A 31-year-old woman presented with abdominal distention and discomfort worsening over the past 6 months. Concurrently, she had development overactive bladder symptoms, bloating, and dyspepsia. Her medical history was pertinent for epilepsy controlled with antiepileptic medications. Urine analysis was negative for any signs of infection, and her pregnancy test was negative. Abdominal examination was positive for a firm and distended abdomen, uniformly enlarged from the xiphoid bone to the pubic symphysis. No tenderness was reported on palpation; however, pressure was endorsed. A bedside abdominal ultrasound was performed that revealed an abdomen fully distended with fluid, initially suspected to be ascites. Computed tomography in 2.5 mm helical slices with both IV and oral contrast suggested the presence of an encapsulated cystic mass containing clear fluid (6 Hounsfield units). Dimensions reported were 36 cm in long axis, 28 cm in transverse diameter, and 15 cm in anteroposterior diameter, corresponding to 7 liters in volume, suggestive of a right ovarian cystadenoma (Figures and ). No capsular irregularities were seen or intracystic vegetations identified. Concurrently noted was right renal pelvicalyceal dilatation resulting from compression due to the proximity of the right ureter with the renal pelvis measuring 2 cm in anteroposterior diameter. No abdominal ascites or other abdominopelvic abnormalities noted. Tumor markers were in the normal ranges (CA125: 12.13 U/ml, CEA:1.51 ng/ml, and AFP: 1.46 IU/ml). While understanding her risks, the patient stressed the avoidance of excision of ovarian or fallopian tissue due to fertility concerns and preferred that the cyst be removed in a cosmetic manner including avoidance of larger laparotomy incisions.\nThe patient underwent resection of the mass. The procedure was begun by drainage of the cyst in order to identify the stalk and excise all cyst walls. A 3 cm supraumbilical incision was performed with careful dissection until reaching the peritoneal cavity. An Alexis O™ wound protector/retractor Applied Medical was introduced through the small incision permitting better visualization of the cyst (). Three hemostats were used to hold the cyst wall in place, followed by meticulous introduction of an 11 mm trocar into the cyst cavity under direct vision. This was followed by insertion of a 5 mm suction tube through the trocar to aspirate the fluid contents while avoiding spillage of fluid into the peritoneal cavity. Eight liters of serous fluid were aspirated. Following fluid evacuation, the cyst wall had collapsed. The trocar site in the cyst wall was sutured shut in a purse-string manner followed by a second closure layer. Then, the cyst was released off the hemostats, and the laparoscopic gel cap was fitted onto the Alexis retractor to convert the abdominal incision into a laparoscopic port site. This was used to insufflate the abdomen with CO2. Thereafter, 2 additional 5 mm trocars on each side of the midline were introduced.\nThe cyst borders were identified (). Using the bipolar forceps and scissors, it was completely dissected off the fallopian tube. Both the fallopian tube and ovarian tissues were noted to be intact. The cyst was removed through the supraumbilical incision and sent to pathology. The trocars were removed and all incisions approximated as per protocol. The patient was discharged soon thereafter from the observation unit.
A 34-year old multigravida was found to have right adnexal mass on her routine gynecologic examination. Her previous medical history was uneventfull and Pap smear was normal. Transvaginal ultrasonography identified a cystic mass adjacent to the right ovary. Serum CA 125 was 5.1 U/ml (reference range: < 35 U/ml). At laparoscopy a dilated fallopian tube with bluish discoloration was found. The contralateral fallopian tube, ovaries and uterus were unremarkable. Exploration of the abdomino-pelvic cavity revealed smooth and shiny peritoneal surphace. Obtained peritoneal and pelvic washing were negative. Fine needle aspiration of dilated part of the fallopian tube revealed a 4 ml of bloody content. Cytological findings were consistent with hematosalpinx. Right salpingectomy was performed without using endoscopic bag. The patient was followed up by means of ultrasonography and serum CA 125 for 4.6 years. During this period she had no evidence of the disease.\nGrossly, a 7.0 cm long fallopian tube was irregularly dilated up to 4.4 cm in diameter at the ampulary region. The fimbriae were intact. The serosal surphace was smooth. Sections of the dilated part of the fallopian tube revealed a cystic tumor with focally yellow to tan, soft papillary excrescences protruding into the lumen (Fig. ) and foci of intracystic hemorrhage. On microscopic examination the papillae were covered by serous type of epithelium, displaying stratification and budding with focal nuclear atypia (Fig. ). Three types of cells were recognised; ciliated cells, hob-nail cells and mesothelium-like cells. Small foci of tumor tissue necroses and hemorrhage were noted. There was no invasion of the supportive stroma of the papillae or into the fallopian tube wall. Focus of endosalpingiosis within the adjacent mesosalpinx was found. DNA analysis determined by flow cytometry paraffin technique revealed DNA diploid tumor with low S-phase fraction of 6.5 %.