Broad ligament ectopic pregnancy at 18 weeks: diagnosis and management in a resource-limited setting (a case report).

Broad ligament ectopic pregnancy is a relatively rare condition described in the literature. We did not find enough data concerning this subject in Cameroon. It is therefore important to know about its existence because late management can lead to increased maternal mortality. This paper reports the case of a 22-year-old lady at 18 weeks gestation who had generalized abdominal pain for two months. Prior to her arrival at our service, an abdominal and pelvic ultrasound done revealed a viable singleton 18-weeks intra-abdominal pregnancy with a moderate amount of abdominal fluid collection. The diagnosis of haemorrhagic shock complicating an abdominal pregnancy at 18 weeks of gestation was retained. An emergency laparotomy was done, and a right total salpingectomy and oophorectomy with resection of the right broad ligament were carried out. After surgery, dissection of the mass revealed a non-viable male foetus weighing 218 grams. In conclusion, there´s a very high morbidity and mortality rate associated with broad ligament pregnancies. Due to the fact that there is late access to antenatal care, the prognosis of pathologic pregnancies is endangered.

Fibrothecoma of broad ligament with minor sex cord elements: Case report and brief literature review.

RATIONALE: Sex cord-stromal tumors are always found in ovary, but the occurrence of this kind of tumor at extraovarian locations is extremely rare. Up to now, the case concerning fibrothecoma of broad ligament with minor sex cord elements has not been reported, and it is extremely challenging to diagnose before surgery. In this case report, we summarized pathogenesis, clinical features, laboratory finding, imaging studies, pathology, and therapeutic schedule of this tumor, with the aim of raising awareness and attention to this type of disease. PATIENT CONCERNS: A 45-year-old Chinese woman was referred to our department with intermittent lower abdominal pain for about 6 years. On examination, both ultrasonography and computed tomography revealed she had a right adnexal mass. DIAGNOSIS: Based on the results of histology and immunohistochemistry, the final diagnosis was confirmed as fibrothecoma of broad ligament with minor sex cord elements. INTERVENTIONS: This patient underwent laparoscopic unilateral salpingo-oophorectomy with excision of the neoplasm. OUTCOMES: Eleven days post-treatment, the patient complained that the symptoms of abdominal pain was disappeared. There is no evidence of disease recurrence 5 years after laparoscopic surgery according to the consequences of radiologic examination. CONCLUSION: The natural history of this kind of tumor is uncertain. Although main treatment of this neoplasm might be surgical resection and good prognosis can be achieved, we believe that long-time follow-up is extremely important in all patients diagnosed as fibrothecoma of broad ligament with minor sex cord. Laparoscopic unilateral salpingo-oophorectomy with excision of the tumor should be recommended to these patients.

Primary uterine broad ligament ependymoma with CHEK2 p.H371Y germline mutation: A CARE-compliant case report uterine broad ligament ependymoma.

Ependymomas arise from ependymal cells lining the ventricles and central canal of the spinal cord and can occur throughout the whole neuraxis. The lesion rarely occurs in extracranial or extraspinal regions, particularly in the uterine broad ligament. Thus, for the pathogenesis of nonsacral extra-central nervous system (CNS) ependymomas remains elusive. Here, we describe a rare case of primary uterine broad ligament. ependymoma with cell-cycle-checkpoint kinase 2 (CHEK2) p.H371Y germline mutation. A 45-year-old woman presented with a uterine mass. The transvaginal sonographic examination confirmed a 4.4 cm × 3.7 cm, cystic and solid, mass located on the right side uterine wall near isthmus. First, laparoscopy with the neoplasm resection was carried out. Based on morphological and immunohistochemical characteristics of tumor cells that expressed glial fibrillary acidic protein (GFAP), S-100, and vimentin, the tumor was diagnosed as an ependymoma. After that, she underwent a laparotomic total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Furthermore, we performed next-generation sequencing (NGS) of the patient's resected tumor tissue and peripheral blood and identified a novel CHEK2 p.H371Y germline mutation. Following surgery, the patient received oral tamoxifen (10 mg 2/day) and followed by letrozole (2.5 mg/day) for 6 months. The patient remained disease-free after 4 years of follow-up. Conceivably, CHEK2 p.H371Y is a driving gene for the development of extra-CNS ependymoma.

Giant broad ligament leiomyoma with postoperative infection diagnosed with contrast-enhanced ultrasound: Case report and literature review.

A 33-year-old woman of giant broad ligament leiomyoma with myxoid degeneration was misdiagnosed as ovarian tumor. The patient underwent a transabdominal myomectomy and developed a pelvic infection after operation diagnosed with contrast-enhanced ultrasound. She was cured and ultimately discharged after symptomatic treatment. Only 21 cases of giant broad ligament leiomyomas with a diameter larger than 12 cm were included. The present systematic review aimed to increase awareness of the clinical characteristics and treatment methods of giant broad ligament leiomyoma, and reduce the rates of misdiagnosis and postoperative complications.

A case of laparoscopically treated broad ligament ectopic pregnancy followed by spontaneous gestation.

We present a case of spontaneous pregnancy after laparoscopic surgery for a broad ligament pregnancy. A 34-year-old nulliparous woman presented with 6 weeks of amenorrhea. Due to the presence of an empty uterus with a 10 mm right adnexal mass on transvaginal ultrasonography and elevated serum human chorionic gonadotropin (hCG), ectopic pregnancy was suspected. Upon diagnostic laparoscopy, the presence of a 2 cm broad ligament ectopic pregnancy was confirmed. Laparoscopic removal of the gestational tissues was performed. Six months after surgery, a spontaneous pregnancy was established. At the 40th week of gestation, a cesarean section was performed due to arrested labor, resulting in live birth. To the best of our knowledge, there have been no reports of a spontaneous pregnancy occurring after laparoscopic surgery for broad ligament pregnancy. Laparoscopic surgery as a treatment option for broad ligament pregnancy may be useful in early gestational age because it can be completed without complications.

Non-Tender Huge Abdominal Mass in an Adolescent: Bilateral paraovarian cysts.

Paraovarian cysts constitute about 10% of all adnexal masses in females and occur most commonly in the third and fourth decades of life. These cysts are benign and usually uncommon in adolescence. Such cysts pose a diagnostic challenge while distinguishing them from ovarian cysts clinically and during radiological investigations. We report a rare case of a 13-year-old female patient with bilateral paraovarian cysts, including a giant cyst in right mesosalpinx presenting to Sohar hospital, Oman in 2018. The definitive origin of the huge mass on the right side of abdominal cavity could not be established in the current case despite contrast enhanced computerized tomography. It was only on laparoscopic exploration that this mass was identified as a giant paraovarian cyst. Both the giant cyst and a smaller paraovarian cyst on the left side were enucleated with minimally invasive surgery while preserving the fertility of the patient. Only one other similar case of bilateral paraovarian cysts in an adolescent, including a giant cyst managed with laparoscopy, has been documented previously.

Herniation Through Defects in the Broad Ligament.

BACKGROUND: We sought to assess hernia characteristics and classification through comprehensive review of the literature involving broad ligament herniation. METHODS: A literature search via MEDLINE and Embase databases was conducted to identify and select broad ligament herniation studies published between January 1, 2000 and September 30, 2020. Extracted data included previous surgical history, previous obstetric history, diagnostic imaging, herniated organ, hernia classification, and repair performed. The reported data has been compared to a unique case of broad ligament herniation that presented to our institution. RESULTS: A total of 44 articles with 49 cases were identified for the study. Eighteen (36.7%) patients had a history of previous abdominal surgery while 29 (59.2%) had a history of previous childbirth. Type I (51.0%) and Type II (18.4%) defects were most commonly reported with most patients reporting only one defect (85.7%) using the Cilley classification. Twenty-nine patients underwent primary laparoscopic repair of the defect while 19 patients underwent exploratory laparotomy. CONCLUSIONS: The analysis of previously reported cases adds to the limited literature on broad ligament hernias and highlights the surgical management of this uncommon pathology. It also highlights the need for a broad differential diagnosis when female patients present with pelvic pain or symptoms of small bowel obstruction. The broad ligament should be fully inspected when mesenteric defects are suspected as multiple defects can be present as evidenced by the attached case study.

Recurrent and metastatic female adnexal tumor of probable Wolffian origin: A case report and review of the literature.

RATIONALE: Female adnexal tumors of probable Wolffian origin (FATWOs) are rare gynecologic neoplasms arising from the mesonephric duct remnants. Less than 90 cases have been reported in the English literature. Although most cases of FATWO are considered benign, recurrence and metastasis may occur in very few cases during the course of the disease. Due to the small number of recurrent and metastatic FATWO cases, there are no clear recommendations regarding optimal treatment. PATIENT CONCERNS: A 75-year-old postmenopausal woman, who underwent a mass excision of the right broad ligament three years ago, was found to have a right adnexal mass during a regular postoperative physical examination. DIAGNOSES: Vaginal ultrasound examination revealed a cystic and solid mass approximately 3.6 × 4.4 × 3.8 cm on the right side of the uterus. Three years ago, the mass of the right broad ligament was diagnosed with FATWO in the local hospital. Following extensive immunohistochemistry analysis and after reviewing the histology slides from the primary tumor, the final diagnosis of the mass on the right side of the uterus was recurrent and metastatic FATWO. INTERVENTIONS: The patient underwent laparoscopic mass excision, hysterectomy and resection of the metastatic lesion in the small intestine, and then she received 6 cycles of docetaxel and carboplatin-based chemotherapy. OUTCOMES: The disease has recurred three years after the first surgery in the local hospital. After the second surgery followed by systemic chemotherapy, there is no evidence of recurrence with 24 months of follow-up till now. LESSONS: FATWO is considered a benign entity. However, a few FATWOs have been shown to behave aggressively. Due to only a few reported cases, there are no comprehensive recommendations regarding the optimal clinical management of recurrent and metastatic FATWOs. Complete surgical resection followed by combination chemotherapy is considered to be the most effective therapy for recurrent and metastatic FATWOs. Chemotherapy with docetaxel plus carboplatin, which is most commonly used in malignant cases, may be effective in the treatment of recurrent and metastatic FATWOs.

Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy.

STUDY OBJECTIVE: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING: Teaching hospital. PATIENTS: Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS: TULH. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension.

STUDY OBJECTIVE: The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. DESIGN: Retrospective propensity-score matched cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. INTERVENTIONS: We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1-3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1-2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7-2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0-2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7-2.8; p = .3). CONCLUSION: In this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.

Broad ligament pregnancy: A case series and literature review.

Broad ligament pregnancies are rare and are often misdiagnosed, leading to serious consequences. In our hospital, we have treated six broad ligament pregnancies since 2000. They were diagnosed and operated on promptly, and treatment was successful. Ultrasound can detect early ectopic pregnancies promptly and effectively, avoiding advanced ectopic pregnancies. Early broad ligament pregnancies should be operated on promptly, and laparoscopic therapy is preferable. During the operation, attention must be paid to avoid massive bleeding and protect the ureter, because the ectopic gestational sac is located near the uterine artery and the ureter.

Recurrent broad ligament leiomyosarcoma with pancreatic and thigh metastasis: a case report.

BACKGROUND: Leiomyosarcoma (LMS) is an uncommon mesenchymal neoplasm, which infrequently metastasizes to pancreas and thigh. Clinical presentation and imaging findings of metastatic broad ligament LMS are often nonspecific. Complete excision plays an important role in treatment of patients with localized LMS. CASE PRESENTATION: Here, we report a case of a 33-year-old woman with recurrent broad ligament LMS metastasizing to pancreas and thigh. Previously, she was diagnosed with broad ligament LMS and underwent hysterectomy, bilateral salpingo-oophorectomy. The disease-free interval was 2.5 years until metastases were found. Computerized tomography (CT) of abdomen and thighs, magnetic resonance imaging (MRI) of thighs and whole-body 18-fluorodeoxyglucose positron emission tomography - computed tomography (PET-CT) performed, revealed pancreatic and thigh metastasis. Ultrasonography-guided biopsy and histological examinations confirmed LMS at both the sites. Pancreatic metastasis was completely resected first. Then the patient underwent surgical resection of thigh metastasis when both chemotherapy and radiotherapy failed. She recovered well and remained free of disease recurrence in the 2 years follow-up. CONCLUSIONS: Though imaging lacks specificity, it is a valuable asset in assessing the burden of disease and characterizing lesions while histological examination with immunohistochemistry is helpful for the diagnosis of LMS. Complete surgical resection of all metastatic sites where-ever feasible should be strongly considered in a treated case of broad ligament LMS with a durable disease-free interval.

Laparoscopic Cervical Encerclage in Pregnancy in 6 Steps.

STUDY OBJECTIVE: Cervical insufficiency occurs in 0.1% to 1 % of all pregnancies and is associated with a high risk of second-trimester abortion and/or preterm delivery [1]. Laparoscopic encerclage is highly recommended for a previous failed vaginal encerclage and is superior to the laparotomy approach in terms of low morbidity and faster recovery [2]. Laparoscopic encerclage in pregnancy is more challenging than that in the nonpregnant state. This is because of the enlarged uterine size, engorged uterine vessels, and infeasibility of using a uterine manipulator. The standardization and description of the technique are the main objectives of this video (Video 1). We have described the surgery in 6 steps that could make this procedure easier and safer. DESIGN: A step-by-step video demonstration of the technique. SETTING: Paul's Hospital, Centre for Advanced Endoscopy & Infertility Treatment, Kochi, India. A 29-year-old pregnant woman, gravida 3 abortions 2, at 13 weeks period of gestation, with a history of 2 second-trimester abortions owing to cervical insufficiency. The patient had a failed vaginal cervical encerclage at 18 weeks in the second pregnancy. INTERVENTIONS: This is a step-wise laparoscopic approach for successful cervical encerclage in pregnancy. In this video, we demonstrate our technique for laparoscopic cervical encerclage in a pregnant woman's uterus in 6 steps using a Mersilene tape (Ethicon US, LLC, Somerville, NJ) as follows: (1) Opening the uterovesical fold and dissecting the bladder, (2) opening the left broad ligament and creating a window, (3) opening the right broad ligament and creating a window, (4) placing the Mersilene tape on the left side medial to the uterine vessels at the cervicoisthmic junction, (5) placing the Mersilene tape on the right side medial to the uterine vessels at the cervicoisthmic junction, (6) tying the Mersilene tape anteriorly. CONCLUSION: The standardization of laparoscopic cervical encerclage in pregnancy using the above 6 steps could make this procedure easier and safer to perform. Moreover, the standardization of the surgical technique could shorten the learning curve.

Huge broad ligament leiomyoma with cystic degeneration: A diagnostic and surgical challenge.

Broad ligament is the common extrauterine site for fibroid. We present a case of huge broad ligament fibroid with cystic degeneration. Patient presented with abdominal swelling and mild pain abdomen. On abdominal examination, a large tense cystic mass of 34 weeks gravid uterus size arising from pelvis was noted. Cervix was pulled up and all fornices were full with mass on pelvic examination. Ultrasound suggested adnexal mass as ovaries were not seen. Contrast-enhanced computed tomography abdomen too reported adnexal mass likely of ovarian origin. On laparotomy, 6 L of straw color fluid drained from the mass which was seen arising from left broad ligament, bilateral ovaries were separate from the mass and appeared healthy. Enucleation of mass was done to ease the hysterectomy and careful evaluation of ureteric course was done throughout the surgery to avoid its injury. Total hysterectomy with bilateral salpingo-opherectomy and pelvic lymphadenectomy was performed. This case is being reported for its rare incidence, diagnostic dilemma and surgical challenge.