Modi A*, Pardeshi S**, Gupta AS***.
(* Junior resident, ** Assistant Professor, *** Professor, Department of Obstetrics & Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Endometriosis is a common benign gynecological disease in women. Here we are presenting a rare case of broad ligament endometriotic cyst.
The broad ligament is a rare site for endometriosis. The most common site for endometriosis is the ovaries which usually present as a chocolate cyst. The prevalence of this disease increases up to 30 % in patients with infertility and up to 45 % in patients with chronic pelvic pain. Depending upon the site of implantation, endometriosis can be either endopelvic or extrapelvic. Extrapelvic endometriosis is rare but it can occur. These sites include gastrointestinal, urinary tracts, the upper and lower respiratory system, the diaphragm, the pleura, the pericardium, and abdominal scars.
A 32 year old multigravida, married for 13 years presented in the gynecology OPD with complaint of dysmenorrhea since 4 years. She was infertile for 4 years. She was relatively asymptomatic 4 years back when she started having dysmenorrhea, increasing pain with each cycle. Pain would appear 4-5 days before menses and subsided when menses stopped. Pain was severe in intensity, not relieved by medication. She tried some non allopathic treatment too however she had no symptomatic relief. Previous menstrual cycle was normal of 30 days and painless. On general examination she was moderately built and had mild pallor. On per abdominal examination, abdomen was soft, had no guarding, tenderness, or rigidity. Per speculum examination showed cervical erosion, vagina was otherwise healthy. On per vaginal examination uterus was of normal size deviated to the left with restricted mobility. Right fornix was ill-defined, pulled up and tender
Prior to excision of the cyst, the cyst was aspirated and endometriotic fluid aspirate was confirmed. Cyst was then dissected from between the leaves of the broad ligament but it ruptured inadvertently punctured. Chocolate colored endometrotic fluid drained out (figure 2). Cyst wall was peeled off and sent for histopathological examination. Base of the cyst cauterized. Right ovary was densely adherent to the posterior uterine wall on its right side and hence could not be separated. Broad ligament was reconstructed.
Adhesiolysis between sigmoid colon and posterior surface of the uterus was attempted; however in view of excessive bleeding during dissection and significant risk of injury to the sigmoid colon further dissection was abandoned. Abdomen was irrigated and then closed in layers. She tolerated the procedure well. Post operatively she was administered injection luprolide 3.75mg monthly for 3 months. Histopathology report of the cyst wall was confirmed an endometriotic cyst.
Figure 2. Aspiration of the endometrioma.
Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. Its prevalence is 5 % with peak age between 25 to 35 years. As endometriosis is an estrogen dependent condition, it mainly affects female of reproductive age group. The most common site is the ovaries followed by fossa ovarica, uterosacral ligaments, and pouch of Douglas.
In our case the endometriosis collection was between the leaves of the right broad ligament. We postulate that the right ovary which had dense adhesions to the posterior surface of the right broad ligament was the site of an endometrioma which must have ruptured through the posterior leaf of the right broad ligament and an endometriotic collection.
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Modi A, Pardeshi S, Gupta AS. A Case Report Of Broad Ligament Endometriotic Cyst. JPGO 2019. Vol 6 No. 6. Available from: https://www.jpgo.org/2019/07/a-case-report-of-broad-ligament.html