Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature

Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature Eugene Leong, James Wai Kit Lee, Christopher Hang Liang Keh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1750165/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Mesenteric cysts are a rare occurrence in clinical practice, and even fewer are found to be of Mullerian origin. Diagnosis of mesenteric cysts is typically based on clinical assessment and radiological imaging. Surgical excision remains the primary treatment option. We report a case of a 42-year-old lady presenting with a giant mesenteric cyst weighing eight kilogrammes and analgesia optimisation with local anaesthetic infusion after en-bloc surgical excision. We also review the current literature of this rare clinical entity. Gastroenterology General surgery Mesenteric cyst Mullerian cyst Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Mesenteric cysts are a rare occurrence in daily clinical practice, with an estimated incidence in the general adult population ranging from 1 in 27,000 to 250,000 1,2 . The diagnosis of mesenteric cysts was traditionally difficult due to an absence of pathognomic clinical features and non-revealing serum biochemistry—consequently many if not most mesenteric cysts were diagnosed at laparotomy 4 , and anecdotally large mesenteric cysts have been misdiagnosed as ascites and treated with repeated aspirations with limited success 6 . The advent of affordable, readily-available and high-quality imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging has allowed for an accurate means of pre-operative diagnosis and consequently allows planning of further management. Once diagnosed, surgical excision via enucleation without spillage of cystic contents remains the mainstay of treatment. Case Report Our patient was a 42-year-old Chinese woman with no significant past medical history aside from two previous normal vaginal deliveries. She was initially referred from her family physician for gynaecological evaluation of a possible giant ovarian cyst, prior to attending our clinic for a general surgical consultation. She complained of worsening abdominal distension over one year, associated with occasional dull, aching discomfort. She works as a physiotherapist and had intentional weight loss of three kilograms over one year from increased physical activity. She did not report any personal or familial history of malignancy. She did not have abdominal pain, anorexia, early satiety, or apparent changes in bowel habit. Her menstrual cycles were regular, and she did not have dysmenorrhoea. There was no significant history of genetic disorders and personal or family history of cancer. Physical examination revealed a grossly distended abdomen with positive fluid thrill, but no discretely palpable mass. Abdominal radiograph revealed a large central homogenous radio-opacity, with displacement of the bowel loops to the right side of the abdomen (Fig. 1 ). Ultrasonography was pertinent for an anechoic uni-loculated cystic mass occupying the entire abdomen and pelvis, with no sonographic features suggestive of a solid component, fat density, internal septations or mural nodules. Computed tomography demonstrated a large unilocular cystic mass measuring 27.2cm by 24.1cm by 15.3cm, extending from the epigastrium into the pelvis (Fig. 2 ). There were no septations, calcifications or soft tissue density within. Bowel loops and other abdominal viscera were displaced laterally, and there was also mild dilatation of both pelvicalyceal systems due to extrinsic compression by the mass. The urinary bladder, uterus and bilateral ovaries appeared to be normal and separate from the cystic mass. Blood biochemistry was unremarkable. Figure 3 . Intra-operative finding of a large fluid-filled cystic lesion displacing the sigmoid colon into the right abdomen The patient was counselled and agreeable for an exploratory laparotomy and excision of the cystic lesion. At laparotomy, the patient was found to have a large and tense cystic lesion arising from the descending colon mesentery, which displaced the collapsed sigmoid colon and small bowel loops into the right abdomen, corresponding to the appearance on pre-operative abdominal radiograph and computed tomography (Figs. 3 and 4 ). The huge mesenteric cyst was carefully dissected and successfully excised without spillage of cystic contents, or damage to adjacent viscera and mesentery. On macroscopic examination, the excised cyst measured 39 centimetres in maximum dimension and weighed eight kilogrammes. It had a thin, translucent wall. It was uni-locular and contained clear serous fluid (Fig. 5 ). Microscopic examination showed that the cyst was lined by tubal-type cuboidal epithelium and there was underlying loose spindle-cell stroma – features in keeping with those of a benign Mullerian cyst (Fig. 6 ). The patient was placed on our institution’s Enhanced Recovery After Surgery (ERAS) care bundle. Post-operative pain was managed by regular oral paracetamol 1g every 6 hours and oral tramadol 50mg every 8 hours as required, as well as a continuous infusion of 2% ropivacaine local anaesthetic delivered at a rate of 7ml/hr into the pre-peritoneal plane via an ON-Q PainBuster® elastometric pump, inserted during wound closure at the end of the patient’s surgery (Fig. 7 ). Recovery was uneventful and the patient was fit for discharge 3 days after surgery. The patient remained well and without recurrence at follow-up 6-months and 1-year post-surgery. Informed consent was obtained from the patient for publication of her case and relevant clinical, radiological and histopathological images for the purposes of research and medical education. Discussion Mesenteric cysts are rare entities with varied presentations. Their estimated incidence in the general adult population ranges from 1 in 27,000 to 250,000—consequently most published studies consist of only a handful of cases 1 , 2 . The earliest report of a mesenteric cyst was by the Florentine anatomist Benevieni in 1507, who described a “callus of messaric veins” during the post-mortem examination of an 8-year-old boy. Von Rokitansky described the first chylous cyst in 1842, and Gairdner in 1852 reported the first omental cyst. The earliest successful resection of a mesenteric cyst was described by Tillaux in 1880, and in 1883 Pean detailed a technique of marsupialising mesenteric cysts. Only 600 cases had been reported in literature by 1954 1,2,3 . Mesenteric cysts can arise within the mesentery of any part of the gastrointestinal tract, from duodenum to rectum. In a review series of 162 patients, 60% occurred in mesentery of small bowel, 24% in colonic mesentery, 14.5% arose in the retroperitoneum and the remaining 1.5% had uncertain origin 1 . These cysts are fluid-filled sacs lined with endothelium or mesothelium, and cysts ranging from 2 to 36 centimetres in diameter have been described in literature. These cysts may be uni-loculated, multi-loculated or septated, and can contain serous, chylous, sanguinous or chylolymphatic fluid. Other cysts may arise in the retroperitoneum but are considerably more difficult to manage although they can present in a similar manner 1 , 4 , 5 . Correct pre-operative diagnosis is usually challenging and is typically reliant on clinical examination and radiological imaging. The condition is most common in the fourth decade of life, and patients can present asymptomatically or with non-specific abdominal pain, abdominal distension, nausea and vomiting, constipation or diarrhoea 12 . Symptoms are usually present for a period prior to clinical presentation, with a mean symptom duration of 6.6 months in one review 1 , 2 , 3 , 8 , 11 . Ultrasonography and computed tomography scans of the abdomen are favoured diagnostic modalities. Ultrasonography typically reveals a hypoechoic cystic mass and can also demonstrate septa, debris, abdominal fluid levels. Computed tomography scan allows for determination of size and occasionally the origin of the mass and its relation to neighbouring organs 13 . The precise aetiology of mesenteric cysts has not been well established. Beahrs et al reported four main aetiologies of mesenteric cysts: developmental (enteric, urogenital, lymphoid and dermoid), infective (mycotic, tuberculous or parasitic) traumatic and neoplastic 5 . Mesenteric cysts can also be classified according to their histopathological findings into six groups: lymphatic origin (simple lymphatic cysts and lymphangiomas), mesothelial origin (simple mesothelial cysts, benign cystic mesotheliomas and malignant cystic mesotheliomas), enteric origin (enteric cysts and enteric duplication cysts), urogenital origin, mature cystic teratomas (dermoid cysts) and non-pancreatic pseudocysts (of traumatic or infectious origin) 12 , 14 . The mesenteric cyst in our case report was a benign Mullerian cyst, which falls under the category of urogenital origin. Mullerian cysts are most commonly found in the vagina, uterus and ovaries in females, in the prostate and seminal vesicles in males, in the lumbosacral paravertebral region and rarely in the mediastinum 15 , 16 , 17 . Mullerian cysts arising in the mesentery are hence exceedingly uncommon, with only a few case reports published in literature 15 , 18 , 19 , 20 , 21 . Urogenital cysts are thought to be derived from vestiges of embryonic urogenital apparatus, and can be subclassified into: pronephric, mesonephric, metanephric and Mullerian 18 . Alternative mechanisms proposed include differentiation of coelomic epithelium or peritoneum into tubal type epithelium 22 . Mullerian cysts (also known as paramesonephric cysts) are embryological remnants of the caudal ends of fused Mullerian ducts, and are typically present if the Mullerian ducts fail to undergo complete agenesis in utero. In males, these ducts undergo full degeneration; while in females, the cephalad segments develop into the oviduct and the caudal segments fuse to form the uterus and upper vagina 15 . The treatment of choice for mesenteric cysts is complete surgical excision – conventionally enucleation via an open approach, which also allows for simultaneous evaluation for other pathologies. More recently, successful resection by minimally invasive techniques has been described—the first report of laparoscopic enucleation was authored by Mackenzie in 1993. Laparoscopic resection of mesenteric cysts is increasingly gaining traction as an alternative approach to laparotomy, with cited benefits of reduced post-operative pain and analgesic requirement, shorter hospital stay, earlier return to daily activities and better cosmesis 7 . Aspiration or unroofing and marsupialisation of the cyst have been described in literature, but are generally not recommended if surgical excision is feasible because both of these options are associated with high risks of infection or recurrence 3 , 4 , 8 , 9 , 10 . The risks of malignancy in mesenteric cysts reported in literature range from 3 to 22% 1,2,5 . Laparoscopic resection for larger mesenteric cysts invariably require aspiration for dissection from surrounding structures or extraction from the abdomen, with attendant risks of spillage of cystic contents into the peritoneal cavity 7 , 11 , 23 . An open procedure was chosen for the patient in our case report due to the size of the cyst—the main concerns were that of inadvertent spillage of cystic contents during aspiration and insufficient working space in the peritoneal cavity for laparoscopy. While open surgery is associated with disadvantages including increased pain when compared to a laparoscopic approach, this was managed with the use of regular oral paracetamol 1g every 6 hours and oral tramadol 50mg every 8 hours as required, as well as a continuous infusion of 2% ropivacaine local anaesthetic delivered at a rate of 7ml/hr into the pre-peritoneal plane via an ON-Q PainBuster® elastometric pump, inserted during wound closure at the end of the patient’s surgery. The patient did not require the use of strong opioids such as morphine and was fit for discharge 3 days after surgery on oral analgesia alone. Declarations Funding: No funding was involved. Conflicts of interests/Competing interests: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethics Approval: No ethics review board or ethics approval was sought for this case report as the patient had provided consent and there was no human experimentation involved. Consent to Participate: The case patient has given written and verbal consent for the publication of images and medical information for the furtherance of medical research and education. Consent for Publication: The case patient has given written and verbal consent for the publication of images and medical information for the furtherance of medical research and education. Availability of Data: Not applicable. Code Availability: Not applicable. Authors’ Contributions EKFL was responsible for literature review, writing and paper revision. LWKJ was responsible for literature review, paper revision, critique and quality assessment. KHLC was responsible for formulation of the article, paper revision, critique and quality assessment. Acknowledgements The authors would like to thank Dr Seet Ju Ee from the Department of Pathology, National University Hospital for her expert opinion in the pathological diagnosis of the surgical specimen. References Kurtz R, Heimann T, Beck A, Holt J. Mesenteric and Retroperitoneal Cysts. Ann Surg. 1986;203(1):109–12. Tan J, Tan K, Chew S. Mesenteric Cysts: An Institution Experience Over 14 Years and Review of Literature. World J Surg. 2009;33(9):1961–5. Caropreso P. Mesenteric Cysts. Arch Surg. 1974;108(2):242. Ma A, Ayre K, Wijeyekoon S. Giant mesenteric cyst: a rare cause of abdominal distension diagnosed with CT and managed with ultrasound-guided drainage. BMJ Case Reports. 2012;2012:bcr0220125916. Beahrs O, Judd E, Dockerty M. Chylous Cysts of the Abdomen. Surg Clin North Am. 1950;30(4):1081–96. Dursun H, Albayrak F, Yildirim R, Uyanik A, Yilmaz O, Okcu N, et al. Giant mesenteric cyst can present as pseudoascites with raised Ca125. Turkish J Gastroenterol. 2009;20(4):305–6. Olat C, Özaçmak İ, Yücel T, Özmen V. Laparoscopic Resection of Giant Mesenteric Cyst. J Laparoendosc Adv Surg Tech. 2000;10(6):337–9. Liew S, Glenn D, Storey D. Mesenteric Cyst. ANZ J Surg. 1994;64(11):741–4. Shamiyeh A, Rieger R, Schrenk P, Wayand W. Role of laparoscopic surgery in treatment of mesenteric cysts. Surg Endosc. 1999;13(9):937–9. Lucey B, Kuligowska E. Radiologic Management of Cysts in the Abdomen and Pelvis. Am J Roentgenol. 2006;186(2):562–73. Shimura H, Ueda J, Ogawa Y, Ichimiya H, Tanaka M. Total excision of mesenteric cysts by laparoscopic surgery: report of two cases. Surg Laparoscopy Endoscopy Percutaneous Techniques. 1997;7(2):173–6. De Perrot M, Bründler M, Tötsch M, Mentha G, Morel P. Mesenteric Cysts. Dig Surg. 2000;17(4):323–8. Guraya S, Salman S, Almaramhy H. Giant Mesenteric Cyst. Clin Pract. 2011;1(4):237–8. Isaia M, Erodotou M, Nakos G, Nikolaou N. Complete Surgical Enucleation of a Giant Chylous Mesenteric Cyst. Case Rep Surg. 2020;2020:1–3. Boghossian S, Dasgupta K, Haugk B, White S. Mǔllerian cyst of the mesentery: A case report of an unusual location. Clin Anat. 2010;23(7):866–9. Inatsuchi H, Masuda A, Katsuoka Y, Hihara T, Murakami Y. Giant Mullerian duct cyst: a case report. Hinyokika Kiyo. 1991;37:1719–22. Thomas-de-Montpréville V, Dulmet E. Cysts of the posterior mediastinum showing müllerian differentiation (Hattori's cysts). Annals of Diagnostic Pathology. 2007;11(6):417–20. Lee J, Song S, Park C, Kim B. Müllerian cysts of the mesentery and retroperitoneum: A case report and literature review. Pathol Int. 1998;48(11):902–6. Kondi-Pafiti A, Papadias K, Kairi-Vassilatou E, Chatzistamou-Kiari I, Kontogianni K, Smyrniotis V. Extraovarian mullerian-type cystic tumors of the female. A report of six cases and review of the literature. Eur J Gynaecol Oncol. 2004;25(5):657–9. Harpaz N, Gellman E. Urogenital mesenteric cyst with fallopian tubal features. Arch Pathol Lab Med. 1987 Jan;111(1):78–80. Mokhtari M, Kumar PV. Cytologic findings of urogenital mesenteric cyst. Arch Iran Med. 2013 Jul;16(7):436–8. Yohendran J, Diaz MM, Eckstein R, Wilson T. Benign retroperitoneal cyst of Mullerian type. Asian J Surg. 2004;27(4):333 – 335. Vu JH, Thomas EL, Spencer DD. Laparoscopic management of mesenteric cyst. Am Surg. 1999;65(3):264–5. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 Aug, 2022 Reviewers invited by journal 25 Jul, 2022 Editor assigned by journal 01 Jul, 2022 First submitted to journal 12 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1750165","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":123633557,"identity":"8a26ee08-e6e4-434e-b1d5-2b6a916e2419","order_by":0,"name":"Eugene Leong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYPACCxjDBogZGw8QoUUCxkgDaWkgScthMIlXC79E+sXHBRUScvzS7RcYv/w5b7e2/TDQlhqbaFxaJGfkFBvPOCNhLDnnTAGzbNvt5G1nEoFajqXlNuDQYnAjJ02at00iccONnARmyYbbyWYHgFoYGw7j1GJ/Iyf9N+8/iXqwFok/55LNzj/Er8VAIv0YM2+DRILBjfQDjB/YDtiZ3SBgi8SZN8zSPMckDGfOyGE4zNiWnGB2A2hLAh6/8LenP/zMU2MjDwy6hw9//LGzNzuf/vDBhxobnFoYGHgM4IzDPAwMiWCVCTiVgwD7AziD8QcwPPAqHgWjYBSMghEJABhfY8/4lDqKAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0001-6926-220X","institution":"National University Health System","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Eugene","middleName":"","lastName":"Leong","suffix":""},{"id":123633558,"identity":"826420a3-3bdb-4e20-abaf-485c3ba211f4","order_by":1,"name":"James Wai Kit Lee","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"James","middleName":"Wai Kit","lastName":"Lee","suffix":""},{"id":123633559,"identity":"e462235d-2d9e-40a4-ab9e-72c6e5fed99a","order_by":2,"name":"Christopher Hang Liang Keh","email":"","orcid":"","institution":"Ng Teng Fong General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"Hang Liang","lastName":"Keh","suffix":""}],"badges":[],"createdAt":"2022-06-12 11:05:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1750165/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1750165/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":24511513,"identity":"cf8bfeb6-e6b1-45ca-9c1c-8976902019ec","added_by":"auto","created_at":"2022-07-29 14:54:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87512,"visible":true,"origin":"","legend":"\u003cp\u003ePlain supine abdominal X-ray showed a large central homogenous radio-opacity with displacement of bowel loops to the right abdomen\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/71984503a3723e7be7aea6e2.jpg"},{"id":24511517,"identity":"d7639e42-a379-479f-ad37-4df8316f32bd","added_by":"auto","created_at":"2022-07-29 14:54:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":225828,"visible":true,"origin":"","legend":"\u003cp\u003eComputer tomography of the mass revealed a homogenous unilocular cyst with no internal septations, calcifications or soft tissue density; it appeared to be discrete from bladder, uterus and bilateral ovaries\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/034fbfc752c3a78bceae14c0.png"},{"id":24511516,"identity":"f4ea52a5-5bfa-4414-bc68-686065b0fee7","added_by":"auto","created_at":"2022-07-29 14:54:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":150274,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-operative finding of a large fluid-filled cystic lesion displacing the sigmoid colon into the right abdomen\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/cbf04f4a77b2e35e6245bea7.jpg"},{"id":24512200,"identity":"e4e6bd89-9d7c-4f34-8752-f67e2cb9f04a","added_by":"auto","created_at":"2022-07-29 15:04:13","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":152507,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-operative finding of a large fluid-filled cystic lesion\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/cd76cdb6bd3562a77cfd0f41.jpg"},{"id":24511514,"identity":"acec5c73-5868-440c-b726-a0b1d15213ff","added_by":"auto","created_at":"2022-07-29 14:54:13","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":152002,"visible":true,"origin":"","legend":"\u003cp\u003eGiant mesenteric cyst measuring 39cm in maximum dimension\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/240869b9c220653168047dd1.jpg"},{"id":24511789,"identity":"33f99b60-de7c-486a-9635-1cef78ece660","added_by":"auto","created_at":"2022-07-29 14:59:13","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1202696,"visible":true,"origin":"","legend":"\u003cp\u003eCyst wall showing single layer of tubul-type epithelium and underlying loose spindle-cell stroma (HE, original magnification x10.)\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/b21bab00b395a3fa83295a0e.png"},{"id":24511790,"identity":"097e923a-d5b7-4961-a586-c3ab970d17c4","added_by":"auto","created_at":"2022-07-29 14:59:13","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":413080,"visible":true,"origin":"","legend":"\u003cp\u003ePre- and post-operative appearance of the anterior abdominal wall\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/c5922536d9ab1eef8e5089ea.png"},{"id":24512201,"identity":"44d5b26d-80df-4a22-b126-2b5c69bd4589","added_by":"auto","created_at":"2022-07-29 15:04:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":875077,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1750165/v1/6f80f89f-ae81-4496-a8f9-b483eb43ebeb.pdf"}],"financialInterests":"","formattedTitle":"Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMesenteric cysts are a rare occurrence in daily clinical practice, with an estimated incidence in the general adult population ranging from 1 in 27,000 to 250,000\u003csup\u003e1,2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe diagnosis of mesenteric cysts was traditionally difficult due to an absence of pathognomic clinical features and non-revealing serum biochemistry\u0026mdash;consequently many if not most mesenteric cysts were diagnosed at laparotomy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, and anecdotally large mesenteric cysts have been misdiagnosed as ascites and treated with repeated aspirations with limited success\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The advent of affordable, readily-available and high-quality imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging has allowed for an accurate means of pre-operative diagnosis and consequently allows planning of further management. Once diagnosed, surgical excision via enucleation without spillage of cystic contents remains the mainstay of treatment.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eOur patient was a 42-year-old Chinese woman with no significant past medical history aside from two previous normal vaginal deliveries. She was initially referred from her family physician for gynaecological evaluation of a possible giant ovarian cyst, prior to attending our clinic for a general surgical consultation. She complained of worsening abdominal distension over one year, associated with occasional dull, aching discomfort. She works as a physiotherapist and had intentional weight loss of three kilograms over one year from increased physical activity. She did not report any personal or familial history of malignancy. She did not have abdominal pain, anorexia, early satiety, or apparent changes in bowel habit. Her menstrual cycles were regular, and she did not have dysmenorrhoea. There was no significant history of genetic disorders and personal or family history of cancer. Physical examination revealed a grossly distended abdomen with positive fluid thrill, but no discretely palpable mass.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAbdominal radiograph revealed a large central homogenous radio-opacity, with displacement of the bowel loops to the right side of the abdomen (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Ultrasonography was pertinent for an anechoic uni-loculated cystic mass occupying the entire abdomen and pelvis, with no sonographic features suggestive of a solid component, fat density, internal septations or mural nodules.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComputed tomography demonstrated a large unilocular cystic mass measuring 27.2cm by 24.1cm by 15.3cm, extending from the epigastrium into the pelvis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There were no septations, calcifications or soft tissue density within. Bowel loops and other abdominal viscera were displaced laterally, and there was also mild dilatation of both pelvicalyceal systems due to extrinsic compression by the mass. The urinary bladder, uterus and bilateral ovaries appeared to be normal and separate from the cystic mass. Blood biochemistry was unremarkable.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Intra-operative finding of a large fluid-filled cystic lesion displacing the sigmoid colon into the right abdomen\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was counselled and agreeable for an exploratory laparotomy and excision of the cystic lesion. At laparotomy, the patient was found to have a large and tense cystic lesion arising from the descending colon mesentery, which displaced the collapsed sigmoid colon and small bowel loops into the right abdomen, corresponding to the appearance on pre-operative abdominal radiograph and computed tomography (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The huge mesenteric cyst was carefully dissected and successfully excised without spillage of cystic contents, or damage to adjacent viscera and mesentery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn macroscopic examination, the excised cyst measured 39 centimetres in maximum dimension and weighed eight kilogrammes. It had a thin, translucent wall. It was uni-locular and contained clear serous fluid (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMicroscopic examination showed that the cyst was lined by tubal-type cuboidal epithelium and there was underlying loose spindle-cell stroma \u0026ndash; features in keeping with those of a benign Mullerian cyst (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was placed on our institution\u0026rsquo;s Enhanced Recovery After Surgery (ERAS) care bundle.\u003c/p\u003e \u003cp\u003ePost-operative pain was managed by regular oral paracetamol 1g every 6 hours and oral tramadol 50mg every 8 hours as required, as well as a continuous infusion of 2% ropivacaine local anaesthetic delivered at a rate of 7ml/hr into the pre-peritoneal plane via an ON-Q PainBuster\u0026reg; elastometric pump, inserted during wound closure at the end of the patient\u0026rsquo;s surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Recovery was uneventful and the patient was fit for discharge 3 days after surgery. The patient remained well and without recurrence at follow-up 6-months and 1-year post-surgery. Informed consent was obtained from the patient for publication of her case and relevant clinical, radiological and histopathological images for the purposes of research and medical education.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMesenteric cysts are rare entities with varied presentations. Their estimated incidence in the general adult population ranges from 1 in 27,000 to 250,000\u0026mdash;consequently most published studies consist of only a handful of cases\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe earliest report of a mesenteric cyst was by the Florentine anatomist Benevieni in 1507, who described a \u0026ldquo;callus of messaric veins\u0026rdquo; during the post-mortem examination of an 8-year-old boy. Von Rokitansky described the first chylous cyst in 1842, and Gairdner in 1852 reported the first omental cyst. The earliest successful resection of a mesenteric cyst was described by Tillaux in 1880, and in 1883 Pean detailed a technique of marsupialising mesenteric cysts. Only 600 cases had been reported in literature by 1954\u003csup\u003e1,2,3\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMesenteric cysts can arise within the mesentery of any part of the gastrointestinal tract, from duodenum to rectum. In a review series of 162 patients, 60% occurred in mesentery of small bowel, 24% in colonic mesentery, 14.5% arose in the retroperitoneum and the remaining 1.5% had uncertain origin\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. These cysts are fluid-filled sacs lined with endothelium or mesothelium, and cysts ranging from 2 to 36 centimetres in diameter have been described in literature. These cysts may be uni-loculated, multi-loculated or septated, and can contain serous, chylous, sanguinous or chylolymphatic fluid. Other cysts may arise in the retroperitoneum but are considerably more difficult to manage although they can present in a similar manner\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCorrect pre-operative diagnosis is usually challenging and is typically reliant on clinical examination and radiological imaging. The condition is most common in the fourth decade of life, and patients can present asymptomatically or with non-specific abdominal pain, abdominal distension, nausea and vomiting, constipation or diarrhoea\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Symptoms are usually present for a period prior to clinical presentation, with a mean symptom duration of 6.6 months in one review\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Ultrasonography and computed tomography scans of the abdomen are favoured diagnostic modalities. Ultrasonography typically reveals a hypoechoic cystic mass and can also demonstrate septa, debris, abdominal fluid levels. Computed tomography scan allows for determination of size and occasionally the origin of the mass and its relation to neighbouring organs\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe precise aetiology of mesenteric cysts has not been well established. Beahrs et al reported four main aetiologies of mesenteric cysts: developmental (enteric, urogenital, lymphoid and dermoid), infective (mycotic, tuberculous or parasitic) traumatic and neoplastic\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Mesenteric cysts can also be classified according to their histopathological findings into six groups: lymphatic origin (simple lymphatic cysts and lymphangiomas), mesothelial origin (simple mesothelial cysts, benign cystic mesotheliomas and malignant cystic mesotheliomas), enteric origin (enteric cysts and enteric duplication cysts), urogenital origin, mature cystic teratomas (dermoid cysts) and non-pancreatic pseudocysts (of traumatic or infectious origin)\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe mesenteric cyst in our case report was a benign Mullerian cyst, which falls under the category of urogenital origin. Mullerian cysts are most commonly found in the vagina, uterus and ovaries in females, in the prostate and seminal vesicles in males, in the lumbosacral paravertebral region and rarely in the mediastinum\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Mullerian cysts arising in the mesentery are hence exceedingly uncommon, with only a few case reports published in literature\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Urogenital cysts are thought to be derived from vestiges of embryonic urogenital apparatus, and can be subclassified into: pronephric, mesonephric, metanephric and Mullerian\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Alternative mechanisms proposed include differentiation of coelomic epithelium or peritoneum into tubal type epithelium\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Mullerian cysts (also known as paramesonephric cysts) are embryological remnants of the caudal ends of fused Mullerian ducts, and are typically present if the Mullerian ducts fail to undergo complete agenesis in utero. In males, these ducts undergo full degeneration; while in females, the cephalad segments develop into the oviduct and the caudal segments fuse to form the uterus and upper vagina\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe treatment of choice for mesenteric cysts is complete surgical excision \u0026ndash; conventionally enucleation via an open approach, which also allows for simultaneous evaluation for other pathologies. More recently, successful resection by minimally invasive techniques has been described\u0026mdash;the first report of laparoscopic enucleation was authored by Mackenzie in 1993. Laparoscopic resection of mesenteric cysts is increasingly gaining traction as an alternative approach to laparotomy, with cited benefits of reduced post-operative pain and analgesic requirement, shorter hospital stay, earlier return to daily activities and better cosmesis\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Aspiration or unroofing and marsupialisation of the cyst have been described in literature, but are generally not recommended if surgical excision is feasible because both of these options are associated with high risks of infection or recurrence\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe risks of malignancy in mesenteric cysts reported in literature range from 3 to 22%\u003csup\u003e1,2,5\u003c/sup\u003e. Laparoscopic resection for larger mesenteric cysts invariably require aspiration for dissection from surrounding structures or extraction from the abdomen, with attendant risks of spillage of cystic contents into the peritoneal cavity\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. An open procedure was chosen for the patient in our case report due to the size of the cyst\u0026mdash;the main concerns were that of inadvertent spillage of cystic contents during aspiration and insufficient working space in the peritoneal cavity for laparoscopy. While open surgery is associated with disadvantages including increased pain when compared to a laparoscopic approach, this was managed with the use of regular oral paracetamol 1g every 6 hours and oral tramadol 50mg every 8 hours as required, as well as a continuous infusion of 2% ropivacaine local anaesthetic delivered at a rate of 7ml/hr into the pre-peritoneal plane via an ON-Q PainBuster\u0026reg; elastometric pump, inserted during wound closure at the end of the patient\u0026rsquo;s surgery. The patient did not require the use of strong opioids such as morphine and was fit for discharge 3 days after surgery on oral analgesia alone.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interests/Competing interests:\u003c/strong\u003e On behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e No ethics review board or ethics approval was sought for this case report as the patient had provided consent and there was no human experimentation involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e The case patient has given written and verbal consent for the publication of images and medical information for the furtherance of medical research and education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e The case patient has given written and verbal consent for the publication of images and medical information for the furtherance of medical research and education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode Availability:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEKFL was responsible for literature review, writing and paper revision.\u003c/p\u003e\n\u003cp\u003eLWKJ was responsible for literature review, paper revision, critique and quality assessment.\u003c/p\u003e\n\u003cp\u003eKHLC was responsible for formulation of the article, paper revision, critique and quality assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dr Seet Ju Ee from the Department of Pathology, National University Hospital for her expert opinion in the pathological diagnosis of the surgical specimen.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKurtz R, Heimann T, Beck A, Holt J. Mesenteric and Retroperitoneal Cysts. Ann Surg. 1986;203(1):109\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan J, Tan K, Chew S. Mesenteric Cysts: An Institution Experience Over 14 Years and Review of Literature. World J Surg. 2009;33(9):1961\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaropreso P. Mesenteric Cysts. Arch Surg. 1974;108(2):242.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa A, Ayre K, Wijeyekoon S. Giant mesenteric cyst: a rare cause of abdominal distension diagnosed with CT and managed with ultrasound-guided drainage. BMJ Case Reports. 2012;2012:bcr0220125916.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeahrs O, Judd E, Dockerty M. Chylous Cysts of the Abdomen. Surg Clin North Am. 1950;30(4):1081\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDursun H, Albayrak F, Yildirim R, Uyanik A, Yilmaz O, Okcu N, et al. Giant mesenteric cyst can present as pseudoascites with raised Ca125. Turkish J Gastroenterol. 2009;20(4):305\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlat C, \u0026Ouml;za\u0026ccedil;mak İ, Y\u0026uuml;cel T, \u0026Ouml;zmen V. Laparoscopic Resection of Giant Mesenteric Cyst. J Laparoendosc Adv Surg Tech. 2000;10(6):337\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiew S, Glenn D, Storey D. Mesenteric Cyst. ANZ J Surg. 1994;64(11):741\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShamiyeh A, Rieger R, Schrenk P, Wayand W. Role of laparoscopic surgery in treatment of mesenteric cysts. Surg Endosc. 1999;13(9):937\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucey B, Kuligowska E. Radiologic Management of Cysts in the Abdomen and Pelvis. Am J Roentgenol. 2006;186(2):562\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimura H, Ueda J, Ogawa Y, Ichimiya H, Tanaka M. Total excision of mesenteric cysts by laparoscopic surgery: report of two cases. Surg Laparoscopy Endoscopy Percutaneous Techniques. 1997;7(2):173\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Perrot M, Br\u0026uuml;ndler M, T\u0026ouml;tsch M, Mentha G, Morel P. Mesenteric Cysts. Dig Surg. 2000;17(4):323\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuraya S, Salman S, Almaramhy H. Giant Mesenteric Cyst. Clin Pract. 2011;1(4):237\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsaia M, Erodotou M, Nakos G, Nikolaou N. Complete Surgical Enucleation of a Giant Chylous Mesenteric Cyst. Case Rep Surg. 2020;2020:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoghossian S, Dasgupta K, Haugk B, White S. Mǔllerian cyst of the mesentery: A case report of an unusual location. Clin Anat. 2010;23(7):866\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInatsuchi H, Masuda A, Katsuoka Y, Hihara T, Murakami Y. Giant Mullerian duct cyst: a case report. Hinyokika Kiyo. 1991;37:1719\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas-de-Montpr\u0026eacute;ville V, Dulmet E. Cysts of the posterior mediastinum showing m\u0026uuml;llerian differentiation (Hattori's cysts). Annals of Diagnostic Pathology. 2007;11(6):417\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee J, Song S, Park C, Kim B. M\u0026uuml;llerian cysts of the mesentery and retroperitoneum: A case report and literature review. Pathol Int. 1998;48(11):902\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKondi-Pafiti A, Papadias K, Kairi-Vassilatou E, Chatzistamou-Kiari I, Kontogianni K, Smyrniotis V. Extraovarian mullerian-type cystic tumors of the female. A report of six cases and review of the literature. Eur J Gynaecol Oncol. 2004;25(5):657\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarpaz N, Gellman E. Urogenital mesenteric cyst with fallopian tubal features. Arch Pathol Lab Med. 1987 Jan;111(1):78\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMokhtari M, Kumar PV. Cytologic findings of urogenital mesenteric cyst. Arch Iran Med. 2013 Jul;16(7):436\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYohendran J, Diaz MM, Eckstein R, Wilson T. Benign retroperitoneal cyst of Mullerian type. Asian J Surg. 2004;27(4):333 \u0026ndash; 335.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVu JH, Thomas EL, Spencer DD. Laparoscopic management of mesenteric cyst. Am Surg. 1999;65(3):264\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Gastroenterology, General surgery, Mesenteric cyst, Mullerian cyst, Case report","lastPublishedDoi":"10.21203/rs.3.rs-1750165/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1750165/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMesenteric cysts are a rare occurrence in clinical practice, and even fewer are found to be of Mullerian origin. Diagnosis of mesenteric cysts is typically based on clinical assessment and radiological imaging. Surgical excision remains the primary treatment option. We report a case of a 42-year-old lady presenting with a giant mesenteric cyst weighing eight kilogrammes and analgesia optimisation with local anaesthetic infusion after en-bloc surgical excision. We also review the current literature of this rare clinical entity.\u003c/p\u003e","manuscriptTitle":"Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-29 14:54:11","doi":"10.21203/rs.3.rs-1750165/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2022-08-11T06:58:20+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-25T06:48:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-01T08:37:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2022-06-12T07:03:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"23e7755a-48f8-4258-80a2-12d7242ff07d","owner":[],"postedDate":"July 29th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-18T11:10:12+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-29 14:54:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1750165","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1750165","identity":"rs-1750165","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}