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 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 ().