Received: 24.10.2007 Accepted: 10.12.2007
J Gastrointestin Liver Dis
December 2008 Vol.17 No 4, 465-468
Address for correspondence: Dr. M. Rangarajan
GEM Hospital
Coimbatore – 641045, India
Email: rangy68@gmail.com
Laparoscopic Excision of an Infected “Egg-shelled”
Retroperitoneal Pseudocyst
Chinnusamy Palanivelu, Muthukumaran Rangarajan, Rangaswamy Senthilkumar, Madhupalayam Velusamy
Madhankumar, Shankar Annapoorni
GEM Hospital, Ramnathapuram, Coimbatore, India
Abstract
Primary retroperitoneal pseudocysts are rare entities.
Though laparoscopic approach has been described in their
treatment, open surgical excision is still the mainstay of
treatment for these lesions. We present a case of infected
retroperitoneal pseudocyst and its successful laparoscopic
excision. The patient was an 80-year old female. Contrast
enhanced CT scan of the abdomen and ultrasonography
confirmed a large retroperitoneal cyst. Laparoscopic resection
was accomplished after puncturing and decompressing the
cyst. There were no complications or conversion. The
operating time was 176 minutes. The patient was discharged
3 days after surgery. Histopathology revealed a pseudocyst.
Retroperitoneal pseudocysts can be resected laparoscopically
with careful and meticulous laparoscopic dissection, utilizing
the advantages of laparoscopy.
Keywords
Retroperitoneal pseudocysts – calcified – cyst –
laparoscopic excision
Introduction
Retroperitoneal cysts are believed to be benign tumors of
the retroperitoneum. Primary retroperitoneal cysts, defined
as retroperitoneal cystic structures not deriving from any
retroperitoneal organs, are rare. They are known to attain
large proportions before causing any symptom, and are often
discovered accidentally [1]. These rare tumors are derived
from remnants of embryonal urogenital apparatus, which
include tissues of both epithelial and mesothelial origin
[2]. Other hypotheses for these cysts involve lymphatic,
traumatic, and parasitic origin [3]. Retroperitoneal cysts that
have no epithelial lining in the wall are called pseudocysts.
Though laparoscopic approach has been described, open
surgical excision (transperitoneal or extraperitoneal) is still
the mainstay of treatment for these lesions. There are few
reports of laparoscopic excision of retroperitoneal cysts in
the literature, but no reports of pseudocysts.
Case report
The patient was an 80-year old female, presented with
a vague ‘dragging’ pain in the left upper quadrant of two
months duration. The patient did not have any recent history
of trauma. Her bowel and bladder habits were normal; and
there was no fever or weight loss. There was no history of
stroke or palpitation, though she was a hypertensive that was
under control. Abdominal physical examination revealed a
large mass in the left hypochondrium, which was mobile
and nontender. The mass was in the retroperitoneal plane.
Left renal angle was free and the mass was not ballotable
but bimanually palpable. Its margins were well defined and
soft/cystic in consistency. Ultrasonography of the abdomen
showed a large retroperitoneal, cystic mass measuring
19 x 17 cm with a calcified wall. The mass was bounded
superiorly by the diaphragm, the spleen inferiorly, stomach
and the lateral abdominal wall. The left kidney was displaced
posteromedially. Contrast enhanced CT scan of the abdomen
(Figs.1, 2) confirmed the ultrasound findings. Relevant
hematological and biochemical investigations were normal.
She was diagnosed as a case of calcified retroperitoneal cyst
(probably adrenal) and laparoscopic excision was planned.
Under general anesthesia, the patient was placed in
a reverse Trendelenburg position with a 35° right lateral
tilt. Pneumoperitoneum was achieved via a Veress needle
and intra-abdominal pressure maintained at 12mmHg. The
monitor was placed to the left of the patient, directly opposite
the surgeon. The operating surgeon stood to the right of the
patient and the camera assistant stood at the right hand side
of the operating surgeon.
A total of four ports were placed in the abdomen: 10mm
port 2cm above the umbilicus; 5mm port (right working
hand) in the left lumbar area, at the level of the midclavicular
466 Palanivelu et al
line; 5mm port (left working hand) in the left upper quadrant,
at the level of the midclavicular line; 10mm port (for stomach
retraction) in the epigastrium.
On laparoscopy, the cyst was clearly seen, with the
fascial planes being well preserved (Fig. 3). Dissection was
commenced on the superior wall of the cyst by dividing
the adhesions with the stomach and diaphragm using
ultrasonic shears. Laterally, the splenic flexure of the colon
was mobilized to expose the lateral border of the cyst and
medially adhesions to the stomach were divided. Inferiorly,
adhesions to the spleen and tail of pancreas were dissected
out. The texture of the left adrenal gland and pancreas
were normal. There were adhesions to the lateral border of
Gerota’s fascia and the adrenal gland, which were mobilized.
Up to this point the cyst wall was preserved. We inadvertently
punctured the cyst wall, which was thick and calcified (Fig.
5). The cyst contained thick, dirty-white fluid with debris.
Due to the calcified cyst wall, it did not collapse even after
decompression. A specimen of the cyst wall was sent for
frozen section to rule out carcinoma. Once the report was
negative, we proceeded with a complete excision of the
cyst using a combination of blunt and sharp dissection.
The specimen was extracted via a minilaparotomy incision
(Fig. 5). All wounds were closed after a thorough wash and
hemostasis.
Total operating time was 176 minutes and blood loss was
about 230 ml. The postoperative period was uneventful. She
was discharged on the 3rd postoperative day. Histopathology
of the fluid revealed acellular cyst fluid, necrotic material
with no malignant cells or epithelial cells. Microscopic
examination showed that the cyst wall was devoid of
lining epithelium with extensive calcification and chronic
Fig 1. Saggital section CT scan showing a large
cyst (arrow) with calcified wall occupying the left
upper quadrant.
Fig 2. Cross section CT scan (gut contrast) showing
a large cyst with calcified wall (arrow) occupying
the left upper quadrant and its relations.
Fig 3. View of the cyst on laparoscopy: A – tip of
left lobe, B – cyst, C – stomach, D – spleen.
Fig 4. Dissection at the inferior aspect of the cyst,
Arrow – inferior aspect of the cyst; A - spleen.
Fig 5. Specimen being removed in an endobag
through a minilaparotomy.
Laparoscopic excision of a retroperitoneal pseudocyst 467
inflammatory cells, confirming the diagnosis of a pseudocyst
(Fig. 6). There was no evidence of pancreatic or adrenal
tissue, or malignancy. The patient was followed up for 23
months, first at the third month and later every six months.
She has remained asymptomatic and there has been no
evidence of recurrence.
Discussion
The potentially large retroperitoneal space contains
organs derived from the ectoderm and endoderm that are
all embedded in a loose network of connective tissue. This
allows both primary and metastatic tumors to grow silently
before the appearance of signs and symptoms. Simple
retroperitoneal cysts rarely present as abdominal masses. If
they are derived from the Wolffian duct, they are filled with
clear fluid, and if teratomatous they are filled with sebaceous
material. Rarely, lymphangiomas and bronchogenic cysts
can also occur in the retroperitoneum [4, 5].
There are no classical clinical signs of retroperitoneal
cysts, though vague abdominal pain and distension are
present in 50% of cases [6]. They may occasionally present
with acute abdominal pain if they become hemorrhagic or
infected. Ultrasonography and CT scan are usually diagnostic
of the condition. These cysts may be unilocular or multilocular
and need to be distinguished from hydronephrosis or giant
ovarian cysts [7, 8]. Depending on their origin, the cyst may
be lined either by the cells of mesothelial or mesonephric
origin. Pseudocysts are rarer in the retroperitoneum and are
characterized by the absence of any lining epithelium [9].
These findings were similar to that of our patient, who
also had extensive calcification of the cyst wall with chronic
inflammatory changes. When we accidentally punctured
the cyst wall, it ‘cracked’ almost as an eggshell does. The
content was a thick, white-colored fluid. Ideally, these cysts
of doubtful origin should be resected in toto, as any spillage
could cause tumor seeding in cases when these are malignant.
In spite of the spillage of the fluid in our patient, there was
no danger of spread, as malignancy was ruled out by the
frozen section.
Fig 6. Features of calcified pseudocyst – cyst
wall devoid of lining epithelium with extensive
calcificationandchronic inflammation(hematoxylin
eosin, x 100).
The treatment of choice for these retroperitoneal
cysts is complete excision with, if necessary, resection
of a portion of the adherent bowel. Marsupialization and
partial excision of the cyst are less satisfactory procedures,
as recurrence is common. The conventional methods of
surgery are laparotomy, an extraperitoneal approach, or a
transperitoneal flank approach [9]. The open extraperitoneal
approach avoids entry into the peritoneal cavity and has
advantages like reduced intraoperative fluid and heat loss,
a brief postoperative ileus, and avoids manipulation of gut
and subsequent development of adhesions. Laparoscopic
excisions of retroperitoneal cysts have been published,
though they are all only case reports [10]. Even though the
laparoscopic approach is transperitoneal, all the advantages
of the extraperitoneal approach like no bowel handling and
no postoperative adhesions can be made use of. Also, heat
loss is minimal as there is no large laparotomy incision.
Laparoscopic excision of a retroperitoneal pseudocyst has
never before been reported, as far as we know. Recurrence
following excision of retroperitoneal cyst can occur if
excision is incomplete. The true incidence of recurrence
is not known; however, in one series a figure of 25% was
quoted [11]. In our case, the excision was complete and there
has not been any evidence of recurrence after 23 months of
follow up.
In conclusion, retroperitoneal pseudocysts of non-
pancreatic origin are very rare lesions and have to be
distinguished from malignancy. Adrenal pseudocysts are
known to occur and have been reported in the literature
[12]. Laparoscopic excision, though tedious, is definitely
beneficial for the patient, as they usually require large
incisions to remove. Laparoscopic excision entails small
incisions, better cosmesis, less pain and early recovery.
References
1. Pace G, Galatioto Paradiso G, Galassi P, Vicentini C. Retroperitoneal
cysts: a case report. Arch Ital Urol Androl 2006; 78: 25-26.
2. Kurtz RJ, Heimann TM, Holt J, Beck AR: Mesenteric and
retroperitoneal cysts. Ann Surg 1986; 203: 109-112.
3. Walker AR, Putnam TC. Omental, mesenteric, and retroperitoneal
cysts: a clinical study of 33 new cases. Ann Surg 1973; 178: 13-
19.
4. Akos MB, Peter K, Edina N, Janos H, Eszter S. Laparoscopic
extirpation of retroperitoneal bronchogenic cyst. Magy Seb 2006;
59: 37-41.
5. Waisberg J, Pezzolo S, Henrique AC, Kerr LM, Speranzini MB.
Retroperitoneal cyst lymphangioma. Arq Gastroenterol 1999; 36:
37-41.
6. Adams JT. Abdominal wall, omemntum, mesentery and retoperitoneum.
In : Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery.
5th ed. McGraw Hill Book 1989; 1491-1524.
7. Smith VC, Edwards RA, Jorgensen JL, et al. Unilocular
retroperitoneal cyst of mesothelial origin presenting as a renal mass.
Arch Pathol Lab Med 2000; 124: 766–769.
8. Herbert CM 3rd, Segars JH, Hill GA. A laparoscopic method for
excision of large retroperitoneal paraovarian cysts. Obstet Gynecol
1990; 75: 139-141.
9. Tsukada O, Kawabe K. A case of retroperitoneal pseudocyst filled
468 Palanivelu et al
with necrotic material. Nippon Hinyokika Gakkai Zasshi 1978; 69:
1667-1670.
10. Cadeddu MO, Mamazza J, Schlachta CM, Seshadri PA, Poulin
EC. Laparoscopic excision of retroperitoneal tumors: technique
and review of the laparoscopic experience. Surg Laparosc Endosc
Percutan Tech 2001; 11: 144-147.
11. Downey, D M, Dolan J P, Hunter J G. Laparoscopic Resection of a
Giant Retroperitoneal Cyst. American College of Surgeons Clinical
Congress, San Francisco, CA 10/2005 (video presentation).
12. Kar M, Pucci E, Brody F. Laparoscopic resection of an adrenal
pseudocyst. J Laparoendosc Adv Surg Tech 2006; 16: 478 -481.
本文档为【腹膜后脓肿】,请使用软件OFFICE或WPS软件打开。作品中的文字与图均可以修改和编辑,
图片更改请在作品中右键图片并更换,文字修改请直接点击文字进行修改,也可以新增和删除文档中的内容。
该文档来自用户分享,如有侵权行为请发邮件ishare@vip.sina.com联系网站客服,我们会及时删除。
[版权声明] 本站所有资料为用户分享产生,若发现您的权利被侵害,请联系客服邮件isharekefu@iask.cn,我们尽快处理。
本作品所展示的图片、画像、字体、音乐的版权可能需版权方额外授权,请谨慎使用。
网站提供的党政主题相关内容(国旗、国徽、党徽..)目的在于配合国家政策宣传,仅限个人学习分享使用,禁止用于任何广告和商用目的。