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Acute abdominal pain in a young female patient with endometrial cyst and acute appendicitis

Authors

Abstract

This video is one of a series of laparoscopic appendicectomies. Evaluation of the pelvic organs in a female patient should be routinely performed to exclude any gynecological pathology.

Keywords

laparoscopic appendicectomies, pelvis, female patient, gynecological pathology

Media type

Duration

05'15''

Publication

2007-09

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E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2195.htm

Acute abdominal pain in a young female patient with endometrial cyst and acute appendicitis

1. Exploration 00'15''

This is a case of a young woman who presented with acute abdominal pain in the right iliac fossa and pelvis. Blood investigations revealed an inflammatory picture. Trocars are placed in the usual positions for laparoscopic appendectomy – optical trocar in the umbilicus, and two working trocars, one in the left lower quadrant and one in the suprapubic position. Exploration begins with identification of the terminal ileal loops. The bowel is then run gently, to exclude any pathologies along the small bowel. We notice a large thick-walled cyst in the right ovary. Closer inspection reveals that this cyst appears to have features consistent with an endometriotic or chocolate cyst. The appendix also shows signs of acute inflammation, confirming the diagnosis.

2. Appendectomy 02'00''

We commence first with the appendectomy. The mesoappendix containing the appendicular artery is controlled with bipolar coagulation. After cautery, it is divided with scissors and then cautery is applied again and procedure continues until the base of the appendectomy is reached. Double ligation of the appendicular stump is then performed with Vicryl loops. An extraction bag is placed in the peritoneal cavity to collect the appendix, which is subsequently divided at the base with scissors. Now we turn our attention to the right ovary.

3. Ovarian cystectomy 03'24''

First, the left ovary is examined carefully to exclude the presence of any pathology. We proceed then with dissection of the right ovarian cyst. The wall of the cyst is separated from the ovary to find a dissection plane. This can be difficult to do and it is necessary to apply effective traction and counter-traction in opposite directions. In this case, the cyst is punctured, and the chocolate coloured contents are consistent with an endometriotic cyst. The dissection continues by peeling the cyst wall away from the ovary. This can be a difficult and tedious procedure, but if one is meticulous, one will be able to excise the cist wall completely. Finally, the cyst is resected and placed in the same extraction bag as the appendix. Haemostasis is controlled on the ovary using the bipolar cautery. The pelvis is washed and the specimens are extracted.

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