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BMJ Case Rep. 2015; 2015: bcr2015210175.
Published online 2015 April 9. doi:  10.1136/bcr-2015-210175
PMCID: PMC4401959

An unusual pelvic cyst found at laparoscopic hernia repair

Description

The finding of unusual contents within hernias merits publication so as to raise surgeons’ awareness of the structures that could be encountered during hernia repair.1 2 We describe a case of a 66-year-old man who underwent elective transabdominal preperitoneal bilateral inguinal hernia repair. At laparoscopy, a large cystic structure was seen arising from the pelvis (figure 1). The hernias were repaired and the patient was informed of the abdominal finding before being discharged home later the same day. The cystic structure was subsequently investigated with a CT scan (figure 2) and MRI (figure 3). The scans showed a benign 16 cm×7.5 cm×6 cm unilocular cyst with calcification in its wall. Aspiration cytology was not performed as this risked puncturing the thin-walled cyst. The radiological diagnosis was of a mesenteric cyst or urogenital cyst. Mesenteric cysts were first described by Benevieni, an Italian anatomist, in 1507.3 They arise during embryological development from ectopic lymphatic tissue or from incomplete fusion of the leaves of the mesentery. They are very rare, occurring in 1 in 200 000 adults. Malignant transformation is exceptionally rare.4 Urogenital cysts are equally rare and arise from vestigial remnants of the urogenital apparatus.5 Malignant change is also exceptionally rare. The management options were to excise the cyst either laparoscopically or by laparotomy to obtain definitive histology, or to adopt a conservative approach with yearly surveillance scans to assess cyst growth or change. In our case, the cyst was completely asymptomatic and radiologically benign, so a conservative approach was adopted. If in future it enlarges and causes pressure symptoms on adjacent structures such as the bladder, excision will be performed.

Learning points

  • If an unusual cystic structure is found incidentally during laparoscopy, it should be photographed to document its size and position, and later investigated with CT scan and MRI.
  • Asymptomatic urogenital and mesenteric cysts can be managed conservatively as malignant transformation is exceedingly rare.
  • Large urogenital and mesenteric cysts should be excised if they cause symptoms by compressing adjacent structures.
  • Urogenital and mesenteric cysts should be excised if serial scans show radiological evidence of malignant transformation.
Figure 1
Operative photograph of pelvic cyst found at laparoscopy.
Figure 2
CT scan showing the pelvic cyst with a calcified wall (arrow).
Figure 3
MRI showing the pelvic cyst (arrow).

Footnotes

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Kassir R, Dubois J, Berremila SA et al. A rare variant of inguinal henira: cryptorchid testis at the age of 50 years. Etiopathogenicity, prognosis and management. Int J Surg Case Rep 2014;5:416–18 doi:10.1016/j.ijscr.2014.03.015 [PMC free article] [PubMed]
2. Kassir R, Tarantino E, Lacheze R et al. Management of spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman. Int J Surg Case Rep 2013;4:1176–8 doi:10.1016/j.ijscr.2013.10.010 [PMC free article] [PubMed]
3. Pantanowitz L, Botero M Giant mesenteric cyst: a case report and review of the literature. Internet J Pathol 2000;1:1–5.
4. Bury TF, Pricolo VE Malignant transformation of benign mesenteric cyst. Am J Gastroenterol 1994;89:2085–7. [PubMed]
5. Mokhtari M, Kumar PV Cytologic findings of urogenital mesenteric cyst. Arch Iran Med 2013;16:436–8 doi:013167/AIM.0015 [PubMed]

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