted from laparoscopy to laparotomy as a result of a caecal injury. The transvaginal ultrasound suggested an endometriotic cyst - a right ovarian cystic mass (71,8/ 61,5 mm) with thick walls and homogeneous low-level internal echoes (Figure 1). The left ovary had a normal appearance and the uterus was absent. Laparoscopy was decided for diagnosis and treatment. After extensive ablation of the adhesions between the abdominal wall and the epiploon,  a round mass developed under the sigmoid mesentery, which was adherent with bladder’s peritoneum covering both ovaries and Douglas pouch (Figure 2). The Douglas pouch was revealed through adhesiolysis, but accessing the tumor was difficult. Direct incision of the mass was performed through the mesentery, exposing a clear brown-green liquid content and internal deposits (Figure 3) - suggestive of a persistent hemorrhagic cyst. These findings were surprising as the sonographic exam showed evident features for an endometrioma.