Author Information
Gupta
P*, Parulekar SV**
(* Second Year Resident, ** Professor and Head of Department
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
A
free-floating intraperitoneal mass is extremely rare, almost always discovered
incidentally.
We
present an anusual case of such a mass found incidentally during vaginal
hysterectomy and vaginal wall prolapse repair. Pathological examination of the
mass showed it to be a serous cystadenofibroma with autolytic changes. The
origin of the mass was most probably one of the ovaries.
Introduction
Free-floating
intraperitoneal masses are extremely rare. These abnormalities can be of
unknown origin or can arise from various organs, most common being ovary due to
autoamputation following torsion or an
appendix following infarction, an organised fat necrosis or an intra abdominal
tumor. These are almost always found incidentally during surgery like an exploration for an acute abdomen or abdominal
distension or while investigating an unrelated
disease. Ours is a case of a free-floating intraperitoneal mass discovered
incidentally during vaginal hysterectomy of a 40 years old perimeopausal woman with
uterine leiomyoma and vaginal wall prolapse. Both the ovaries were found to be
normal. Pathological examination of the mass showed it to be a serous
cystadenofibroma with autolytic changes. This is the first case of a
free-floating intraperitoneal ovarian cyst in presence of normal ovaries.
Case report
A
40 years perimenopausal woman presented with complaints of menorrhagia and
something coming out vaginally for four months. There was no history of any episode of an acute pain in the
abdomen. Her past medical and surgical history was not contributory. Her general
condition was fair. General and systemic examination revealed no abnormality.
Gynecological examination showed a uterus of 6 weeks’ size, moderate cystocele
and moderate rectocele. Her hemogram and biochemical tests were normal. Abdominopelvic
ultrasonography revealed a leiomyoma measuring 2 cm in diameter in the anterior
wall of the uterus. There was no mass or free fluid. A vaginal hysterectomy
with anterior colporrhaphy and posterior colpoperineorrhaphy was done under
spinal anesthesia. After clamping, cutting and ligating the uterine vessels, a
mass was noticed posterior and superior to the uterine fundus. After clamping,
cutting and ligating the cornual structures on both the sides and removal of
the uterus, the mass was found to be free-floating in the peritoneal cavity. It
was removed easily. It was 8.0×4.5×5.0 cm in size, soft, and cystic (figure 1).
Both the ovaries were found to be normal and in their normal positions. The patient
made an uneventful recovery. Pathological examination showed a cystic mass with
20 ml of pultaceous material in it, suggestive of autolytic changes. Multiple
nodulopapillary exascences were identified . Morphologically it resembled
of serous cystadenofibroma. Histopathological
examination was uninformative due to autolytic changes in the mass.
Figure
1. Free-floating intraperitoneal mass.
Figure
2. View of pelvic cavity after vaginal hysterectomy. Both the ovaries (arrows)
are normal and seen in normal positions.
Discussion
Free
floating intraperitoneal masses are exceedingly rare masses. Such a mass may be
the result of an auto amputation of an ovary (normal or with a cyst or tumor)
following its torsion,[1,2] a mass from the appendix separated after
auto amputation, infarcted appendices epiploicae, a hydatid cyst,[3]
a mass from the rectum,[4] or organised fat necrosis or hematoma.[5]
Such patients would have a history of an acute abdomen in the past, which
resolved with conservative treatment. Most of these masses are detected
incidentally at the time of an abdominal operation for some other indication.
The concerned organ like ovary or appendix is absent in such cases. The case
presented was unusual in that the structure of the mass was that of an ovarian serous
cystadenofibroma, but both the ovaries were normal. Probably it was a tumor
which had developed at a pole of ovary, the part between the tumor and the rest
of the ovary being constricted due to past ovulations and scarring. This must
have been the site of torsion of the mass, which caused necrosis of the
connection and the separation of the mass. The rest of the ovary remained
behind and survived. Another possibility is that it arose from ectopic ovarian
tissue of embryological origin, a supernumerary ovary.[6,7] It is
not possible to determine which of the two was the source of the mass.
Irrespective of the source, all loose free-floating masses in the peritoneal
cavity should be removed, as they can get infected.
References
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3.
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Citation