Author Information
Parulekar SV.
(Professor and head of Department of Obstetrics and
Gynecology, Seth GS Medical College and KEM
Hospital, Mumbai, India.)
Abstract
Broad ligament lipoma is a very rare tumor. There are only
11 cases reported in the English world literature.[1,2,3,4,5] This is the first
case reported in which the lipoma was removed vaginally.
Introduction
Primary retroperitoneal tumors account for 0.2% of all
neoplasms, of which about 80% are malignant neoplasms.[6] Retroperitoneal
benign lipomas are extremely rare, being 2.9% of all primary retroperitoneal
tumors.[7] We present a case of a broad ligament lipoma diagnosed and removed
during vaginal hysterectomy.
Case Report
A 58 year old postmenopausal woman presented with complaint
of something coming out per vaginum for 6 months. She was found to have a third
degree uterine prolapse, moderate cystocele and moderate rectocele. The uterus
was small and the fornices were free. She was subjected to vaginal hysterectomy
and repair of vaginal wall prolapse. During the operation, the right borad
ligament was found to be bulging out after the uterosacral and uterine pedicles
were clamped, cut, and ligated. The cornual structures of both sides were
clamped, cut and ligated with No. 1 polyglactin, the clamp on the right side
being applied medial to the broad ligament mass. Then the two leaves of the
right broad ligament were separated. A well defined tumor measuring 7X4X3 cm
was found in it, having the appearance of a lipoma (figure 1). It was dissected
out of the broad ligament, taking care not to injure the ureter. There was no
active bleeding from the bed of the tumoe after its removal. The pelvic
peritoneal opening was closed with a purse-string suture of No. 1-0 polyglactin,
leaving the right broad ligament partially open towards the vagina. The angles
of the vagina were anchored to the pedicles of the uterosacral ligaments with
No. 1 polyglactin sutures. The vagina was closed with No. 1-0 polyglactin
sutures, leaving space for vaginal drainage of right broad ligament. The
patient had no vaginal bleeding postoperatively. She made an uneventful
recovery. Histopathological examination of the tumor showed it was lipoma.
Figure 1. Right broad ligament lipoma (L). The uterine corpus
(Ut), cervix (Cx), and right ovary (black arrow) are shown.
Figure 2. The broad ligament has been opened and the lipoma
is seen being enucleated out.
Figure 3. The lipoma.
Figure 4. The uterine corpus (Ut), cervix (Cx), and right
broad ligament (black arrow) are shown after removal of the lipoma.
Discussion
Pelvic lipomas are exceedingly rare. They can arise from the
iliac vessels and paravaginal tissues.[8] A lipoma is a soft tumor, and it may
be missed clinically in broad ligament location when it is small to medium in
size. In the case presented, it was not palpable on bimanual examination. No
imaging of the pelvis was done because no indication was perceived. Otherwise
the tumor can be diagnosed by ultrasonography, computed tomography (CT), or
magnetic resonance imaging (MRI). As there are no significant optical
differences between a lipoma and a well-differentiated liposarcoma on CT or
MRI, observed prior to surgery between lipomas and well-differentiated
liposarcomas, one has to be prepared to deal with the latter when undertaking
removal of a lipoma in this location. If the tumor is coincidentally diagnosed
at the time of a laparotomy or a vaginal hysterectomy for a different
indication, prior awareness of the possibility of a sarcomatous nature should
help in better surgical management of the tumor. Vaginal dissection of the lipoma can be
difficult, and should be undertaken only if the tumor is diagnosed during a
vaginal hysterectomy, and that too in presence of pelvic tissue relaxation, as
in this case. Otherwise it is a lot safer to abandon the vaginal approach and
remove the tumor abdominally by the extraperitoneal route. The ureter has to be
isolated prior to any dissection and safeguarded during the dissection. As
these lipomas are known to recur and undergo malignant transformation, these
patients require a close follow-up.
Acknowledgement
I thank Dr Anil Mirchandani for the operative photographs.
References
1.
Eltabbakh GH. Broad ligament lipoma
presenting as a pelvic mass: a case report. J Reprod Med. 2007 Jun;52(6):543-4.
2.
Cantin PFR. Lipoma of the Broad Ligament
Br Med J 1959;1:1242.
3.
Pai MR, Naik R, Raughuveer CV. Primary retroperitoneal tumors: a
25 year study. Indian J Med Sci 1995;49:139-41.
4.
Gardner GH, Greene RR, Peckham B. Tumors
of the broad ligament. Am J Obstet Gynecol 1957;73:536-8.
5.
Hull WB, Blumenfeld ML, Jacques D. Large
paravaginal pelvic lipoma: A case report. J Reprod Med 1999;44:636-8.
6.
Armstrong JR, Cohen I. Primary malignant
retroperitoneal tumors. Am J Surg 1965; 110:937-43.
7.
Pai MR, Naik R, Raughuveer CV. Primary retroperitoneal tumors: a
25 year study. Indian J Med Sci 1995;49:139-41.
8.
Genadry R, Parmley T, Woodruff JD. The
origin and clinical behavior of parovarian tumor. Am J Obstet Gynecol
1977;129:873-6.
Citation
Parulekar SV. Broad Ligament Lipoma. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/broad-ligament-lipoma.html