A giant ovarian cyst torsion: Case report

INTRODUCTION

Adnexal torsion (AT) is one of a gynecological condition characterized by an acute abdomen. Clinically, a giant ovarian cyst torsion with a diameter of 30 cm is rare. Therefore, an accurate and timely diagnosis and treatment are important.

PATIENT CONCERNS

A 25-year-old unmarried female, presented to the emergency department with intermittent abdominal cramps after a sudden change in position. Considering her symptoms and examination, ultrasound, and magnetic resonance imaging (MRI) results, ovarian cyst torsion was suspected.

DIAGNOSIS

Giant ovarian cyst torsion.

INTERVENTIONS

Surgical intervention with exploratory laparotomy was performed immediately.

OUTCOMES

Intraoperatively, we found a 30-cm left ovarian cyst with a clear root. The left fallopian tube, infundibulopelvic ligament, and ovarian ligament were twisted 900 degrees. Finally, the pathological report revealed mucinous cystadenoma.

CONCLUSION

Giant ovarian cyst torsion with a diameter of 30 cm is rare. Considering her symptoms and examination, ultrasound, and MRI results, ovarian cyst torsion was suspected. The patient was successfully treated using emergency surgery.

Asymptomatic uterine perforation and IUD migration to the broad ligament: A case report

RATIONALE

Uterine perforation is a serious complication of intrauterine contraceptive device (IUD) placement. However, as complete uterine perforation and extrauterine migration may remain asymptomatic, thorough localization of the IUD is important prior to reinsertion.

PATIENT CONCERNS

A 33-year-old patient who has had 4 IUD insertions, wherein the location of the first IUD (inserted 14 years ago) was not identified prior to reinsertion and replacement of the subsequent three. She presented to hospital with a 6-month history of abdominal pain. Pelvic ultrasonography (US), radiography, hysteroscopy and laparoscopy examinations confirmed that a retained migrated IUD in the right broad ligament.

DIAGNOSIS

Uterine perforation, IUD migration to the broad ligament.

INTERVENTIONS

The patient underwent hysteroscopy and laparoscopy.

OUTCOMES

Both IUDs were successfully removed without any complications.

[Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

Unusual case of a leiomyoma in the space of Retzius mimicking broad ligament fibroid

This case report will discuss an interesting case of a patient who presented with pain in the lower abdomen of 2-month duration. Clinical examination and imaging findings were suggestive of a broad ligament fibroid. However, intraoperatively, the mass was found to be present in the space of Retzius, which is an extremely rare location for such a pathology. The access to the tumour was very challenging. Successful surgical excision was done with the help of a multidisciplinary team involving a gynaecologist, a urologist and an anaesthetist. Histopathology reported it to be benign leiomyoma. Postoperatively, the patient made an uneventful recovery.

Reaction of Arterial and Venous Branches of the Broad Ligament of the Rat Uterus to Low-Intensity Red Laser Irradiation

Using the biomicroscopy method, we studied the reaction of arterial and venous vessels of the broad ligament of the uterus in outbred female rats to irradiation with helium-neon laser (λ=632.8 nm; power output 2 mW). Small arteries were found to be most sensitive to laser irradiation. The veins of the broad ligament of the uterus demonstrated lower reactivity to laser irradiation of the same duration than arterial vessels, which can be explained by morphological, functional, and hemodynamic differences.

Allen-Masters syndrome as a cause of status ileus - case report

INTRODUCTION

Internal hernias are rare and are encountered in a small percentage of cases. The hernia in the broad ligament of uterus (Allen-Masters syndrome) is a unique type of internal hernia which represents only approximately 4% of all internal hernias.

CASE REPORT

We present the case of a 39-year-old woman admitted for clinical signs of mechanical bowel obstruction. CT examination revealed a dilated loop of small intestine in the left lower abdomen. The patient underwent laparoscopic surgery with the finding of an incarcerated small bowel loop in the ligamentum latum uteri. Small bowel deliberation and ligament defect suture were performed.

CONCLUSION

A defect in the ligamentum latum uteri (Allen-Masters syndrome) is a rare diagnosis, usually discovered as an incidental finding in female patients with ileus. This syndrome may explain the vague problems of many patients whose symptoms include dyspareunia, dysmenorrhea, acute and chronic pelvic pain. Allen-Masters syndrome can be diagnosed and successfully managed by laparoscopic approach.

Small Bowel Obstruction by Broad Ligament Hernia: Three Case Reports, Management and Outcomes

Internal hernias are a rare cause of bowel obstruction (1%) and can be caused by broad ligament defects in 4% to 7% of the cases. These defects may be congenital or acquired and are classified according to its anatomical location. This paper reports three cases of small bowel obstruction by broad ligament hernia. The patients, three women aged from 35 to 51 years old, were admitted to the emergency department with small bowel obstruction. An exploratory laparotomy was performed during which an internal hernia through a broad ligament defect was identified. In all cases the hernia content was reduced and the defect closed. One of the patients required a segmental enterectomy. All patients had a favorable outcome. This paper aims to raise awareness about the broad ligament hernia as a cause of bowel obstruction, namely in middle-aged women with no surgical history.

An incidental diagnosis of a giant paraovarian cyst in a female teenager: A case report

RATIONALE

Paraovarian cysts (PCs) are cystic tumors that can be encountered between the ovarian hilum and the ovarian fimbria located within the mesosalpinx and broad ligament, being usually diagnosed within the 3rd and 4th decade of life.

PATIENT CONCERNS

We report the case of a 15-year-old female admitted in our clinic for consciousness loss, who was incidentally diagnosed with a giant pelvic cystic at ultrasound.

DIAGNOSES

The magnetic resonance image showed a cystic mass of 170/140/85 mm, suggesting an origin from the left ovary, reaching the subhepatic area.

INTERVENTIONS AND OUTCOMES

The surgical intervention revealed 3 PCs, a giant one and 2 smaller ones within the large ligament. The cysts were removed by laparoscopic approach, and the histologic examination did not reveal any signs of neoplasia.

LESSONS

In addition to their rarity, giant PCs can be an incidental diagnosis in patients presenting unrelated symptoms resulting in increased difficulties related to the diagnosis. Moreover, the imagistic tools might not establish precisely the origin of these cysts, and therefore, the final diagnosis and treatment approach could be determined sometimes only during the surgical intervention.

Broad Ligament Haematoma Following Normal Vaginal Delivery

A 37-year-old, patient presented in emergency with history of normal vaginal delivery followed by development of abdominal distention, vomiting, constipation for last 3 days. She was para 4 and had normal vaginal delivery by traditional birth attendant at peripheral hospital 3 days back. Imaging study revealed a heterogeneous complex mass, ascites, pleural effusion, air fluid levels with dilatation gut loops. Based upon pelvic examination by senior gynaecologist in combination with ultrasound; a clinical diagnosis of broad ligament haematoma was made. However, vomiting and abdominal distention raised suspicion of intestinal obstruction. Due to worsening abdominal distention exploratory laparotomy was carried out. It was pseudo colonic obstruction and caecostomy was done. Timely intervention by multidisciplinary approach saved patient life with minimal morbidity.

Surgical speed and risk for maternal operative morbidity in emergent repeat cesarean delivery

OBJECTIVE

The purpose of this study was to determine whether surgical speed is associated with maternal outcomes in women who have a history of previous cesarean delivery (CD) and who require emergent delivery.

STUDY DESIGN

This is a secondary analysis of a multicenter, prospective observational study of women with a history of previous CD. Women who attempted a vaginal birth after CD and required emergent CD were dichotomized into those with a skin incision-to-fetal delivery time of ≤2 min (I-D ≤2) or >2 min (I-D >2), based on the mode I-D. Rates of composite maternal complications and specific surgical complications were compared.

RESULTS

Seven hundred ninety-three women had an emergency repeat CD: 108 women (13.6%) had I-D ≤2, and 685 women (86.4%) had I-D >2. The composite of maternal morbidity occurred in 36% of women with I-D≤2 and 23% with I-D>2 (P < .01). Women with I-D ≤2 had higher odds of intraoperative transfusion, uterine artery ligation, and broad ligament hematoma. In a multivariable regression model, the only variable that remained associated with maternal outcome was I-D (relative risk, 1.66; 95% confidence interval, 1.23-2.23). There was no difference in the incidence of neonatal acidemia between groups.

CONCLUSION

Among women who underwent emergent repeat cesarean delivery, surgical speed was associated with an increased risk for maternal complications.

A case of symptomatic mass in the right iliac fossa: a Bermuda Triangle which often lies the right diagnosis

Disease of the iliac fossa can often be accompanied by non-specific symptoms and some of these are exclusively caused by the compression of bulky masses of other neighboring structures. In young women a differential diagnosis is a non trivial task as several possible causes have to be taken into account. Thus, intraligamentary tumors, which are extremely rare finding, are frequently confused with uterus, ovary or intestinal tumors. Even if myomas are the most benign tumors of the female genital tract, broad ligament leiomyomas are an unusual finding in women of reproductive age. These tumors are often asymptomatic until they reach a volume likely to cause symptoms related to the mass pressure. An accurate patient's anamnesis and examination serve as a guide to further examinations. Ultrasound is the first line imaging as it can show ovarian or other pelvic mass and doesn't involve exposure to radiations in young patients, who can be pregnant. We describe the clinical presentation and imaging features of a broad ligament leiomyoma, which presented as an inguinal mass in a patient with a right iliac fossa pain. We also report our diagnostic process performing the differential diagnosis with other potential pathologies of RIF. In these cases, a preoperative disease classification discriminating the benign or malignant tumor nature is closely linked to the proper patient management.

[Exceptional hemoperitoneal third trimester of pregnancy]

We report a case of spontaneous break of the wide ligament revealed by an abdominal pelvic painful syndrome of rough appearance in 36 weeks+2 days with an acute foetal suffering and an important hemoperitoneal to a primigeste of 32 years. The laparotomy explorer allowed to make the diagnosis but the foetal forecast was dramatic. The foetal extraction has to be made as a matter of urgency and at the same time that the vascular haemostasis.

[Internal hernia to the broad ligament: report of a rare case solved with laparoscopy and review of the literature]

We note a specific case report of a 38 year old patient, who presented to an emergency room with an 8-hour history of a continuous and progressive, abdominal pain syndrome. Without fever, nausea, vomiting, or urinary tract symptoms, and with a 36-hour history of constipation. We established as a first possibility the clinical diagnosis of, acute appendicitis vs. an ovarian cyst complication, such as rupture or torsion. After the initial basic diagnostic tests, we decided to do a laparoscopic approach for purposes of diagnosis and treatment.

Full-term broad ligament pregnancy

A broad ligament pregnancy is an extremely rare condition. The eventuality of such pregnancies reaching full term is even rarer. A full-term broad ligament pregnancy occurring through a rent in a previous lower segment caesarean scar has only been mentioned in literature but not reported. Our patient is an unbooked case, reported to us at 39 weeks of pregnancy. On clinical examination, an ultrasound and an MRI, a diagnosis of abdominal pregnancy was made. Ultimately the final diagnosis was made only on laparotomy. A broad ligament pregnancy was found with a rent in the previous caesarean scar communicating the fetal sac.

[Ectopic intraligamentary pregnancy]

Intraligamentary pregnancy is a rare form of ectopic pregnancy and a type of abdominal pregnancy, preoperative diagnosis is very difficult. This paper describes the case of a 24-year-old woman with a history of uterine curettage uncomplicated; she consulted due to abdomina pain in the right lower quadrant of seven days of duration, which gradually increased in intensity being 10/10 visual scale analogous (VAS). Obstetrical ultrasound was performed reporting: ectopic localization to annex right of 15.2 weeks gestational age, with heart rate of 152 beats per minute. The patient was admitted and underwent to emergency exploratory laparotomy, which found right paratubaric ectopic pregnancy. The histopathology report was of broad ligament ectopic pregnancy. Specimen of 9 x 8 x 7.5 cm and 200 grams.

[Incarcerated internal hernia through a breach of the broad ligament, a case report]

We report a case of 44-year-old women presented with an acute small bowel obstruction revealated by tomodensitometry. Laparotomy showed an incarcerated internal hernia through the broad ligament. We performed liberation of the ileal segment and closed the hernial orifice. The patient evolution was excellent.

Broad ligament leiomyosarcoma in a premenopausal nulliparous woman: case report and review of the literature

Leiomyosarcomas of the broad ligament of the uterus are extremely rare tumors. Most of the time they are diagnosed in older women and despite radical surgical treatment prognosis is dismal. We present a rare case of a 38-year-old nulligravida presenting with a large, firm mass, fixed in the pelvis. After enucleation of the tumor, histological examination revealed the presence of a broad ligament leiomyosarcoma, leading to total abdominal hysterectomy and bilateral salpingo-ophorectomy three weeks later. Management options and cases reported in the literature are reviewed.

Leiomyosarcoma of the broad ligament: a case report and review of the literature

Leiomyosarcoma of the broad ligament is a rare tumour, since only 15 cases have been reported thus far in the English literature. We describe the case of a 35-year-old patient with primary leiomyosarcoma of the broad ligament. The histologic diagnosis and management of this rapidly progressive and highly malignant tumour are also discussed. The tumor had high mitotic activity and more than ten mitotic figures were found for ten high-power fields. The treatment consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection. The patient received pelvic radiotherapy and chemotherapy considering the high grade of malignancy. No evidence of metastasis has been noted after a follow-up of 12 months.

[Pelvic PEcoma of the broad ligament with lymph node metastasis: case report and bibliographic review]

OBJECTIVE

We describe and document the first case of PEcoma published in Spain following the PubMed database. We review the bibliography about these tumors.

METHODS/RESULTS

39 year-old female patient with a 9 cm pelvic tumor discovered in a routine gynecologic review. CT scan showed multiple periaortic adenopathies extending up to the left renal vein. The diagnosis of PEcoma was obtained by needle biopsy. Tumor excision including left annex and aortoiliac lymphodenectomy were performed. Pathology confirmed the diagnosis after immunohistochemical study with smooth muscle actin and HMB-45. No adjuvant treatment was given. After one year of follow-up the patient does not show signs of recurrence of the CT scan. A PubMed search was performed finding 73 references about this kind of tumor the conclusions of which are exposed in this article.

CONCLUSIONS

Perivascular epithelioid cell tumor, PEcoma, is a very low incidence mesenchymal neoplasia with uncertain malignancy.

Neoadjuvant bleomycin, etoposide, and cisplatin in adult neuroblastoma arising from the broad ligament of the uterus

BACKGROUND

A case of primary neuroblastoma arising from the broad ligament with excellent response to neoadjuvant bleomycin, etoposide, and cisplatin (BEP) is reported.

CASE

A 48-year-old woman, G0, who presented with acute renal failure, an enlarged pelvic mass, and abdominal pain was diagnosed with adult neuroblastoma arising from the broad ligament of the uterus. She received three cycles of neoadjuvant therapy consisting of bleomycin, etoposide, and cisplatin (BEP) given every 3 weeks and had an excellent initial response. She then underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and appendectomy, with pathologic analysis revealing small residual disease on the broad ligament of the uterus and omentum. The patient died of recurrent disease 20 months after her initial diagnosis.

CONCLUSIONS

The clinical management of cancer in the broad ligament of the uterus must be tailored to the pathologic diagnosis. Although our patient had an excellent initial response to BEP, further study is needed to identify a treatment that can reduce recurrences and improve clinical outcomes.

[Extra-uterine pelvic leiomyoma: diagnosis and practical management]

OBJECTIVES

To analyze the possibilities of setting up a therapy for extra-uterine pelvic leiomyomas.

METHODS

Three cases of leiomyomas of the broad ligament, of the round ligament and of the ovary, and literature review.

RESULTS

Little is known about physiopathology of extra-uterine leiomyoma. The diagnosis of extra-uterine leiomyoma is based on histopathological analysis, using standard histology, and immunohistochemistry with anti-desmin and anti smooth muscle actin antibodies. The main differential diagnoses are fibroma, fibrothecoma, ovarian fibrosarcoma, and gastrointestinal stromal tumors. To define criteria of malignancy, we use Bell's classification without being sure that the uterine and extra-uterine models are comparable. So there is a risk of ignoring a low grade leiomyosarcoma. Providing therapy depends on the clinicopathologic features: the so called "parasitic leiomyoma", a tumor developed at the expense of local smooth muscle cells, metastasis of a benign metastasizing leiomyoma or leiomyomatosis peritonealis disseminata.

CONCLUSION

The extra-uterine leiomyoma has no precise nosologic status and no specific criteria of benignity; thus no precise evolution can be predicted. We must be extremely careful, and the issue of the monitoring and long-term therapy of patients must come up.

Incarcerated internal hernia of the small intestine through a breach of the broad ligament: two cases and a literature review

Two cases of internal herniation through a defect in the broad ligament of the uterus are described. Both were successfully treated laparoscopically. This rare condition should be borne in mind when a middle-aged woman presents with colicky lower abdominal pain. The cause is unknown, but both congenital and acquired origins have been proposed. As far as emergency situations are concerned, laparoscopy has proven to be both a diagnostic and a therapeutic tool.

Broad ligament hernia-associated bowel obstruction

BACKGROUND AND OBJECTIVE

We present the case of a female patient 29 years of age with antecedents of laparoscopic laser ablation for endometriosis, laparoscopic appendectomy, and umbilical hernioplasty.

METHODS

The patient was admitted to the hospital's emergency room for abdominal pain in the epigastrium, transfixing, irradiating to both upper quadrants and to the lumbar region, accompanied by nausea and gastrobiliary vomiting. Lipase determination was 170 mg/dL. Other laboratory findings were normal. Plain abdominal films on the patient's admission were normal, and computed tomography (CT) showed data compatible with acute pancreatitis. Without improvement during the patient's hospital stay, pain and vomiting increased in intensity and frequency.

RESULTS

New abdominal x-rays revealed dilatation of small bowel loops. Management was begun for intestinal obstruction, with intravenous hydration and placement of a nasogastric tube without a good response. At 48 hours, a diagnostic laparoscopy was performed, revealing a 3-cm internal hernia in the left broad ligament in which a 20-cm segment of terminal ileum was encased. We performed liberation of the ileal segment and closed the hernial orifice by using the laparoscopic approach.

CONCLUSION

The patient's evolution was excellent.

Internal hernia through the broad ligament presenting with acute on chronic intestinal obstruction: A case report

BACKGROUND

Internal hernias are rare. Their occurrence through the broad ligament is one of the rarest forms. We present a report of a 45 year Nigerian female with acute on chronic intestinal obstruction due to an internal hernia of the broad ligament.

METHODS

Patients case notes and a review of relevant literature using manual library and Medline search was used.

RESULTS

A 45-year-old multiparous woman presented with a ten-year history of features of partial intestinal obstruction, and no previous abdominal surgery. Examination revealed right iliac fossa tenderness and a plain abdominal radiograph showed air fluid levels. Conservative management was not successful and laparatomy confirmed an internal hernia of the right broad ligament which was repaired with satisfactory outcome.

CONCLUSION

This report is to highlight the fact that though rare, internal hernia should be considered in the differential diagnosis of intestinal obstruction.

Granulosa cell tumor arising in the wall of müllerian cyst of the broad ligament: report of a case and immunohistochemical study

CASE

A unique case of granulosa cell tumor arising in a müllerian cyst of the broad ligament in a 57-year-old woman is presented. The surgically resected unilocular cyst, measuring 9.5 x 9.5 x 6.5 cm3, situated within the right broad ligament. The inner surface of the cyst was lined by a single layer of ciliated columnar cells. Solid cell sheath of the spindled cells were demonstrated in this cystic wall. Immunohistochemically, these spindled cells were diffusely positive for cytokeratin 7, AE1/AE3, vimentin, smooth muscle actin, calretinin and weakly positive for inhibin, but negative for cytokeratin 20, epithelial membrane antigen and CD10.

CONCLUSION

Immunohistochemical findings suggested solid cell sheath surrounding the cyst was granulosa cell tumor. Granulosa cell tumor coexisted with müllerian cyst in the current case was recognized a unique histological feature.

Leiomyosarcoma of the broad ligament: a case report and review of literature

Leiomyosarcoma of the broad ligament is a rare tumor, since only 12 cases have been reported so far in the literature. A 53-year-old patient was diagnosed with leiomyosarcoma of the broad ligament at the Department of Gynecology Oncology of the National Cancer Research Institute in Genoa. The tumor had low mitotic activity and less than ten mitotic figures were found for ten high-power fields. The treatment consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy with bilateral ureteral neoanastomosis and omentectomy. The patient has not received either radiotherapy or chemotherapy, considering the low grade of malignancy, but she is only followed up on an outpatient basis. No evidence of metastasis has been noted after a follow-up of 13 months. It is concluded that low-grade leiomyosarcoma of the broad ligament should be treated only with surgery.

Female adnexal tumor of probable wolffian origin: clinicopathological, immunohistochemical and cytofluorimetric analyses of a 22-year-old virgin. case report

The term female adnexal tumor of probable Wolffian origin "FATWO" designs this tumor wich arises by the rare persisting remnants of the mesonephric duct (Wolffian duct). About 40 cases have been reported in literature. Few cases of recurrence have been reported, FATWO usually shows no signs of hormonal activity. We report a case of the youngest patient affected by FATWO in October 2002. At laparotomy the left adnexa were deformed by a well-capsulated mass, totally removed and sent to the pathologist with a specimen of peritoneal fluid and of the omentum. The histological examination showed a prevalent tubular structure with focal retiform area, without intraluminal mucines. Immunohistochemical findings of the case reported are similar to those described by other authors, except for inhibin which has not been detected by us. The cytofluorimetry showed the low presence of aneuploid cells, with a very low prolifing component (< 1%).

Primary papillary serous cystadenocarcinoma of broad ligament

A rare case of an advanced primary broad ligament carcinoma is discussed, with a review of the literature regarding its incidence, presentation and management. This patient showed a complete response to adjuvant cisplatin-based chemotherapy following panhysterectomy and is presently without any evidence of disease, 15 months after completion of her treatment.

Internal herniation through a defect of the broad ligament of the uterus

Internal herniation through a defect of the uterine broad ligament is rarely encountered. We report a case of a 52-year-old woman in whom a closed bowel loop with approximation of its ends to the uterus was the definitive computed tomographic finding. This type of internal herniation should be considered in the differential diagnosis of female patients presenting with ileus.

Loss of caspase-2, -6 and -7 expression in gastric cancers

Female adnexal tumor of probable Wolffian origin (FATWO) is a rare entity which is believed to originate from mesonephric (Wolffian) remnants on the basis of its location where the remnants are abundant. Its behavior is usually indolent, although some cases can recur or metastasize. The authors present the clinicopathological features of two cases of FATWO arising in the broad ligament, and focus on the expression of adhesion molecules and proliferative marker. Mesonephric duct remnants are also examined in an attempt to elucidate the histogenesis of FATWOs. The two FATWOs were well-circumscribed solid masses arising in the leaves of the broad ligament and histological examination revealed a mixture of cysts and tubules imparting a sieve-like pattern and mucin-negative eosinophilic secretion within these tubules. Immunohistochemically, the tumors showed the expression of cytokeratin 7 and 20, high-molecular-weight cytokeratin, and calretinin, which closely resembled that of the mesonephric duct remnants. Regarding CK 20, CD 10, EMA, S-100 protein, and vimentin their expression was in part not identical with previous studies. E-cadherin, alpha and beta-catenin were strongly expressed along the cell membrane of the tumor cells. The Ki-67 labeling index of FATWO was 0% and 3.2% in each case. The preservation of the E-cadherin-catenin complex and low Ki-67 labeling index could explain the indolent behavior and low malignant potential of this tumor.

A Simple Procedure for the Prevention of Ureteral Injury in Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE

To introduce a surgical technique to minimize the chance of ureteral injury during laparoscopic-assisted vaginal hysterectomy (LAVH).

DESIGN

Retrospective case review (Canadian Task Force classification II-3).

SETTING

Show Chwan Memorial Hospital, Changhua, Taiwan.

PATIENTS

Two thousand and six women who underwent LAVH between January 1992 and June 2001.

INTERVENTION

A simple step of creating a "window" over the anterior and posterior broad ligaments to push inferolaterally the areolar tissue (in which the ureter is embedded) on the posterior broad ligament.

MEASUREMENTS AND MAIN RESULTS

No ureteral injury occurred in patients whose cases were reviewed. There were, however, five bladder injuries (0.25%) and three nerve pareses (0.15%). Other minor complications, including fever, abscess or hematoma of the vaginal cuff, subcutaneous emphysema, and delayed vaginal cuff bleeding, occurred in less than 5% of patients.

CONCLUSION

The technique proposed is simple and very effective in preventing ureteral injury during LAVH.

Successful laparoscopic treatment of an abdominal pregnancy in the broad ligament

Laparoscopic management of tubal ectopic pregnancy is the ideal form of treatment in most tertiary centres. Approximately 1% of ectopic pregnancies are abdominal pregnancies and these are usually managed by laparotomy. We present the first report of successful laparoscopic treatment of a 6.5 cm abdominal pregnancy located in the broad ligament of a 25-year-old woman.

Endothelin-1 and endothelial nitric oxide synthase immunoreactivity in lymphatic vessels of the uterine broad ligament during the estrous cycle in the pig

Immunohistochemical localization and distribution of endothelin (ET-1) and nitric oxide synthase (eNOS) were investigated in precollector and collector lymphangions of lymphatic vessels leaving the ovary and were found in the vascular subovarian plexus (mesovarium) as well as in those emanating from the oviductal isthmus and uterine horn (mesosalpinx and mesometrium, respectively) forming the paraovarian lymphatic plexus in the broad ligament of the uterus during different phases of the estrous cycle in pigs. The polyclonal antibody for ET-1 and the monoclonal antibody for eNOS isoform were used for studies on the light-microscopic level. Immunoreactivities to both ET-1 and eNOS were observed in the endothelial cell cytoplasm of precollector and collector lymphangions and were not demonstrated in smooth muscle cells of the lymphatics examined. In the endothelium, the intensity of immunostaining for ET-1 and eNOS was found to be estrous phase-dependent and differed between precollector and collector lymphangions. In general, immunoreactivity to ET-1 was more intense in the endothelium of shrunken lymphangions, whereas that for eNOS was more intense in lymphangions with the large lumen. These results suggest that ET-1 and eNOS can play a role in mechanisms regulating the vascular contractile activity promoting lymph flow during the estrous cycle in the porcine broad ligament.

Incarceration of small bowel herniation through a defect of the broad ligament of the uterus: report of a case

Intestinal herniation through a defect in the broad ligament of the uterus is uncommon among internal herniations. We herein report a 59-year-old woman with intestinal obstruction, who had no previous history of surgical treatment except for an appendectomy. The laparotomy revealed an incarceration of the small bowel herniation through the defect of the right broad ligament. This possibility should therefore be considered in the differential diagnosis for female patients presenting with an intestinal obstruction without any history of a prior laparotomy.

Leiomyosarcoma of the broad ligament arising in a pre-existing pure neurilemmoma-like leiomyoma

A 35-year-old woman presented with an adnexal mass which came out as a leiomyosarcoma of the broad ligament arising in a pre-existing pure neurilemmoma-like leiomyoma. This is the first reported case of leiomyosarcoma arising in a pure neurilemmoma-like leiomyoma, the third reported case at an unusually young age showing evidence of a pre-existing leiomyoma and the 12th reported case of leimyosarcoma of the broad ligament. Is the likelihood of malignant transformation, especially in large leiomyomas of the broad ligament, a rare event?

Small bowel incarceration in a broad ligament defect

We report the case of a 33-year-old woman whose medical history included three normal pregnancies without previous abdominal or pelvic surgery. She presented with small bowel obstruction. An abdominal computed tomography (CT) scan study revealed air fluid levels in the pelvis. Laparoscopic exploration revealed a viable ileal loop incarcerated through the mesoligamentum teres. The intestinal loop was reduced and the broad ligament defect was closed with a laparoscopic absorbable clip. Among internal hernias, hernias through a defect in the broad ligament represent only 4-7%. Defects within the broad ligament can be either congenital (ruptured cystic structures reminiscent of the mesonephric or mullerian ducts) or secondary to operative trauma, pregnancy and birth trauma, or prior pelvic inflammatory disease. CT scan may be diagnostic by showing incarceration of a dilated intestinal loop in the Douglas pouch with air fluid levels. This is the first reputed case of a totally laparoscopic repair of a bowel incarceration through a broad ligament defect.

Malignant epithelial tumor of unknown origin of the broad ligament

Malignant epithelial tumor of the broad ligament is rare and to our knowledge only 17 cases have been reported. We report a 54-year-old Japanese woman in whom transvaginal sonography (TVS) and magnetic resonance imaging (MRI) showed a left adnexal tumor. Serum CA125 was elevated to 10,000 U/ml. Preoperatively, we diagnosed this tumor was a left ovarian malignant tumor though, it was confirmed a the 47x57 mm tumor in the left broad ligament at laparotomy. Histologically most of the tumor showed serous papillary adenocarcinoma with changes similar to poorly differentiated carcinoma and as seen in transitional cell carcinoma on hematoxylin-eosin staining. After three courses of platinum based adjuvant chemotherapy, the patient is alive with no recurrence at 18 months postoperatively.