A 17-year-old woman was admitted to our hospital complaining of abdominal pain that had persisted for 3 days. She seemed alert and was not pale, with blood pressure of 112/70 mmHg and a regular pulse of 78 bpm. Laboratory data showed a white blood cell count of 7530/μL, hemoglobin concentration of 11.0 g/dL, a platelet count of 249,000/μL, glutamic oxaloacetic transaminase concentration of 22 IU/L, glutamic pyruvic transaminase concentration of 9 IU/L, and lactic dehydrogenase concentration of 259 IU/L.
Computed tomography (CT) revealed a 10 × 10 × 10-cm low-density area in the patient’s mid-abdomen (Fig. 1a), and magnetic resonance imaging (MRI) showed a large abdominal cystic lesion (Fig. 1b). However, the tumor position differed notably between CT and MRI, and an unfixed, mesenteric cystic lesion was suspected. Single-port laparoscopic-assisted resection was therefore performed instead of conventional laparotomy.
A single-incision access platform and wound protector were introduced through a 1.5-cm transumbilical skin incision. Laparoscopy showed a large cyst derived from the greater omentum (Fig. 2a), which was moved to a position under the umbilical wound. The cyst fluid (which was serous in nature) was aspirated using a tissue adhesive (Dermabond™, Ethicon Inc., Somerville, NJ), a suction tube with negative pressure, and a 16-gage over-the-needle catheter and syringe; this reduced the size of the tumor and none of the cyst fluid was released into the abdominal cavity (Fig. 2b, c). Then, the tumor was successfully removed via the small incision (Fig. 2c, d) and was diagnosed histopathologically as a cystic lymphangioma (Fig. 3).
The surgery was uneventful, and the postoperative recovery was normal.
Discussion
Intraperitoneal cystic tumors are rare. A large cystic tumor usually requires a large skin incision for its removal. However, if the size of the cyst can be reduced by extracting its contents, it is possible to operate via a small wound [8]. In the present case, an abdominal cystic tumor was successfully removed via a small incision after aspirating the cyst fluid and thereby reducing the size of the tumor. The cystic fluid was successfully aspirated without spillage using a tissue adhesive, suction tube, and 16-gage over-the-needle catheter. The abdominal laparoscopic procedure used a smaller incision than is required for conventional laparotomy, and the laparoscope allowed more detailed observation, which was useful for the operative diagnosis.
Tumors close to the body surface may be resected via a small incision without a laparoscope, but movable tumors that shift to a site distant from the body surface cannot be resected in this way. However, even in such cases, a laparoscope can confirm the lesion and be used to guide it to an appropriate position. Even tumors fixed to a site distant from the body surface can be brought to the surface using a laparoscope after removing the surrounding tumor tissue. Laparoscopy allows for the manipulation of various types of tumor.
When cystic lesions can be reduced by aspirating the cyst contents, it is possible to perform a minimally invasive procedure with a small incision. However, it is crucial that none of the cyst contents leak into the peritoneal cavity. Preoperatively, our patient’s cystic tumor was predicted to be benign; therefore, surgery without lymph node dissection or extended resection was planned. However, the cyst contents may have been infected. In addition, a malignant cystic tumor could not be ruled out. Thus, care was taken to avoid any leakage of the cyst fluid into the surrounding areas. Trocar site recurrences due to bile leakage into the site of incision have been reported during cholecystectomy [9].
In our case, surgery was performed without any leakage of cyst fluid using medical equipment that is readily available at all surgical facilities. Laparoscopic-assisted surgery should be used to resect intraperitoneal cystic lesions wherever possible. This method can be applied to various types of cases, such as gynecological abdominal cystic diseases [7, 10]. The procedure used for the present case was easy to perform and required no special materials.
