Wagh P*, Samant PY**, Parulekar SV***
(* Senior resident, ** Additional Professor, *** Professor and Head, Department of obstetrics and gynecology, Seth G S Medical college and KEM Hospital, Mumbai, India.)
Giant ovarian tumors may distort the anatomy and pose operative difficulties. We present an image study of a huge ovarian tumor which had grown into the broad ligament leaves and distorted the pelvic organ relationship.
Usually large ovarian cysts, displace the uterus to opposite side or downwards . They may also cause displacement of ureters changing their course which increases the risk of ureteric injuries during surgeries. Such masses may also cause compression of the ureters causing hydroureters and hydronephrosis . Obstruction of pelvic lymphatics by such masses may cause edema of the lower limbs.
In our case, the large cyst had grown into the leaves of broad ligament hence the uterus and fallopian tube were stretched upwards. The relationship of pelvic organs was distorted which posed challenge during removal of the ovarian mass and hysterectomy. Herewith we share the intra-operative images and how challenges were overcome.
A 45 years old, morbidly obese woman weighing 102 kg presented with abdominal distension for one and a half month, associated with dull abdominal pain and breathlessness on and off .
Her abdomen was non tender and over distended. A large cystic mass was felt arising from the pelvis, extending up to the epigastrium. On bimanual examination, the cervix was high up in anterior fornix, a cystic non-tender mass was felt above it, while the uterine size could not be assessed due to obesity. Her Ca 125 levels were 26 u/ml. Ascitic fluid tapped in private hospital showed ADA -63 u/l and no abnormal cells. Computerised Tomography reported a 34x25x22 cm sized ovarian multiloculated cystic lesion suggestive of mucinous or serous cystadenoma. There was no comment on organ relationship distortion.
On laparotomy, a large cyst of the right ovary seen occupying most of the abdominal cavity, it had grown into the broad ligament. A normal sized uterus was seen over the right anterior broad ligament at a level of 2 inches below the level of umbilicus. The right fallopian tube was stretched over the anterior and superior surface of the mass, the fimbriae fanned out over a distance of 3 cm. The left ovary and fallopian tube were normal. The cyst: approximately 35x40x35 cm, smooth surface, large cystic component and nearly 5x 8x 8 cm solid component at the base on right side.
Figure 1: Arrow showing uterus stretched over the anterior wall of the cyst.
Figure 2: Black arrows showing fimbrial end of right fallopian tube, yellow arrow showing the uterus.
Figure 3: White arrow showing left ovary, yellow arrow showing the left fallopian tube, black arrow showing uterus.
Figure 4. Inside of cut section of the cyst
A large ovarian cyst usually expands the fallopian tube over its surface.[1,2,3] It usually displaces the uterus to the opposite side and either downwards or upwards. What was most unusual in the case presented was the location of the uterus on the anterior surface of the ovarian tumor, 5 cm below the umbilicus. Another unusual feature was the fimbrial end of the fallopian tube stretched over a length of 3 cm. Careful identification of these structures as well as other structures like the ureters and the infundibulopelvic ligament is important in successful surgical management of the case and preventing injury to the ureter.
We thank Dr Rashmi Prasad for taking the operative pictures.
- Menahem S, Shvartzman P. Giant ovarian cyst mimicking ascites. J Fam Pract 1994;39:479–481.
- Farinetti A, Butazzi A, Tazzioli G, Saviano L, Saviano M. Giant ovarian cyst. A case weighing 23 kg. Literature review. Minerva Chir 2003;58:261–265.
- Hart WR. Mucinous tumors of the ovary: a review. Int J Gynecol Pathol 2005;24:4–25.
- Zanini P, Cavalca A, Benatti E, Drei B. Benign giant ovarian cystadenoma. Description of a clinical case. Minerva Ginecol 1996;48:215–219.
Wagh P, Samant PY, Parulekar SV. Giant Ovarian Cyst. JPGO 2015. Volume 2 Number 10. Available from: http://www.jpgo.org/2015/10/giant-ovarian-cyst.html