they have an incidence of  < 1 in 100,000 patients . most mesenteric cysts present with variable and nonspecific symptoms .
fortunately , they usually behave as benign tumors , and malignancy accounts for only 3% of the cases , arising gradually or de novo .
the first successful report of laparoscopic surgery for a mesenteric cyst was in 1993 , and subsequently only a handful of laparoscopic cases have been reported , , , , .
single - incision laparoscopic surgery has been performed for resection of benign and malignant gastrointestinal tumors in recent years ; however , its safety and feasibility is still controversial , and there have been no reports of its use in resecting mesenteric cysts .
this report deals with the first case of a mesenteric chylous cyst successfully treated by single - incision laparoscopic surgery .
a 49-year old woman presented to her primary care physician s office with a 1-month history of vague abdominal pain . at the physical examination
abdominal ultrasonography confirmed a rounded cystic formation 4.8  cm in diameter in the region of the pancreatic tail .
the pain was described as intermittent and was not brought on by any particular events , nor was it relieved by anything specific .
prior to the operation for the mesenteric cyst , she was found to have normal laboratory values , including normal levels of markers for malignancy .
1 ) showed a 5.0-cm - diameter intraabdominal , homogenous cystic lesion containing surface formation with an enhanced capsule located on the mesentery of the small intestine .
magnetic resonance imaging ( mri ) revealed a solitary circumscribed cyst measuring 4.9  cm    4.2  cm , with a thick capsule containing a dense , high - fat fluid .
based on the findings of preoperative ct and mri , a single port laparoscopic operation was chosen .
gelpoint ( applied medical , rancho santa margarita , ca , usa ) was used for the surgery .
gelpoint contains a gelseal cap , alexis wound retractor , and 4 sleeves ( ports ) .
the alexis wound retractor accommodated the abdominal wall , and three sleeves ( ports ) were kept impaled on the gelseal cap . during the laparoscopic exploration , it was noted that the mesenteric cyst was in the upper - left quadrant .
it was a thick - walled structure and fixed in the mesentery with mesenteric vessels of attachment ( fig .
we completely controlled the major vessels running near the tumor and sealed the chylous and blood vessels to and from the cyst .
once free , the cyst was removed from the abdomen via the incision which measured from 40-mm to 50-mm in length within the umbilicus without making any punctures and using a surgical retrieval bag . the operation time and
blood loss were 169  min and 90  ml , respectively.by 5  days after the operation , the dull abdominal pain had vanished .
the patient was discharged on the 5th postoperative day . a pathological examination of the cyst revealed the fluid to be benign .
the wall of the cyst was found to be fibrous with a histology consistent with chronic inflammation ( fig .
most mesenteric cysts are rare and benign but tend to present with variable and nonspecific symptoms , such as abdominal pain , nausea , vomiting , anorexia , and a change in bowel habits , and cause complications , including intestinal obstruction , volvulus , torsion , bleeding , or rupture .
similar lesions have been found to be cystic lymphangiomas , cystic stromal tumors , and mesotheliomas on a pathologic analysis .
in addition , carcinomas have been found to arise in mesenteric cysts , albeit rarely .
the diagnosis of mesenteric cysts can be challenging , as chylous cysts mimic other pathologies , such as pancreatic pseudocysts or cystic tumors , pelvic diseases , and aortic aneurysms .
a preoperative diagnosis may be achieved using imaging techniques ( ultrasonography , ct , nuclear mri ) , , .
ultrasonography is the first - line technique , as it can localize the cystic mass and often the involvement of the near anatomical structures .
ct can then be used to confirm the diagnosis based on the ultrasonography findings and is important for adequately planning the surgical approach . in a review of a series of 162 patients , 60% of mesenteric cysts occurred in the small - bowel mesentery , 24% in the large bowel mesentery , and 14.5% in the retroperitoneum , while the site of 1.5% of cases was indefinite .
the etiology of mesenteric cysts remains unclear , but a failure of the lymph nodes to communicate with the lymphatic or venous systems or the blockage of the lymphatic system as a result of previous pelvic surgery , trauma , pelvic inflammatory disease , infection , endometriosis , or neoplasia have been suggested as contributing factors .
mesenteric cysts are rare , but surgeons must consider the diagnosis in the presence of a cystic abdominal tumor , if they are symptomatic or cause complications .
although a number of treatment methods are available , surgical excision is considered the mainstay for therapy .
the first - choice therapy is complete surgical excision to avoid recurrence and possible malignant transformation , which may require the removal of part of the mesentery with the mass .
the decision for a surgical approach depends on the size of the cyst , its dimensions , and its relationships with major abdominal structures , as well as the surgeon 's degree of experience in minimal access surgery . in the present case ,
the procedure was performed by an experienced endoscopic surgeon licensed for such techniques ( endoscopic surgical techniques certification of the japan society for endoscopic surgery ) .
under laparoscopy we judged the tumor to be located in the jejunal mesentery near the treitz s ligament .
we placed the cannulas with the aim of achieving good control of the superior mesenteric vessels and the first small bowel loops , should it have been necessary to mobilize the jejunum . in this case , the progressive dissection of the cyst was initiated at its cephalic edge , near the jejunal mesentery , where the branches of superior mesenteric vessels were accurately detached from the mass , taking care to avoid a risk of iatrogenic injury to the major abdominal vessels and bowel loops . to avoid any risk of a chylous fistula
we were eventually able to remove the cyst without any injury , and endobags were used to retrieve the cyst .
only surgeons sufficiently experienced in laparoscopic surgery and single - incision laparoscopic surgery should perform this procedure .
single - incision laparoscopic surgery has been performed for resection of benign and malignant gastrointestinal tumors in recent years ; however , its safety and feasibility is still controversial . to our knowledge
, this is the first report of single - incision laparoscopic surgery for a mesenteric cyst .
in conclusion , we believe that single port laparoscopic surgery can be performed safely for excision of a chylous mesenteric cyst in adults and should be considered if contraindications are not present .
written informed consent was obtained from the patient for the publication of this case report and any accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal .
 highlightssingle - incision laparoscopic surgery has been performed for resection of benign and malignant gastrointestinal tumors in recent years ; however , its safety and feasibility is still controversial , and there have been no reports of its use in resecting mesenteric cysts.this report deals with the first case of a mesenteric chylous cyst successfully treated by single - incision laparoscopic surgery . 
Introduction
Presentation of case
Discussion
Conclusion
Consent
Conflict of interest statement