Imaging features of accessory cavitated uterine mass (ACUM): a peculiar yet correctable cause of dysmenorrhea

Accessory cavitated uterine mass (ACUM) is a rare form of developmental mullerian anomaly which causes chronic pelvic pain, dysmenorrhea and infertility in young females. It is a non-communicating, accessory cavity within an otherwise normal uterus, lined by functional endometrium and surrounded by myometrium-like smooth muscle cells which imparts it uterus-like appearance. USG and MRI are the imaging modalities which help in reaching the diagnosis. Knowledge of this entity and awareness of its imaging features can help diagnose this often underdiagnosed and surgically correctable cause of dysmenorrhea.

Laparoscopic complete excision of an enormous simple hepatic cyst occupying the entire abdomen in a child: a case report and literature review

Background

Simple hepatic cysts are common lesions in adults, but rare in children. Because of their benign nature, simple hepatic cysts may not be detected until they grow too large to be diagnosed and resected in a minimally invasive manner.

Case presentation

An 18-month-old girl presented with an enormous cyst occupying the entire abdomen. The beak sign on computed tomography revealed the hepatic origin of the cyst. The cyst was decompressed through the umbilicus, which was opened by the three-triangular-skin-flap technique, thus creating a working space that enabled laparoscopic surgery. The cyst was excised en bloc together with the attached hepatic parenchyma.

Conclusions

Giant simple hepatic cysts occupying the entire abdomen are rare in children. Of 14 reported cases, only 1 underwent laparoscopic treatment. We have herein reported another case of a giant simple hepatic cyst in which the beak sign on imaging and the three-triangular-skin-flap umbilical opening technique were useful for its diagnosis and laparoscopic excision, respectively. Complete excision is desirable because there is a possibility of recurrence or other diseases that require total removal, including hydatid cysts and mesenchymal hamartomas.

Risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions

BACKGROUND

The incidence of retrorectal lesions is low, and no consensus has been reached regarding the most optimal surgical approach. Laparoscopic approach has the advantage of minimally invasive. The risk factors influencing perioperative complications of laparoscopic surgery are rarely discussed.

AIM

To investigate the risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions.

METHODS

We retrospectively reviewed the medical records of patients who underwent laparoscopic excision of retrorectal cystic lesions between August 2012 and May 2020 at our hospital. All surgeries were performed in the general surgery department. Patients were divided into groups based on the lesion location and diameter. We analysed the risk factors like type 2 diabetes mellitus, hypertension, the history of abdominal surgery, previous treatment, clinical manifestation, operation duration, blood loss, perioperative complications, and readmission rate within 90 d retrospectively.

RESULTS

Severe perioperative complications occurred in seven patients. Prophylactic transverse colostomy was performed in four patients with suspected rectal injury. Two patients underwent puncture drainage due to postoperative pelvic infection. One patient underwent debridement in the operating room due to incision infection. The massive-lesion group had a significantly longer surgery duration, higher blood loss, higher incidence of perioperative complications, and higher readmission rate within 90 d (P < 0.05). Univariate analysis, multivariate analysis, and logistic regression showed that lesion diameter was an independent risk factor for the development of perioperative complications in patients who underwent laparoscopic excision of retrorectal cystic lesions.

CONCLUSION

The diameter of the lesion is an independent risk factor for perioperative complications in patients who undergo laparoscopic excision of retrorectal cystic lesions. The location of the lesion was not a determining factor of the surgical approach. Laparoscopic surgery is minimally invasive, high-resolution, and flexible, and its use in retrorectal cystic lesions is safe and feasible, also for lesions below the S3 level.

Diagnosis and laparoscopic excision of accessory cavitated uterine mass in a young woman: A case report

BACKGROUND

Accessory and cavitated uterine mass (ACUM) is an uncommon form of connate Müllerian anomaly seen in young and nulliparous women, which presents as chronic periodic pelvic pain and severe dysmenorrhea. The entity is often underdiagnosed due to a broad differential diagnosis, including rudimentary uterine horn, true cavitated adenomyosis and degenerating fibroids.

CASE SUMMARY

A 22-year-old woman who presented with severe dysmenorrhea and was initially misdiagnosed with cystic adenomyosis. Gynecological examination and ultrasonography were performed. The patient underwent laparoscopic excision of the mass and histopathological examination confirmed the diagnosis. Postoperatively, the patient did well, with no further dysmenorrhea.

CONCLUSION

ACUM is difficult to diagnose. A correct diagnosis can be made only after excision and histopathological evaluation. Surgical excision is necessary and can be carried out by laparoscopy.

Cystic lymphangioma of the greater omentum treated by laparoscopic resection

We report a rare case of cystic lymphangioma of the greater omentum, which was treated by laparoscopic resection. A 61-year-old man was referred to our hospital for the treatment of a perigastric cystic lesion. Esophagogastroduodenoscopy revealed neither a mucosal lesion nor a submucosal tumor in the stomach. Abdominal contrast-enhanced computed tomography imaging showed a cystic lesion in the ventral side of the lower part of the stomach and no mass lesions in the liver. The patient underwent laparoscopic resection of the cystic lesion. The intraoperative observation confirmed that a well-defined cystic lesion was present wrapped in the greater omentum and located predominantly in the right side. Although the cystic lesion was located directly beside the right gastroepiploic artery and vein, excision of the cystic lesion along with the cuff of the omentum was performed without sacrificing the vessels. Macroscopic examination of the resected specimen showed an ovoid, cystic mass measuring 7.5 × 4.3 cm within the omentum. The pathological diagnosis was "cystic lymphangioma without malignant signs." Following surgery, the patient remained symptom-free without evidence of recurrence for 6 months. The laparoscopic approach, being minimally invasive, can be considered the most feasible approach for the resection of an abdominal cystic lymphangioma.

An unprecedented occult non-communicating rudimentary uterine horn treated with laparoscopic excision and preservation of both fallopian tubes: a case report and review of the literature

Background

Müllerian duct anomalies are congenital malformations of the female genital tract and may be of various types. For decades they have been classified according to the American Society of Reproductive Medicine, which mentions unicornuate uterine malformations as the second subgroup. They result from the arrested development of one of the Müllerian ducts and appear in approximately 1/1000 women. These anomalies are usually diagnosed in the second decade of life, because they tend to remain asymptomatic until adolescence and their initial symptoms may vary. Patients present with symptoms such as dysmenorrhea, infertility, and chronic or acute abdominal pain.

Case presentation

We report on a 21-year-old Caucasian German patient who suffered from dysmenorrhea for 7 years. After a transvaginal ultrasound and magnetic resonance tomography of the pelvis was performed, the patient underwent a diagnostic hysteroscopy and operative laparoscopy, and was finally diagnosed with a Müllerian duct anomaly presenting with a non-communicating rudimentary uterine horn. The left tube arose directly in orthotopic location from the cornua of uterus, with no connection to the rudimentary uterine horn or structure.

Conclusion

The anatomic features of this case have not been reported previously and were not consistent with any existing classification. More cases are needed in order to confirm our hypothesis. Gynecologists should always consider Müllerian anomalies as an important differential diagnosis in young patients with abdominal pain.

Laparoscopic excision of a voluminous mesenteric cyst: Case report of a rare entity and review of literature

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Mesenteric cysts are rare but may cause symptoms or complications.

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If so, surgical excision is considered the cornerstone of therapy.

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Laparoscopic excision is feasible.

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The types of mesenteric cyst are discussed though their aetiology is uncertain.

Introduction

The diagnosis and treatment of mesenteric cysts (MC) is a challenge due to rarity, lack of specific symptoms and variability in location and size. Mesenteric cysts are rare surgical entities that occur approximately in 1: 200,000–1: 350,000 hospitalizations.

Presentation of case

A 47-year-old female patient presented in August 2018 with occasional abdominal pains and an abdominal swelling palpable in the lower right quadrant. A CT scan with contrast enhancement confirmed a 11 cm mass with liquid content in the right iliac fossa, clearly separate from other intra-abdominal structures. The mass was completely excised laparoscopically. The patient was discharged on the third postoperative day. She was symptom-free at 30-day follow-up. Histology demonstrated a solitary non-pancreatic cyst of the mesentery with negative cytology for neoplastic cells.

Discussion

The origin of mesenteric cysts (MC) is uncertain. Imaging (by ultrasonography, CT, and MRI) can be diagnostic. Therapy for these cysts should be performed if they are symptomatic or cause complications. The treatment of choice is complete surgical excision. The advent of laparoscopy has allowed the excision of these cysts without laparotomy in the expert hands of surgeons with good experience in advanced laparoscopy. Laparoscopy is not a standard for the presence in the literature of only case reports.

Conclusion

MC are commonly asymptomatic and discovered incidentally. If symptomatic, surgical excision is considered the cornerstone intervention and laparoscopic resection is feasible, causing less pain, a shorter postoperative stay, and quicker recovery of the patient than open operation. Further studies with a higher level of evidence are needed.

Transverse Vaginal Septum with a Hemiuterus: A Laparoscopic-Guided Abdominoperineal Approach

BACKGROUND

Transverse vaginal septum is a rare Müllerian anomaly that can coexist with other defects.

CASE

A 12-year-old patient was referred to our clinic for cyclic, lower abdominal pain. Magnetic resonance imaging revealed the presence of a transverse vaginal septum, a hemiuterus with a nonfunctioning rudimentary horn, and left unilateral ureter and kidney. The septum was excised laparoscopically assisted by a vaginal dilator to guide the dissection. The mucosal gap of the vagina was then bridged with sutures using the perineal approach. The postoperative course was uneventful and the patient was discharged with instructions for vaginal dilations.

SUMMARY AND CONCLUSION

Early identification of a transverse vaginal septum and careful planning of the operation can improve the outcome of corrective surgery and prevent possible complications.

Laparoscopic Excision of Cesarean Scar Ectopic Pregnancy

Background

Cesarean scar ectopic pregnancies are increasing in frequency, due to rise in cesarean deliveries. They should be managed early in pregnancy, preferably by surgical excision, failing which they may rupture, or later develop into morbidly adherent placenta.

Methods

This is a series of five cases described to explain the instrumentations and techniques in the laparoscopic excision of cesarean scar ectopic pregnancies. Written consent was taken from the patients.

Results

All five patients underwent successful laparoscopic excision. Follow-up period was uneventful.

Conclusion

Laparoscopic excision of cesarean scar ectopic is a technically demanding procedure, but with excellent results. All gynecologists should be familiar with this technique due to the increasing incidence of cesarean scar ectopic gestations.

Diagnosis and laparoscopic excision of accessory cavitated uterine mass in young women: Two case reports

Introduction

An accessory cavitated uterine mass (ACUM) is a rare congenital Mullerian anomaly where an accessory cavity with normal endometrial lining lies within a normally functioning uterus. It is common among young and nulliparous women presenting with severe dysmenorrhea and infertility.

Presentation of the Cases

We present two cases of ACUM. The first case was a 22-year-old woman who presented with severe dysmenorrhea and was initially misdiagnosed with non-communicating rudimentary horn The second case was a 36-year-old woman who presented with primary infertility and dysmenorrhea. Gynecological examination and ultrasound scanning were done for both patients. Subsequently, laparoscopic excision of the ACUM was performed on both patients. Histopathological examination confirmed the diagnosis. Postoperatively, both patients did well, with no further dysmenorrhea. The second patient conceived spontaneously at the first attempt and at the time of writing was 33 weeks pregnant without any maternal or fetal problems.

Conclusion

The diagnosis of ACUM is often confused with non-communicating rudimentary uterine horn, true cavitated adenomyosis and degenerating fibroids. It is important to understand and distinguish ACUM. A thorough history, detailed gynecological examination and correct radiological modalities are critical to a proper diagnosis so that the correct surgery can be performed, especially when fertility is desired.

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Accessory cavitated uterine mass is rare congenital Mullerian anomaly.

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It happens among young, nulliparous women presenting with dysmenorrhea and infertility.

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It is a diagnostic challenge and often confused with other differential diagnosis.

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A thorough history, detailed and proper examination and imaging are mandatory.

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Laparoscopic excision is crucial to relieve symptoms and improve reproduction.

Laparoscopic excision of seminal vesicle cystadenoma

We present a case of seminal vesicle cystadenoma in a 58 years old man who presented with obstructive urinary symptoms. Computed tomography scan and magnetic resonance imaging revealed a mass in the left seminal vesicle of the patient with the maximal diameter of 63mm. PSA levels were within normal range. A trans rectal ultrasonography biopsy revealed benign fibromuscular tissues. Emission computed tomography result was negative for bone metastasis. Laparoscopic excision of the seminal vesicle cystadenoma was performed successfully. Pathology results were consistent with benign seminal vesicle cystadenoma. The patient was discharged on the third postoperative day and is currently asymptomatic.

Gastric ectopic pancreas mimicking a gastrointestinal stromal tumour: A case report

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The diagnosis and management of gastric submucosal tumours are fraught with difficulty and uncertainty.

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After a thorough work-up with gastroscopy and endoscopic ultrasonography, a gastrointestinal stromal tumour of the antrum was diagnosed.

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Laparoscopic excision was performed – histopathologically, an ectopic pancreas was diagnosed.

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Despite an adequate work-up, surgery was performed for an essentially benign lesion.

Introduction

The diagnosis and management of upper gastrointestinal tract submucosal tumours can be challenging due to the difficulties with adequate pre-operative characterization and tissue sampling.

Presentation of the case

A 61-year-old female patient underwent esophagogastroduodenoscopy because of epigastric pain and episodic vomiting. A submucosal tumour was found along the greater curvature in the antrum. On endoscopic ultrasound, the mass was suspected to be a gastrointestinal stromal tumour. The patient was referred for laparoscopic excision. The final histopathological examination confirmed an ectopic pancreas, not a gastrointestinal stromal tumour as thought preoperatively.

Discussion

Despite an adequate pre-operative diagnostic workup with endoscopic ultrasonography, the lesion was misdiagnosed as a gastrointestinal stromal tumour and surgery was performed to excise an ectopic pancreas, essentially a benign lesion.

Conclusion

The case highlights the absence of firm diagnostic criteria to differentiate submucosal gastric lesions.

Complete laparoscopic excision of a giant retroperitoneal paraganglioma

Paragangliomas (or 'extra-adrenal phaeochromocytomas') are rare tumours arising from neural crest cells. They occur most commonly in the abdomen along the paraspinal sympathetic ganglion. The malignancy rate can be up to 35% and surgical resection is the recommended treatment. While laparoscopic excision of phaeochromocytomas is now well established, the overall number of cases of paragangliomas reported is much smaller owing to their rarity (even more so for giant paragangliomas of ≥8cm) and controversy remains over the completeness of excision. Furthermore, the risk of malignancy and recurrence rate are higher in paragangliomas, with incomplete excision giving rise to recurrent endocrinopathy and carcinomatosis. We report the case of a 26-year-old woman who underwent laparoscopic excision of an 8.2cm functioning paraganglioma. Complete resection of the tumour was achieved and the patient's symptoms resolved. Twelve months later, she remains well with no evidence of recurrence.

Laparoscopic excision versus open excision for the treatment of choledochal cysts: a systematic review and meta-analysis

In 1723, Vater first described choledochal cyst and in 1977, Todani et al classified this disease. For many years, open excision (OP) as the standard procedure made a great impact in the treatment of choledochal cyst. Since 1995, when Farello et al first reported laparoscopic choledochal cyst excision, laparoscopic excision (LA) has been used worldwide. However, its safety remains a major concern. The aim of this meta-analysis was to compare OP with LA in treating choledochal cyst and then to determine whether LA is safe and valid. The design of this study involved systematic review and meta-analysis. Data sources were Medline, Ovid, Elsevier, Google Scholar, Embase, and Cochrane library. The study selection entailed comparative cohort studies. For data extraction, 2 investigators independently assessed selected studies and extracted the following information: study characteristics, quality, outcomes data, etc. For the results, 7 comparative cohort studies about the effectiveness of LA compared with OP were performed meta-analysis. The results showed that although the LA group had a longer operative time (MD = 56.57; 95% CI = 32.20–80.93; P < 0.00001), LA had a shorter duration of hospital stay (MD = −1.93; 95% CI = −2.51 to −1.36; P < 0.00001), and recovery of bowel function (MD = −0.94; 95% CI = −1.33 to −0.55; P < 0.00001). Meta-analysis found no significant difference between most of the 2 groups: bile leak (RR = 0.60; 95% CI = 0.29–1.24; P = 0.17), abdominal bleeding (RR = 0.33; 95% CI = 0.01–8.98; P = 0.51), pancreatitis (RR = 0.26, 95% CI = 0.06–1.03; P = 0.06), total postoperative complications (RR = 1.04; 95% CI = 0.66–1.62; P = 0.88). The LA group had significant lower rates in intraoperative blood transfusion (RR = 0.20; 95% CI = 0.11–0.38; P < 0.00001), and adhesive intestinal obstruction (RR = 0.17, 95% CI = 0.04–0.77; P = 0.02). In conclusion, compared with open excision, laparoscopic excision is a safe, valid, and feasible alternative to open excision.

Comparison of laparoscopic excision versus open transvesical excision for symptomatic prostatic utricle in children

PURPOSE

The aims of this study were to report our clinical experience with laparoscopic excision (LE) and to compare the outcomes of LE versus open transvesical excision (OTE) for the management of prostatic utricle (PU) in children.

PATIENTS AND METHODS

This was a retrospective single-center study of 14 children who underwent OTE or LE for managing symptomatic PU between April 2003 and December 2014. Age, utricle size, operative time, estimated blood loss, duration of hospital stay, indwelling time of the urethral catheter, presence of residual postoperative utricular stump, and complications were compared between the two groups.

RESULTS

There were no significant differences in age or utricle size between the two groups. Compared to the OTE group, the LE group experienced shorter operative times, lower estimated blood losses, and shorter hospital stays. Indwelling time of the urethral catheter was nearly 8days in the OTE group and 6days in the LE group. All patients had a follow-up visit between 6months and 2years after surgery. Two patients in the OTE group had transient UTI. Postoperative VCUG showed minimal residual utricular stump for 3 patients in the OTE group. However, no patient in either group required further operative therapy.

CONCLUSIONS

LE is a safe and feasible procedure for symptomatic PU in children. Compared to OTE, LE can provide minimally invasive access for achieving good exposure with good short-term outcomes.