Limits...
Laparoscopic management of a large torted ovarian cyst in an adolescent virgin: a case report.

Sabry M, Ait Allah AS, Roshdy E, Al-Hendy A - Int J Womens Health (2012)

Bottom Line: We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient's request to maintain the integrity of the hymen.Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag.Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetrics and Gynecology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt.

ABSTRACT
We report a case of a torted mature cystic teratoma in a 23-year-old, sexually inactive, virgin female which necessitated immediate laparoscopy. The patient and her family stressed that the integrity of the hymen must be maintained at any cost, for cultural reasons. We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient's request to maintain the integrity of the hymen. Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag. Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.

No MeSH data available.


Related in: MedlinePlus

Panoramic view of the abdominal cavity. Left dermoid cyst torted × 3 (panel A). A view of the pelvis after removal of the left adnexa (panel B). The right adnexa appear normal.
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC3367404&req=5

f1-ijwh-4-223: Panoramic view of the abdominal cavity. Left dermoid cyst torted × 3 (panel A). A view of the pelvis after removal of the left adnexa (panel B). The right adnexa appear normal.

Mentions: After general anesthesia was induced, we carefully and gently examined the patient’s vaginal area and found it to be almost completely sealed, with a microperforate hymen containing a hymenal opening that would not fit even one finger without disturbing the hymen. To fulfill the patient’s request to maintain her virginity, we asked the circulating nurse to be extra careful around the vulvar area and not to perform the routine intravaginal part of surgical preparation to avoid disturbing the hymen. We positioned the patient in the dorsal supine position instead of the typical dorsal lithotomy position for laparoscopy. After placing the trocars and panoramically viewing the abdominal cavity (Figure 1), we used a 5 mm probe to stent and antivert the uterus, and we also used a self-locking atraumatic grasper to handle the uterus carefully as needed. We found a left ovarian cyst torted × 3 (Figure 1, panel A). Because we lacked the option of a uterine manipulator, we raised the intra-abdominal pressure to 22 mmHg to generate additional room for intra-abdominal manipulation and then used a 5 mm laparoscopic uterine probe to manipulate the uterus during the procedure. After finding the right ovary and tube to be normal (Figure 1, panel B), we untwisted the cyst and started to perform the cystectomy. However, we soon observed some hair and decided to proceed instead with a left salpingo-oophorectomy so as to avoid possible puncture of a dermoid cyst, which could cause chemical peritonitis and affect the patient’s future fertility potential. The left adnexa, which were about 11 × 13 cm upon intraoperative assessment (Figure 1A), did not fit into the normally available endobag, so we used a large nephrectomy bag to remove the specimen from the abdominal cavity. We used the nephrectomy bag through a 10 mm central port, and for visualization, we switched to a 5 mm laparoscope through one of the two 5 mm lateral ports. At the end of the procedure, we noticed that the patient was experiencing moderate bilateral periorbital air emphysema, and although periorbital edema is a rare observation with our surgical team, it likely to have been caused by a combination of relatively high intra-abdominal pressure and a steep Trendelenburg position. However, the periorbital emphysema resolved spontaneously over the next few hours. The patient was kept under observation for 23 hours and then discharged in excellent condition.


Laparoscopic management of a large torted ovarian cyst in an adolescent virgin: a case report.

Sabry M, Ait Allah AS, Roshdy E, Al-Hendy A - Int J Womens Health (2012)

Panoramic view of the abdominal cavity. Left dermoid cyst torted × 3 (panel A). A view of the pelvis after removal of the left adnexa (panel B). The right adnexa appear normal.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3367404&req=5

f1-ijwh-4-223: Panoramic view of the abdominal cavity. Left dermoid cyst torted × 3 (panel A). A view of the pelvis after removal of the left adnexa (panel B). The right adnexa appear normal.
Mentions: After general anesthesia was induced, we carefully and gently examined the patient’s vaginal area and found it to be almost completely sealed, with a microperforate hymen containing a hymenal opening that would not fit even one finger without disturbing the hymen. To fulfill the patient’s request to maintain her virginity, we asked the circulating nurse to be extra careful around the vulvar area and not to perform the routine intravaginal part of surgical preparation to avoid disturbing the hymen. We positioned the patient in the dorsal supine position instead of the typical dorsal lithotomy position for laparoscopy. After placing the trocars and panoramically viewing the abdominal cavity (Figure 1), we used a 5 mm probe to stent and antivert the uterus, and we also used a self-locking atraumatic grasper to handle the uterus carefully as needed. We found a left ovarian cyst torted × 3 (Figure 1, panel A). Because we lacked the option of a uterine manipulator, we raised the intra-abdominal pressure to 22 mmHg to generate additional room for intra-abdominal manipulation and then used a 5 mm laparoscopic uterine probe to manipulate the uterus during the procedure. After finding the right ovary and tube to be normal (Figure 1, panel B), we untwisted the cyst and started to perform the cystectomy. However, we soon observed some hair and decided to proceed instead with a left salpingo-oophorectomy so as to avoid possible puncture of a dermoid cyst, which could cause chemical peritonitis and affect the patient’s future fertility potential. The left adnexa, which were about 11 × 13 cm upon intraoperative assessment (Figure 1A), did not fit into the normally available endobag, so we used a large nephrectomy bag to remove the specimen from the abdominal cavity. We used the nephrectomy bag through a 10 mm central port, and for visualization, we switched to a 5 mm laparoscope through one of the two 5 mm lateral ports. At the end of the procedure, we noticed that the patient was experiencing moderate bilateral periorbital air emphysema, and although periorbital edema is a rare observation with our surgical team, it likely to have been caused by a combination of relatively high intra-abdominal pressure and a steep Trendelenburg position. However, the periorbital emphysema resolved spontaneously over the next few hours. The patient was kept under observation for 23 hours and then discharged in excellent condition.

Bottom Line: We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient's request to maintain the integrity of the hymen.Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag.Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetrics and Gynecology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt.

ABSTRACT
We report a case of a torted mature cystic teratoma in a 23-year-old, sexually inactive, virgin female which necessitated immediate laparoscopy. The patient and her family stressed that the integrity of the hymen must be maintained at any cost, for cultural reasons. We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient's request to maintain the integrity of the hymen. Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag. Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.

No MeSH data available.


Related in: MedlinePlus