Laparoscopic Management of Torted Paraovarian Cysts in Adolescent Girls

Abstract

Introduction: Paraovarian cysts account for under 7% of all adnexal cysts and are probably even rarer in adolescent girls.¹ They are normally asymptomatic, but may present acutely as lower abdominal pain due to hemorrhage, rupture, or torsion.^2,3 Large cysts have a high risk of torsion, which can involve local structures, including the Fallopian tube and ovary.⁴ Laparoscopy allows prompt diagnosis and intervention to preserve adnexal organs, function, and fertility. Description of video: The video shows two cases of laparoscopic repair of torted paraovarian cysts, demonstrating laparoscopic detorsion and excision of necrotic material with the preservation of both ovaries. Case 1: A 12-year-old girl presented with a 4-day history of worsening lower abdominal pain. Transabdominal ultrasound identified a 7 × 8-cm unilocular cystic lesion with irregular thickening of part of the posterior wall. Tumor markers were negative, but involvement of the ovary could not be excluded. At laparoscopy, a large torted left paraovarian cyst was seen, distorting the associated Fallopian tube. The cyst was decompressed, detorted, and excised, leaving the adjacent ovary intact. Clips were placed at the resection site to secure hemostasis. Case 2: A 15-year-old girl attended the emergency department with an acute onset of severe lower abdominal pain. Ultrasound showed a 10-cm unilocular cyst in the pelvis, but could not identify its precise origin. Laparoscopy revealed a large necrotic, hemorrhagic, right paraovarian cyst. Decompression of the cyst, followed by detorsion and excision are demonstrated. The ovaries remained untouched. Results and Conclusions: Histology of the cysts suggested that they were both probably of Wolffian duct origin. Both patients recovered well and were discharged within 24 h of surgery. Large paraovarian cysts rarely resolve spontaneously and have a high risk of torsion. When presenting acutely, radiological investigations are of limited value, as distinction from ovarian lesions is difficult. Laparoscopy is therefore useful in both diagnosis and therapy.⁵ As malignancy is very rare, laparoscopic decompression and detorsion is safe and effective and enables the preservation of ovaries. None of the authors have any pecuniary interest in the materials used. Runtime of video: 4 mins 38 secs This article was first presented as a poster at IPEG's 22nd Annual Congress for Endosurgery in Children, Beijing, China, June 2013.⁶ Acknowledgements: The authors are most grateful to Mr. James Lewis for his expertise in the preparation of this video.