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World Journal of
Clinical Cases
ISSN 2307-8960 (online)
World J Clin Cases 2020 August 26; 8(16): 3377-3620
Published by Baishideng Publishing Group Inc
WJCC https://www.wjgnet.com IAugust 26, 2020 Volume 8 Issue 16
World Journal of
Clinical Cases
W J C C
Contents Semimonthly Volume 8 Number 16 August 26, 2020
OPINION REVIEW
Novel computerized psychometric tests as primary screening tools for the diagnosis of minimal hepatic
encephalopathy
3377
Luo M, Mu R, Liu JF, Bai FH
REVIEW
Management of cancer patients during COVID-19 pandemic at developing countries
3390
González-Montero J, Valenzuela G, Ahumada M, Barajas O, Villanueva L
MINIREVIEWS
Liver in the limelight in the corona (COVID-19) time
3405
Chela HK, Pasha SB, Basar O, Daglilar E, Tahan V
Steroid-responsive pancreatitides
3411
Pelaez-Luna M, Soriano-Rios A, Lira-Treviño AC, Uscanga-Domínguez L
ORIGINAL ARTICLE
Clinical and Translational Research
Application of molybdenum target X-ray photography in imaging analysis of caudal intervertebral disc
degeneration in rats
3431
Su QH, Zhang Y, Shen B, Li YC, Tan J
Accuracy study of a binocular-stereo-vision-based navigation robot for minimally invasive interventional
procedures
3440
Wang R, Han Y, Luo MZ, Wang NK, Sun WW, Wang SC, Zhang HD, Lu LJ
Retrospective Study
Value of virtual bronchoscopic navigation and transbronchial ultrasound-guided sheath-guided
exploration in diagnosis of peripheral lung cancer
3450
Liu Y, Wang F, Zhang QC, Tong ZH
Significance of serum fibroblast growth factor-23 and miR-208b in pathogenesis of atrial fibrillation and
their relationship with prognosis
3458
Chen JM, Zhong YT, Tu C, Lan J
Home quarantine compliance is low in children with fever during COVID-19 epidemic
3465
Lou Q, Su DQ, Wang SQ, Gao E, Li LQ, Zhuo ZQ
WJCC https://www.wjgnet.com II August 26, 2020 Volume 8 Issue 16
World Journal of Clinical Cases
Contents Semimonthly Volume 8 Number 16 August 26, 2020
Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in
early mucinous gastric cancer: Role of lymph node metastasis
3474
Li H, Zhao LL, Zhang XC, Liu DX, Wang GY, Huo ZB, Chen SB
Factors affecting failed trial of labor and countermeasures: A retrospective analysis
3483
Wang JG, Sun JL, Shen J
Value of miR-1271 and glypican-3 in evaluating the prognosis of patients with hepatocellular carcinoma
after transcatheter arterial chemoembolization
3493
Guo Z, Wang J, Li L, Liu R, Fang J, Tie B
Observational Study
Follow-up study on symptom distress in esophageal cancer patients undergoing repeated dilation
3503
Liu L, Liu QW, Wu XD, Liu SY, Cao HJ, Hong YT, Qin HY
Long-term medical treatment of patients with severe burns at exposed sites
3515
Du Y, Lv GZ, Yu S, Wang D, Tan Q
CASE REPORT
Laparoscopic management of a giant mucinous benign ovarian mass weighing 10150 grams: A case report
3527
Sanna E, Madeddu C, Melis L, Nemolato S, Macciò A
Concurrent hepatocellular carcinoma metastasis to stomach, colon, and brain: A case report
3534
Kim R, Song J, Kim SB
Disseminated osteomyelitis after urinary tract infection in immunocompetent adult: A case report
3542
Kim YJ, Lee JH
Pelvic lipomatosis and renal transplantation: A case report
3548
Zhao J, Fu YX, Feng G, Mo CB
Intestinal obstruction in pregnancy with reverse rotation of the midgut: A case report
3553
Zhao XY, Wang X, Li CQ, Zhang Q, He AQ, Liu G
Clinical laboratory investigation of a patient with an extremely high D-dimer level: A case report
3560
Sun HX, Ge H, Xu ZQ, Sheng HM
Recovery from a biliary stricture of a common bile duct ligature injury: A case report
3567
Fan Z, Pan JY, Zhang YW
Spontaneous pneumomediastinum in an elderly COVID-19 patient: A case report
3573
Kong N, Gao C, Xu MS, Xie YL, Zhou CY
Acute generalized exanthematous pustulosis with airway mucosa involvement: A case report
3578
Li LL, Lu YQ, Li T
WJCC https://www.wjgnet.com III August 26, 2020 Volume 8 Issue 16
World Journal of Clinical Cases
Contents Semimonthly Volume 8 Number 16 August 26, 2020
Multifocal neuroendocrine cell hyperplasia accompanied by tumorlet formation and pulmonary sclerosing
pneumocytoma: A case report
3583
Han XY, Wang YY, Wei HQ, Yang GZ, Wang J, Jia YZ, Ao WQ
Giant benign phyllodes breast tumour with pulmonary nodule mimicking malignancy: A case report
3591
Zhang T, Feng L, Lian J, Ren WL
Spontaneous multivessel coronary artery spasm diagnosed with intravascular ultrasound imaging: A case
report
3601
Wu HY, Cao YW, Chang FJ, Liang L
Delayed perforation after endoscopic resection of a colonic laterally spreading tumor: A case report and
literature review
3608
Zhou GYJ, Hu JL, Wang S, Ge N, Liu X, Wang GX, Sun SY, Guo JT
First branchial cleft cyst accompanied by external auditory canal atresia and middle ear malformation: A
case report
3616
Zhang CL, Li CL, Chen HQ, Sun Q, Liu ZH
WJCC https://www.wjgnet.com IX August 26, 2020 Volume 8 Issue 16
World Journal of Clinical Cases
Contents Semimonthly Volume 8 Number 16 August 26, 2020
ABOUT COVER
Editorial board member of World Journal of Clinical Cases, Dr. Kvolik is a Professor in the School of Medicine, Osijek
University, Croatia. She obtained her MD degree, with specialization in the field of anesthesiology, resuscitation
and intensive care from the Zagreb Medical School, Croatia. Afterwards, she undertook postgraduate training in
Clinical Pharmacology at the same institution, defending both a Master’s thesis and PhD thesis. In 2006, she joined
the Osijek University Medical Faculty as a lecturer and was promoted to Professor in 2009. In 2012, she was elected
Head of the Department of Anesthesiology, Resuscitation, Intensive Care and Pain Therapy, a position she
occupies to this day. She is also the current Head of the Intensive Care Unit at the Osijek University Hospital,
Croatia. (L-Editor: Filipodia)
AIMS AND SCOPE
The primary aim of World Journal of Clinical Cases (WJCC, World J Clin Cases) is to provide scholars and readers from
various fields of clinical medicine with a platform to publish high-quality clinical research articles and
communicate their research findings online.
WJCC mainly publishes articles reporting research results and findings obtained in the field of clinical medicine
and covering a wide range of topics, including case control studies, retrospective cohort studies, retrospective
studies, clinical trials studies, observational studies, prospective studies, randomized controlled trials, randomized
clinical trials, systematic reviews, meta-analysis, and case reports.
INDEXING/ABSTRACTING
The WJCC is now indexed in Science Citation Index Expanded (also known as SciSearch®), Journal Citation
Reports/Science Edition, PubMed, and PubMed Central. The 2020 Edition of Journal Citation Reports® cites the
2019 impact factor (IF) for WJCC as 1.013; IF without journal self cites: 0.991; Ranking: 120 among 165 journals in
medicine, general and internal; and Quartile category: Q3.
RESPONSIBLE EDITORS FOR THIS ISSUE
Production Editor: Ji-Hong Liu; Production Department Director: Xiang Li; Editorial Office Director: Jin-Lei Wang.
NAME OF JOURNAL INSTRUCTIONS TO AUTHORS
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FREQUENCY PUBLICATION ETHICS
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EDITORS-IN-CHIEF PUBLICATION MISCONDUCT
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WJCC https://www.wjgnet.com 3527 August 26, 2020 Volume 8 Issue 16
World Journal of
Clinical Cases
W J C C
Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2020 August 26; 8(16): 3527-3533
DOI: 10.12998/wjcc.v8.i16.3527 ISSN 2307-8960 (online)
CASE REPORT
Laparoscopic management of a giant mucinous benign ovarian
mass weighing 10150 grams: A case report
Elisabetta Sanna, Clelia Madeddu, Luca Melis, Sonia Nemolato, Antonio Macciò
ORCID number: Elisabetta Sanna
0000-0002-6680-5560; Clelia
Madeddu 0000-0001-8940-6987; Luca
Melis 0000-0003-1670-2704; Sonia
Nemolato 0000-0002-7746-6672;
Antonio Macciò 0000-0003-0577-
7217.
Author contributions: Macciò A
was responsible for the case
management, the approach design,
the manuscript writing and the
revision of the manuscript for
important intellectual content;
Macciò A and Sanna E were the
patient’s surgeons and were
involved in the direct patient care;
Macciò A, Sanna E, Madeddu C,
Nemolato S and Melis L analyzed
the clinical and pathological data,
and interpreted the imaging
findings; Maccio A, Sanna E and
Madeddu C performed the data
analysis, reviewed the literature
and drafted and revised the
manuscript; all authors issued final
approval for the version to be
submitted.
Informed consent statement:
Informed written consent was
obtained from the patient for the
surgical procedure, the publication
of this report and any
accompanying images.
Conflict-of-interest statement: The
authors declare that they have no
conflict of interest.
Elisabetta Sanna, Antonio Macciò, Department of Gynecologic Oncology, Azienda Ospedaliera
Brotzu, Cagliari 09100, Italy
Clelia Madeddu, Department of Medical Sciences and Public Health, University of Cagliari,
Monserrato 09042, Italy
Luca Melis, Department of Nuclear Medicine, Azienda Ospedaliera Brotzu, Cagiari 09100, Italy
Sonia Nemolato, Department of Pathology, Azienda Ospedaliera Brotzu, Cagliari 09100, Italy
Corresponding author: Antonio Macciò, MD, Chief Doctor, Department of Gynecologic
Oncology, Azienda Ospedlaiera Brotzu, Via Jenner, Cagliari 09100, Italy.
clelia.madeddu@tiscali.it
Abstract
BACKGROUND
Giant ovarian cysts (≥ 15 cm in diameter) are rare. The size limit of cysts and the
methodology for a safe and successful minimally invasive surgery has not been
established. Here we report a case of a large 10-kg multi-locular ovarian mass,
which was successfully laparoscopically removed: Our aim was to innovate the
surgical practice in this field by providing a safe, effective, and minimally
invasive management method for such complex and rare cases.
CASE SUMMARY
A 49-year-old nulliparous woman presented with abdominal distension, lasting
from six Mo prior to admission; she reported worsening abdominal pain,
abdominal swelling, and mild dyspnea. Imaging showed a presumed benign
multi-locular (> 10 locules) left ovarian cyst that measured about 30 cm in
diameter. Based on the IOTA-ADNEX model the mass had a 27.5% risk of being a
borderline or malignant tumor. The patient was successfully treated via a direct
laparoscopic approach with salpingo-oophorectomy, followed by the external
drainage of the cyst. Tumor spillage was successfully avoided during this
procedure. The final volume of the drained mucinous content was 8950 L; the cyst
wall, extracted through the minilaparotomy, weighed about 1200 g. The
pathologic gross examination revealed a 24 cm × 15 cm × 10 cm mass; the
histologic examination diagnosed a mucinous cystoadenoma. To our knowledge,
this is the first case of a giant multi-locular ovarian cyst treated with a direct
laparoscopy with salpingo-oophorectomy followed by external decompression.
Sanna E et al. Laparoscopic management of a giant mucinous ovarian cyst
WJCC https://www.wjgnet.com 3528 August 26, 2020 Volume 8 Issue 16
CARE Checklist (2016) statement:
The authors have read the CARE
Checklist (2016), and the
manuscript was prepared and
revised according to the CARE
Checklist (2016).
Open-Access: This article is an
open-access article that was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution
NonCommercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See: htt
p://creativecommons.org/licenses
/by-nc/4.0/
Manuscript source: Unsolicited
manuscript
Received: May 5, 2020
Peer-review started: May 5, 2020
First decision: May 21, 2020
Revised: May 27, 2020
Accepted: July 30, 2020
Article in press: July 30, 2020
Published online: August 26, 2020
P-Reviewer: Chong CS, Norčič G
S-Editor: Zhang L
L-Editor: A
P-Editor: Wang LL
CONCLUSION
Choosing the appropriate technique and surgeon skill are necessary for a safe and
effective minimally-invasive approach of unique cases involving giant ovarian
cysts.
Key words: Giant ovarian cyst; Minimally-invasive surgery; Laparoscopy; Benign ovarian
mass; Spillage; Case report
©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
Core tip: To date, there are no standard guidelines regarding the maximum size of cysts
that can be safely and effectively laparoscopically treated. To our knowledge, our case
report is the first to describe a very large multi-locular ovarian cyst weighing 10150 g that
was treated via a direct laparoscopic approach with salpingo-oophorectomy, followed by
external decompression. Choosing the most appropriate technique is necessary for safely
and effectively treating unique cases involving large cysts, and this choice is dependent on
the experience and efficiency of the surgical team.
Citation: Sanna E, Madeddu C, Melis L, Nemolato S, Macciò A. Laparoscopic management of a
giant mucinous benign ovarian mass weighing 10150 grams: A case report. World J Clin Cases
2020; 8(16): 3527-3533
URL: https://www.wjgnet.com/2307-8960/full/v8/i16/3527.htm
DOI: https://dx.doi.org/10.12998/wjcc.v8.i16.3527
INTRODUCTION
Giant ovarian cysts (≥ 15 cm in diameter) are rare in women of reproductive age.
To date, all reported techniques for managing such cysts include the preventive
decompression of the cyst, followed by laparoscopic cystectomy and/or the removal
of the adnexa[1,2]. However, the methodology for performing these techniques have not
been fully standardized, and these techniques are technically complex, especially in
cases of multi-locular masses. Moreover, the size limit of cysts for determining
appropriate, safe, and successful minimally invasive surgery has not been
established[3].
The minimally invasive management of giant adnexal cysts with laparoscopic
adnexectomy as first step has yet to be described.
Herein, we describe a case of a large 10-kg multi-locular ovarian mass with no signs
of malignancy. This mass was successfully treated via laparoscopic salpingo-
oophorectomy, followed by the external drainage of the cyst without tumor spillage.
Our aim is to attempt to innovate the surgical practice in this field by providing a
safe, effective, and minimally invasive management method for such complex and rare
cases.
CASE PRESENTATION
Chief complaints
A 49-year-old nulliparous Philippine woman who was admitted to the Department of
Gynecologic Oncology, Azienda Ospedaliera Brotzu Hopital in Cagliari, Italy,
presented with abdominal distension, which had been present for six Mo prior to
admission.
History of present illness
She reported worsening abdominal pain, abdominal swelling, and mild dyspnea.
Moreover, she had not experienced any vomiting or urinary symptoms.
History of past illness
She had no previous history of any illnesses.
Sanna E et al. Laparoscopic management of a giant mucinous ovarian cyst
WJCC https://www.wjgnet.com 3529 August 26, 2020 Volume 8 Issue 16
Physical examination
Upon physical examination, we determined that she was afebrile and peripheral
edema was not present. Further, her abdomen was distended by a pelvic-abdominal
mass that extended from the pubic symphysis to approximately 1 cm under the
xiphoid process (Figure 1A).
Personal and family history
She had no family history of malignancies and had a body mass index of 18.5 kg/m2.
Laboratory examinations
The patient’s tumor marker levels were as follows: 23.5 U/mL of CA 125 protein
(normal range, < 35 U/mL), 1.0 ng/mL of carcinoembryonic antigen (normal range, 0-
5 ng/mL), 62 U/mL of Ca 19.9 (normal range, < 37 U/mL), 5.7 U/mL of CA 15-3
(normal range, 0-32.4 U/mL), and 32.2 U/mL of HE4 (normal range < 70 U/mL).
Imaging examinations
An abdominal ultrasound examination revealed a multi-locular (> 10 locules) mass
that measured about 30 cm in diameter. No papillary projections, blood flow, or ascites
were detected in the mass. Based on the patient’s clinical characteristics and
ultrasound findings, the IOTA-ADNEX Model indicated a 72.6% chance of a benign
tumor, 16.5% chance of a borderline tumor, 8.9% chance of stage I ovarian cancer, 0.4%
chance of stage II-IV ovarian cancer, and 1.7% chance of metastatic cancer to the
adnexa.
The patient also underwent a computed tomography (CT) scan of her abdomen,
which revealed a mass that spanned from the pubic symphysis to the xiphoid process
(Figure 2). The mass presented with internal septations, but no solid components were
observed. The CT retroperitoneal examination did not reveal lymphadenopathy or
metastasis. The uterus and adnexa were not visible at CT.
FINAL DIAGNOSIS
The final diagnosis was a multi-locular ovarian cyst.
TREATMENT
The patient was counselled and signed informed consent for laparoscopic bilateral
salpingo-oophorectomy, total hysterectomy, omentectomy, and laparotomy, as
needed. The case report was performed in accordance with the institutional ethics
committee guidelines and the Helsinki Declaration principles. Written informed
consent was obtained from the patient for the publication of this case report and the
accompanying images.
In order to visually assesses the patient’s large abdominal mass and avoid rupturing
the cyst and spilling its contents during cyst removal, we performed open-entry
laparoscopy with an approximately 1 cm incision, in which a 10-12 mm trocar was
inserted just below the xiphoid process. Agg 0 degree.
A pneumoperitoneum pressure of 12-14 mmHg was achieved and was maintained
throughout the procedure. Another 10-12 mm trocar was placed directly in the
periumbilical position, two ancillary 5-mm trocars were placed bilaterally in the lower
abdominal quadrants, and another 5-mm trocar was placed in the suprapubic region.
The surgery was performed under general anesthesia with the patient in the
lithotomy position. Throughout the procedure, the surgical table was put in the
Trendelenburg position. The angle was modified accordingly to the anesthesiologist’s
needs at different phases of the surgery.
Through the laparoscope, the abdominal cavity could only be partially visualized
because the large cyst was in the way. However, we were able to observe the cyst’s
origin from the left ovary, by moving away parts of the mass by a laparoscopical
device. After visually examining the abdominal cavity and large mass, we started left
salpingo-oophorectomy under laparoscopy guidance with the coagulation and
transection of the left round ligament using a Ligasure device (Tyco Healthcare,
AutoSuture Co., United States, Surgical Corp., Norwalk, CT), preparation of the left
infundibulo-pelvic ligament, coagulation of the left infundibulo-pelvic ligament using
BiClamp LAP forceps (ERBE GmbH, Tubingen, Germany), and following transection
Sanna E et al. Laparoscopic management of a giant mucinous ovarian cyst
WJCC https://www.wjgnet.com 3530 August 26, 2020 Volume 8 Issue 16
Figure 1 View of the abdomen before and after surgery. A: Enlarged abdomen with the patient lying supine before surgery; B: View of the abdomen after
surgery.
using Ligasure (Tyco Healthcare, AutoSuture Co., United States, Surgical Corp.,
Norwalk, CT). Subsequent mobilization of the adnexa toward the upper abdomen and
visualization of the pelvis revealed an enlarged fibromatous uterus, almost double the
normal size, and an approximately 3-4-cm ovarian cyst in the right adnexa.
Afterwards, a minilaparotomy was made at 4 cm above the umbilicus. The mini-
laparotomy incision was protected using a wound protector/retractor (Wound Edge
Protector–3MTM Steri-DrapeTM 1073, Diegem, Belgium). Then, through a mini-open
procedure the cyst was externally decompressed via the aspiration of each locular
component by multiple punctures completely draining their contents except two sub-
compartments that were not drained because the cyst could exit by the mini-
laparotomy. Indeed, the cyst was gradually removed in this way until the mass was
completely extracted. The tumor spillage was successfully avoided during this part of
the procedure. The final volume of the drained mucinous content was 8950 L. The cyst
wall was then extracted through the minilaparotomy (Figure 3). It weighed about 1200
g.
Afterwards, we re-sutured the mini-laparotomy incision, we induced the
pneumoperitoneum again, and laparoscopically visually assessed the abdominal
cavity. The liver, gallbladder, spleen, and diaphragm appeared normal, and there were
no macroscopic signs of malignancy. As such, we proceeded with omentectomy, total
laparoscopic hysterectomy, and right salpingo-oophorectomy in accordance with our
previously described technique[4]. The removal of the uterus, right adnexa, and
omentum was performed through the vagina. The vaginal cuff was then
laparoscopically sutured with a V-Loc wound closure device (Covidien-Medtronic,
Minneapolis, MN, United States).
OUTCOME AND FOLLOW-UP
No blood loss or other intraoperative complications occurred. The total operative time
Sanna E et al. Laparoscopic management of a giant mucinous ovarian cyst
WJCC https://www.wjgnet.com 3531 August 26, 2020 Volume 8 Issue 16
Figure 2 Preoperative computed tomography imaging scan. Computed tomography images showing the sagittal and transverse view of the multi-locular
giant cyst.
Figure 3 The cyst wall after extraction from the abdomen.
was 180 min. The patient had an uneventful recovery and was discharged on
postoperative day 2. Figure 1B showed the cosmetic after surgery (Figure 1B).
The pathologic gross examination revealed a 24 cm × 15 cm × 10 cm mass with an
intact smooth wall. A histologic examination showed that the cyst wall was composed
of a single layer of columnar epithelium without cytologic atypia. The final diagnosis
was mucinous cystoadenoma.
DISCUSSION
Herein, we describe, for the first time at our knowledge, a case of a large 10-kg multi-
locular presumed benign ovarian mass that was successfully treated via laparoscopic
salpingo-oophorectomy, followed by the external drainage of the cyst without tumor
spillage. Laparoscopy is the gold standard treatment for presumed benign ovarian
cysts that range between small and moderate in size[5]. However, there are currently no
Sanna E et al. Laparoscopic management of a giant mucinous ovarian cyst
WJCC https://www.wjgnet.com 3532 August 26, 2020 Volume 8 Issue 16
standard guidelines or consensus for how to manage large (> 10 cm) and very large
(up to the umbilicus) ovarian cysts and what the maximum ovarian cyst size should be
for safe and effective laparoscopic management. The main concern regarding
laparoscopic management of giant ovarian cyst is the potential risk of the capsular
rupture of an unexpected ovarian cancer, resulting in cyst content spillage into the
peritoneum and subsequent seeding. This has resulted in the reluctance of performing
minimally invasive surgery in women with large adnexal masses[3]. However, a
laparoscopic approach has been increasingly preferred due to current advances in
mini-invasive surgery, including the introduction of innovative devices and
techniques that have been shown to avoid tumor spillage, result in shorter hospital
stays, provide better cosmetic results, and are well known for being minimally
invasive.
In current literature, the laparoscopic management of large masses has been based
on a preventive laparoscopic or percutaneous decompression of the cyst, followed by
laparoscopic cystectomy and/or the removal of the adnexa[6-9]. This approach is
typically chosen due to the limited working space during laparoscopy, which is
overcome by the preliminary aspiration of cyst contents.
In our case, the presumed benign cyst was multi-locular and, based on the IOTA-
ADNEX model, had a 27.5% risk of being a borderline or malignant tumor[10]. This was
our reason for implementing a direct laparoscopic approach with adnexectomy using
Ligasure, followed by the accurate external decompression of the cyst. We also chose
this approach because the inability to completely mobilize the mass did not make it
possible to perform initial decompression of multiple chambers. Further, this approach
completely eliminated the risk of cyst content spillage into the peritoneum. To date,
there has only been one report of a case involving the decompression of a giant multi-
locular cyst. In this case by Leys et al[11] the first surgical steps were performed
transcutaneously and, therefore, completely blind. As such, it was not possible to
verify any potential cyst content spillage. Moreover, in cases where there is an
approximate 30% risk of a borderline or malignant mass, like in our case, a technique
that strictly avoids cyst content spillage is required.
In fact, the spillage of the cyst content in case of ovarian malignancy may worsen
patient prognosis even if different studies obtained controversial findings. Some
authors[12-14] found that in case of stage 1 epithelial ovarian cancer intra-operative cyst
rupture did not influence the rate of relapse or prognosis. Vice versa, other authors
reported that intraoperative rupture of stage 1 ovarian cancers worsened patient
prognosis[15-17], even if in the tumor grade remained the most powerful indicator of
disease free survival[17]. A retrospective analysis carried out including 194 patients with
stage I mucinous ovarian carcinoma showed that capsule rupture was a significant
negative prognostic factor for overall survival[18]. Noteworthy, intraoperative spillage
of a mucinous cystadenoma may potentially cause pseudomyxoma peritonei.
However, this condition is usually already detectable at the time of initial surgical
laparoscopy inspection of the abdomen and is mostly associated with a diagnosis of
mucinous cystadenocarcinoma[19,20].
Unfortunately, a direct laparoscopic approach with initial salpingo-oophorectomy
for treating giant ovarian cysts can be extremely technically difficult because of the
limited working space. It was due to the vast experience that the surgical team had in
performing such complex techniques that allowed for the surgical outcomes in our
case[21,22]. Therefore, a certain amount of experience in mini-invasive surgery for
treating giant cysts and very large fibromatous uteri is required to successfully
perform this procedure.
Another key requisite for successful surgery in our case was the modification of
trocar position based on cyst size and the surgeon’s requirements. Particularly, the
position of the 10-12 mm trocar placed just below the xiphoid process, which was
placed via open procedure, was crucial in providing safe access to the mass and,
therefore, avoiding cyst rupture. It also allowed for the best possible view when
managing large abdominal masses. Moreover, the positioning of the periumbilical
trocar was fundamental in allowing for the mobilization of the giant mass and the
accurate assessment of the anatomy and identification of the adequate anatomical
plans for safely performing the procedure.
CONCLUSION
To our knowledge, our case report is the first to describe a very large multi-locular
ovarian cyst that was treated via a direct laparoscopic approach with salpingo-
Sanna E et al. Laparoscopic management of a giant mucinous ovarian cyst
WJCC https://www.wjgnet.com 3533 August 26, 2020 Volume 8 Issue 16
oophorectomy, followed by external decompression. To date, there are no standard
guidelines regarding the maximum size of cysts that can be safely and effectively
laparoscopically treated. Choosing the most appropriate technique is necessary for
safely and effectively treating unique cases involving large cysts, and this choice is
dependent on the experience and efficiency of the surgical team.
REFERENCES
Dolan MS, Boulanger SC, Salameh JR. Laparoscopic management of giant ovarian cyst. JSLS 2006; 10:
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Ghezzi F, Cromi A, Bergamini V, Uccella S, Siesto G, Franchi M, Bolis P. Should adnexal mass size
influence surgical approach? A series of 186 laparoscopically managed large adnexal masses. BJOG 2008;
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