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An unusual pelvic cyst found at laparoscopic hernia repair Ioannis Sarantitis,1 Chamindri Weerasinghe,1 Haren Varia,2 Stephen Pettit1 1
Department of Surgery, Blackpool Victoria Hospital, Blackpool, UK 2 Department of Radiology, Blackpool Victoria Hospital, Blackpool, UK Correspondence to Stephen Pettit, [email protected] Accepted 13 March 2015
To cite: Sarantitis I, Weerasinghe C, Varia H, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015210175
DESCRIPTION The finding of unusual contents within hernias merits publication so as to raise surgeons’ awareness of the structures that could be encountered during hernia repair.1 2 We describe a case of a 66-year-old man who underwent elective transabdominal preperitoneal bilateral inguinal hernia repair. At laparoscopy, a large cystic structure was seen arising from the pelvis (figure 1). The hernias were repaired and the patient was informed of the abdominal finding before being discharged home later the same day. The cystic structure was subsequently investigated with a CT scan (figure 2) and MRI (figure 3). The scans showed a benign 16 cm×7.5 cm×6 cm unilocular cyst with calcification in its wall. Aspiration cytology was not performed as this risked puncturing the thin-walled cyst. The radiological diagnosis was of a mesenteric cyst or urogenital cyst. Mesenteric cysts were first described by Benevieni, an Italian anatomist, in 1507.3 They arise during embryological development from ectopic lymphatic tissue or from incomplete fusion of the leaves of the mesentery. They are very rare, occurring in 1 in 200 000 adults. Malignant transformation is exceptionally rare.4 Urogenital cysts are equally rare and arise from vestigial remnants of the urogenital apparatus.5 Malignant change is also exceptionally rare. The management options were to excise the cyst either laparoscopically or by laparotomy to obtain definitive histology, or to adopt a conservative approach with yearly surveillance scans to assess cyst growth or change. In our case, the cyst was completely asymptomatic and radiologically
Figure 1 Operative photograph of pelvic cyst found at laparoscopy.
Figure 2 CT scan showing the pelvic cyst with a calcified wall (arrow). benign, so a conservative approach was adopted. If in future it enlarges and causes pressure symptoms on adjacent structures such as the bladder, excision will be performed.
Figure 3
MRI showing the pelvic cyst (arrow).
Sarantitis I, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210175
1
Images in… Competing interests None.
Learning points
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
▸ If an unusual cystic structure is found incidentally during laparoscopy, it should be photographed to document its size and position, and later investigated with CT scan and MRI. ▸ Asymptomatic urogenital and mesenteric cysts can be managed conservatively as malignant transformation is exceedingly rare. ▸ Large urogenital and mesenteric cysts should be excised if they cause symptoms by compressing adjacent structures. ▸ Urogenital and mesenteric cysts should be excised if serial scans show radiological evidence of malignant transformation.
REFERENCES 1
2
3 4 5
Kassir R, Dubois J, Berremila SA, et al. A rare variant of inguinal henira: cryptorchid testis at the age of 50 years. Etiopathogenicity, prognosis and management. Int J Surg Case Rep 2014;5:416–18. Kassir R, Tarantino E, Lacheze R, et al. Management of spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman. Int J Surg Case Rep 2013;4:1176–8. Pantanowitz L, Botero M. Giant mesenteric cyst: a case report and review of the literature. Internet J Pathol 2000;1:1–5. Bury TF, Pricolo VE. Malignant transformation of benign mesenteric cyst. Am J Gastroenterol 1994;89:2085–7. Mokhtari M, Kumar PV. Cytologic findings of urogenital mesenteric cyst. Arch Iran Med 2013;16:436–8.
Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Sarantitis I, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210175
An unusual pelvic cyst found at laparoscopic hernia repair Ioannis Sarantitis,1 Chamindri Weerasinghe,1 Haren Varia,2 Stephen Pettit1 1
Department of Surgery, Blackpool Victoria Hospital, Blackpool, UK 2 Department of Radiology, Blackpool Victoria Hospital, Blackpool, UK Correspondence to Stephen Pettit, [email protected] Accepted 13 March 2015
To cite: Sarantitis I, Weerasinghe C, Varia H, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015210175
DESCRIPTION The finding of unusual contents within hernias merits publication so as to raise surgeons’ awareness of the structures that could be encountered during hernia repair.1 2 We describe a case of a 66-year-old man who underwent elective transabdominal preperitoneal bilateral inguinal hernia repair. At laparoscopy, a large cystic structure was seen arising from the pelvis (figure 1). The hernias were repaired and the patient was informed of the abdominal finding before being discharged home later the same day. The cystic structure was subsequently investigated with a CT scan (figure 2) and MRI (figure 3). The scans showed a benign 16 cm×7.5 cm×6 cm unilocular cyst with calcification in its wall. Aspiration cytology was not performed as this risked puncturing the thin-walled cyst. The radiological diagnosis was of a mesenteric cyst or urogenital cyst. Mesenteric cysts were first described by Benevieni, an Italian anatomist, in 1507.3 They arise during embryological development from ectopic lymphatic tissue or from incomplete fusion of the leaves of the mesentery. They are very rare, occurring in 1 in 200 000 adults. Malignant transformation is exceptionally rare.4 Urogenital cysts are equally rare and arise from vestigial remnants of the urogenital apparatus.5 Malignant change is also exceptionally rare. The management options were to excise the cyst either laparoscopically or by laparotomy to obtain definitive histology, or to adopt a conservative approach with yearly surveillance scans to assess cyst growth or change. In our case, the cyst was completely asymptomatic and radiologically
Figure 1 Operative photograph of pelvic cyst found at laparoscopy.
Figure 2 CT scan showing the pelvic cyst with a calcified wall (arrow). benign, so a conservative approach was adopted. If in future it enlarges and causes pressure symptoms on adjacent structures such as the bladder, excision will be performed.
Figure 3
MRI showing the pelvic cyst (arrow).
Sarantitis I, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210175
1
Images in… Competing interests None.
Learning points
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
▸ If an unusual cystic structure is found incidentally during laparoscopy, it should be photographed to document its size and position, and later investigated with CT scan and MRI. ▸ Asymptomatic urogenital and mesenteric cysts can be managed conservatively as malignant transformation is exceedingly rare. ▸ Large urogenital and mesenteric cysts should be excised if they cause symptoms by compressing adjacent structures. ▸ Urogenital and mesenteric cysts should be excised if serial scans show radiological evidence of malignant transformation.
REFERENCES 1
2
3 4 5
Kassir R, Dubois J, Berremila SA, et al. A rare variant of inguinal henira: cryptorchid testis at the age of 50 years. Etiopathogenicity, prognosis and management. Int J Surg Case Rep 2014;5:416–18. Kassir R, Tarantino E, Lacheze R, et al. Management of spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman. Int J Surg Case Rep 2013;4:1176–8. Pantanowitz L, Botero M. Giant mesenteric cyst: a case report and review of the literature. Internet J Pathol 2000;1:1–5. Bury TF, Pricolo VE. Malignant transformation of benign mesenteric cyst. Am J Gastroenterol 1994;89:2085–7. Mokhtari M, Kumar PV. Cytologic findings of urogenital mesenteric cyst. Arch Iran Med 2013;16:436–8.
Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Sarantitis I, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210175
