An obese 31-year-old nulliparous woman was admitted to the general emergency service with back pain that had started one week earlier and gradually become constant and increased in intensity. She was also vomiting but denied fever, dysuria, constipation, diarrhoea or anorexia. She had never been pregnant and had had amenorrhea for the past 7 years, due to polycystic ovary syndrome. Her body mass index was 39 kg/m2 (height 168 cm; weight 110 kg); she was taking no medication and had no other surgical or medical history to disclose.\nDuring her physical exam, her vital signs were normal and abdominal examination revealed only tenderness in right quadrants, without guarding or rebound. Blood tests were performed and revealed a high white blood cell count (16,700 per mm3, 72% neutrophils), normal renal function and were negative for C-reactive protein. Urine analysis and pregnancy test were also negative.\nBecause her pain worsened, despite the administration of analgesic drugs, the patient underwent an abdominal and pelvic computed tomography (CT) scan, which showed a huge central abdominal-pelvic cyst arising from the right adnexa (). The cyst measured 25 cm × 20 cm × 14 cm and there was an adjacent enlarged oedematous ovary, highly suggestive of torsion. The left ovary, uterus and the appendix were normal and no free fluid in the abdomen and pelvis was observed.\nShe was then referred to the gynaecology department. Her gynaecologic exam was apparently normal but limited due to obesity. A pelvic ultrasound revealed a 20 cm × 20 cm thin-walled mass of the right adnexa, not clearly separate from it. Doppler examination showed that the right ovary was visible and had a polycystic ovarian morphology and apparent presence of vascular flow. The left ovary had the same polycystic pattern.\nHer pain became acutely worse, which reinforced the hypothesis of adnexal torsion. Based on these findings and the increased pain, we decided to perform exploratory laparotomy. Intraoperatively, a giant (~25 cm) cystic median mass of apparent right adnexal origin was seen, occupying the entire pelvis up to the diaphragm. The cyst wall was intact, adhesion-free and swollen. Necrotic ovarian tissue was identified within the mass, but no cleavage planes were identified. The pedicle, which included the infundibulopelvic and utero-ovarian ligaments, was twisted twice around its stalk (). The left adnexa and the uterus looked normal.\nThe patient underwent resection of the mass without rupture. Frozen-section analysis was not available since the surgery was performed during the night. The final pathology report noted a paratubal serous papillary cystadenoma, an ovary with polycystic morphology and a normal fallopian tube. All fragments had congestion, oedema and haemorrhage, consistent with obstruction of the arteriovenous flow (torsion). The postoperative course was uneventful.
A 30-year-old woman visited the outpatient clinic seeking treatment for abdominal\ndistention present since the last 4 months. She had no history of surgery. Bowel and\nbladder functions were normal. Menstruation was regular and without any pain. The\npatient was nulliparous. Computed tomography (CT) scan with contrast showed a thin\nwalled unilocular cyst arising from the left adnexa with dimensions of\n22.3 cm × 18.4 cm × 6.8 cm; no papillary projections or nodules were observed (). The Ca 125 level\nwas 13.64 U/mL.\nBecause of the large size of the cyst and the patient’s preference, a laparotomy was\nperformed. We performed a midline incision above the umbilicus, trying to\nexteriorize the cyst without any rupture. Intraoperative exploration showed a large,\nthin-walled, unilocular cyst arising from the left para-tubal tissue without any\nadhesions; the left tube and left ovary were normal (). The para tubal cyst was dissected\nto separate it from the normal ovary and tube (). The para tubal cyst was removed\nand sent for histopathological examination (). The left tube and left ovary were\npreserved (). The\nuterus and right adnexa were normal. Frozen section examination confirmed by final\nhistopathological examination revealed a benign serous cyst of size\n22 cm × 17 cm × 6 cm.\nWritten, informed consent was obtained from the patient for the publication of this\nreport and its accompanying images ().