Innovative laparoscopic technique for the resection of a giant abdominal cyst in a young female: A case report.

A 23 year old female with 2 years history of progressive abdominal distension, early satiety and urinary urgency but no pain, weight loss or systemic symptoms. Her mother had family history of ovarian cyst, and her menstrual cycles were normal. Abdominal distension with dull percussion was found, but no tenderness or guarding. Ultrasound identified a cyst 16 × 24 cm that compressed abdominal organs. A 30 × 25.6 × 16.8 cm midline intraperitoneal cyst was seen on contrast enhanced CT with mass effect, involving the uterus, ovaries and extending from the liver to the pelvis. With a fluid density of 20 HU and no calcifications, soft tissue components, or enhanced septations, the cyst was felt to have a benign etiology. Laboratory investigations, including tumor biomarkers alpha-fetoprotein, carcinoembryonic antigen, cancer antigen 19-9, cancer antigen 125, were all within normal ranges, with a Risk of Malignancy Algorithm (ROMA) score of 4.1 %. Serological testing for Echinococcus granulosus was negative. A giant intra-abdominal cyst was diagnosed preoperatively, and laparoscopic cyst aspiration with exploration, ensuring oncological safety, was planned under general anesthesia as an alternative to laparotomy. Antibiotic prophylaxis was given one day before the operation. Then discharge home with only analgesia. During the procedure, we encountered challenges with the insertion of the primary trocar due to a cyst occupying the umbilical and left hypochondrium regions ( Fig. 1 ). A supraumbilical 10 mm incision was made, and after deepening to the peritoneum ( Fig. 2 ), needle aspiration was performed through the tense cyst. After disconnecting the syringe from the needle, a small suction device was inserted through the needle to aspirate approximately 4 l of clear, frothy fluid, ensuring careful management to avoid spillage ( Fig. 3 ). Fig. 1 Cyst in the umbilical and left hypochondrium regions. Fig. 1 Fig. 2 Supraumbilical incision and peritoneal access. Fig. 2 Fig. 3 Aspiration of clear, frothy fluid from the cyst. Fig. 3 Cyst in the umbilical and left hypochondrium regions. Supraumbilical incision and peritoneal access. Aspiration of clear, frothy fluid from the cyst. The cyst was then grasped with two artery forceps and extracted through the incision, with gauze placed around the wound to prevent any fluid leakage ( Fig. 4 ). After creating a small opening in the cyst and aspirating an additional 7 l of fluid, the cyst collapsed. The opening was ligated, and the cyst was reintroduced into the abdomen ( Fig. 5 ), facilitating the insertion of the primary 10 mm trocar and a 5 mm port in the right lumbar region, followed by the establishment of pneumoperitoneum at 12–15 mmHg. Intraoperative exploration confirmed the presence of a 30 × 20 cm cyst originating from the right adnexa, adherent to the right ovarian tube and ovary, with no evidence of malignancy or significant pathology in the pelvis ( Fig. 6 ). Fig. 4 Cyst extracted with fluid containment. Fig. 4 Fig. 5 Cyst collapsed after additional aspiration and ligation. Fig. 5 Fig. 6 Intraoperative view of cyst originating from right adnexa. Fig. 6 Cyst extracted with fluid containment. Cyst collapsed after additional aspiration and ligation. Intraoperative view of cyst originating from right adnexa. Consultation with gynecology team led to a decision to convert to open surgery, resulting in a small Pfannenstiel incision. A cystectomy was performed while preserving the right tube and ovary, alongside a partial omentectomy ( Fig. 7 ). Peritoneal washings were conducted, hemostasis was achieved, and the incision was closed. The excised cyst measured 19 × 21 × 8 cm, weighed 11.5 kg, and contained clear to pale yellow fluid with thickened walls and no solid formations ( Fig. 8 ). The surgery yielded no unexpected complications during recovery and thus allowed the patient's discharge with good health results. The patient exhibited standard postoperative healing throughout the first week without any undesirable outcomes. The patient showed no postoperative symptoms during her five-month follow-up period alongside evidence of no persistent issues. Fig. 7 Open surgery for cystectomy and partial omentectomy. Fig. 7 Fig. 8 Excised cyst with clear fluid, thickened walls. Fig. 8 Open surgery for cystectomy and partial omentectomy. Excised cyst with clear fluid, thickened walls. Histopathology report showed the cyst is lined with non-atypical, cuboidal epithelium resembling fallopian tube or non-ciliated epithelium resembling ovarian surface epithelium. The Stroma contains fibroblasts with an Absence of infiltrative pattern. Final Diagnosis: Ovarian cyst adenofibroma measuring 21 × 19 × 8 cm. Absence of proliferativeepithelial component. Absence of neither borderline component nor malignancy.

A case report. Author: Dr. Reem Shadaid AlQahtani. Co-Author: Dr. Khaldoon Alkhums.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. Written consent is attached.

The study was reviewed by the Research Committee, Security Forces Hospital Dammam, and an ethical approval letter is available.

This research received no funding or financial support from any sources.

This study does not involve any new techniques or technologies; therefore, research registration is not required.

Dr. Reem Shadaid AlQahtani.

The laparoscopic management of this unusually large adnexal mass offers valuable insights for surgical planning in complex gynecological cases. With thorough preoperative evaluation and careful patient selection, large pelvic masses can be treated laparoscopically by experienced surgeons. Further research is needed to identify predictors of successful laparoscopic resection for massive adnexal pathologies.

This case marked our institution's first laparoscopic resection of such a large mass and it was notable in our clinical practice. These are typically done by open laparotomy. Based on the careful considerations of patient's age, benign tumor appearance and potential benefits of minimally invasive surgery, laparoscopic intervention was deemed the optimal treatment approach. Cyst removal was done safely through the laparoscopic approach, avoiding open laparatomy with cosmetic outcome due to a small Pfannenstiel incision. This not only reduced post-operative pain and recovery time for the patient, but also decreased the risk of wound-related complications compared to a traditional open procedure [ [4] , [5] , [6] , [7] ]. However, for the laparoscopic approach to the resection of large adnexal cysts, some crucial criteria need to be considered in our patient selection criteria, anatomical constraints as well as institution expertise. Then, laparoscopic surgery is indicated when imaging and biomarker assessments strongly favor benign pathology so as to provide a minimally invasive approach less morbid. Nevertheless, previous studies have documented the occurrence of conversion to open surgery when poor visualization, extensive adhesions, intraoperative hemorrhage or suspicion of malignancy occurred. However, in our case the laparoscopic technique was mostly successful apart from the need to convert from a small Pfannenstiel incision due to the size of the cyst and lack of gynecologic laparoscopic expertise. According to literature, factors influencing conversion of laparoscopic repair of ovarian cysts include tumor size >10 cm, limited laparoscopic experience, and intraoperative complications such as cyst rupture. A preoperative identification of these predictors may help in patient selection and surgical planning for the management of large adnexal cyst that optimizes patient outcomes [ 9 ]. It is essential to highlight that the procedure initially performed laparoscopically by general surgery team then ultimately required conversion to open with a small pfannestiel incision due to the massive size and the gynecologist's limited laparoscopic experience. However, the majority of the procedure was completed using minimally invasive techniques, and the patient benefited from the reduced morbidity of the laparoscopic approach up until the point of conversion. Managing large adnexal cysts often involves reducing their size, and a scheduled puncture to aspirate the cyst's contents can help minimize the risk of spillage compared to an incidental rupture during surgical procedures. Some practitioners have employed a purse string suture technique around the cyst's surface, followed by creating an opening to aspirate its contents [ 12 ]. This method allows for the quick closure of the opening with the purse string, effectively limiting any potential spillage of cyst contents. Subsequently, cystectomy or salpingo-oophorectomy can be performed more seamlessly after the cyst has reduced in size [ 4 , 7 ]. Some practitioners have employed a suction-irrigation system to precisely access the cyst, allowing for the aspiration of its contents. This method facilitates the removal of cyst fluid in a controlled manner [ 8 ]. Despite the application of stringent criteria to restrict laparoscopic procedures to tumors with a higher likelihood of being benign, a few patients were still found to have malignant tumors. A retrospective study spanning six years indicated that the unexpected rate of malignancy following laparoscopic excision of adnexal cysts is approximately 0.7 %, while the rate of borderline malignancies is around 0.8 % [ 9 ]. Intraoperative rupture of an unforeseen ovarian malignancy can lead to disease upstaging, necessitating additional surgical intervention and the requirement for adjuvant chemotherapy. The 2016 green-top guideline established a flowchart for managing ovarian tumors in postmenopausal women based on a risk of malignancy index [ 10 ]. The risk of malignancy index is calculated by multiplying the ultrasound score by the menopausal status and the serum CA125 level (U/mL). The ultrasound score can be 0, 1, or 3, depending on the presence of specific traits. One point is assigned concerning each of the following indicators: multilocular cyst, solid areas, metastases, ascites, and bilateral lesions. A score of 5 is given if more than one aspect is noted; 0 if none. Menopausal status contributes a score of 3 if the patient is postmenopausal and 1 if otherwise [ 13 ]. A total score below 200 signifies a low risk of malignancy, while a score of 200 or higher indicates an increased risk. This formula suggests that Management of large adnexal tumors by two port laparoscopic trocar suction should be done with caution, in post-menopausal women [ 14 ]. As outlined by the National Comprehensive Cancer Network NCCN guidelines, if ovarian cancer is found following recent surgery, recommend that an imaging of the chest, abdomen and pelvic should be done, and that surgery to stage or cytoreduce any remaining tissue must be contemplated. Subsequent Stage Appropriate Adjuvant treatments are stage specific [ 3 ].

Abdominal cystic lesions encompass a wide range of pathologies, with the majority originating from the ovary. These cysts can vary significantly, from simple functional cysts to malignant tumors [ 1 ]. The differential diagnosis is broad, including conditions such as peritoneal cysts, Para-ovarian cysts, appendiceal mucoceles, cystic adenomyosis, hepatic cysts, pancreaticobiliary cysts, lymphoceles, cystic lymphangiomas, intestinal duplication cysts, and bladder diverticula, to enumerate only a few. As ovarian cysts increase in size, they may become symptomatic, exhibiting signs of abdominal, pelvic, or back pain, progressive distension, nausea, and vomiting. Although ultrasound, computed tomography, and magnetic resonance imaging can provide clues as to the cyst's origin, they might not aid in diagnosis if a more specific organic origin cannot be found [ 2 ]. Laparoscopic techniques, as compared with laparotomy, offer reduced hospitalization, less postoperative discomfort and quicker recovery. Consequently, laparoscopy is often considered the optimal surgical approach for benign adnexal cysts. However, the size of the adnexal cyst poses a significant challenge to laparoscopic intervention. Interposition of large cysts can restrict surgical field and lead to accidental rupture. In view of these limitations, an optimal surgical approach to the management of large adnexal cysts must be determined carefully [ 3 ]. In this case, we present a novel technique for laparoscopic management of large abdominal cysts, featuring simultaneous closed aspiration of intracystic fluid while ensuring oncological safety. This work has been reported in line with the SCARE criteria [ 11 ].

There are no conflicts of interest to declare.