Laparoscopic Excision of a Pelvic Mass in a Patient with Primary Amenorrhea

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This video demonstrates the excision of a large pelvic mass performed laparoscopically.

Presented By

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Dr. Jaclyn Madar


University of Saskatchewan

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What is Pelvic Mass in a Patient with Primary Amenorrhea?

Laparoscopic excision of a pelvic mass in a patient with primary amenorrhea is a minimally invasive surgery aimed at removing an abnormal growth in the pelvis of a woman who has not experienced menstrual bleeding by the expected age. This procedure uses small incisions for inserting a camera and surgical tools to remove the mass, offering benefits such as less pain, quicker recovery, and minimal scarring compared to open surgery. The presence of a pelvic mass can be a significant factor in primary amenorrhea, potentially hindering normal menstrual function due to congenital anomalies, tumors, or gynecological issues. Removing the mass not only aims to relieve any associated symptoms but also helps in diagnosing the specific cause of amenorrhea. Analyzing the removed mass provides critical insights that can guide further treatment to improve the patient’s reproductive health. This approach is crucial for addressing both the immediate concern of the pelvic mass and the underlying issue of amenorrhea.

What are the Risks of Pelvic Mass in a Patient with Primary Amenorrhea?

The laparoscopic excision of a pelvic mass in a patient with primary amenorrhea carries specific risks, similar to other surgical interventions, but also unique considerations given the patient’s condition:

  • Infection: Surgical procedures, including laparoscopy, can lead to infections at the incision sites or within the pelvic cavity.
  • Bleeding: There is a risk of significant bleeding during or after the procedure, which may necessitate further intervention.
  • Damage to Surrounding Organs: The procedure carries a risk of accidental injury to nearby organs such as the bladder, intestines, or blood vessels.
  • Adhesions: Post-surgical scar tissue can form, potentially leading to pelvic pain, bowel obstruction, or fertility issues.
  • Anesthesia Risks: Complications related to anesthesia can occur, although rare, including reactions or respiratory issues.
  • Fertility Impact: While laparoscopic surgery is often fertility-preserving, any pelvic surgery carries a potential risk to a patient’s future fertility, especially if the ovaries or fallopian tubes are affected.
  • Delayed Diagnosis: If the mass is symptomatic of a broader condition affecting amenorrhea, there’s a risk that surgery might delay the diagnosis and treatment of the underlying cause.

Patients considering this surgery should discuss these risks thoroughly with their healthcare provider, weighing the benefits of removing the pelvic mass against the potential complications.

Video Transcript: Pelvic Mass in a Patient with Primary Amenorrhea

In this video, we present laparoscopic excision of a pelvic mass in a patient with primary amenorrhea. Our objective was to demonstrate laparoscopic resection of an adherent pelvic mass, and to discuss the associated diagnostic dilemma in the context of primary amenorrhea in a 27-year-old patient.

A 27-year-old nulligravid woman presented with primary amenorrhea. She reported thelarche and adrenarche at 13 years old. She had some hirsutism, but no acne, galactorrhoea, or cyclic abdominal pain. She was never sexually active. She was previously investigated and told she had blood buildup on pelvic ultrasound. Her past medical history was significant for hypertension and obesity.

 Bloodwork revealed abnormally low levels of FSH, LH, and oestradiol. A pelvic ultrasound showed a 6.7 cm cystic structure within the uterus, in keeping with previously seen hematometra. The ovaries and adnexa appeared unremarkable.

 Conversely, a pelvic MRI demonstrated an abnormality posterior and superior to the uterus, and abutting the medial aspect of the right ovary, felt to be separate. The images favoured an endometrioma with a differential diagnosis of hematosalpinx or haemorrhagic cyst.

Given the uncertainty regarding hematometra versus pelvic mass, the patient was consented for laparoscopic right salpingectomy, possibly ovarian cystectomy, possible right salpingo-oophorectomy, and hysteroscopy.

 In the operating room, an examination under anaesthetic showed sexual infantilism, with Tanner stage one breast development, and a hyperestrogenised vulva and vagina. She had normal pubic hair. The uterus was small on bimanual examination. Hysteroscopy was abandoned given the physical examination findings.

 A large pelvic mass is visualised after laparoscopic entry. Omental adhesions are taken down sharply from the anterior abdominal wall with the laparoscopic Metzenbaums in order to prevent visualisation of the pelvic organs. Pelvic washings are taken.

We are now able to visualise an infantile uterus. Metzenbaums are used to dissect omental adhesions off of the mass. Electrosurgery is used for haemostasis. The mass is adherent to the posterior uterus. Its origin appears to be from the left ovary. Filmy adhesions to the posterior uterus are sharply dissected.

Once again, the mass appears to be related to the left ovary. Omental and sigmoid adhesions are sharply dissected off of the left pelvic side wall. The right fallopian tube is visualised. The right ovary is located. We note the left ovary, left ureteral ovarian ligament, and left IP ligament. Further adhesiolysis is performed between the left ovary and the omentum.

We are now able to note the left ovary and its attached mass, the left round ligament and IP ligament. Blunt dissection is used to separate the mass from the posterior cul-de-sac. Sharp dissection is then performed. Adhesions between the mass and the right pelvic side wall are taken down sharply with the laparoscopic Metzenbaums and using electrosurgery. The right ovary is released from the right pelvic side wall. Note the normal right ovary and right fallopian tube.

The left IP ligament is clammed, cauterised, and cut with the Gyrus HALO bipolar instrument. Laparoscopic scissors are then used to dissect off the remaining adhesions to the left pelvic side wall. Adhesions to the mass are carefully dissected medial to the right ureter.

A plane is identified by creating pillars with a gentle pushing motion. The pillars are then cut, and the mass is gradually peeled off the right pelvic side wall. The mass is freed on the right side, medial to the ureter. Sharp and blunt dissection with the laparoscopic scissors are used on the remaining adhesions between the mass and the omentum. Peristalsis of the right ureter is noted. The mass is moved out of the pelvis, and we note the normal right ovary and fallopian tube, normal right ureter, and normal left ureter.

The left lower quadrant port is extended to 15 mm, and the mass placed in a 15 mm Endo Catch bag. The specimen is sent for frozen section. Haemostasis is verified. A Gerlach needle is used to close the fascia in the left lower quadrant.

Frozen section showed an at least borderline serious papillary cystadenoma. Gynae oncology was called for staging.

This video demonstrates the laparoscopic excision of a large adherent pelvic mass. We also illustrate the incidental finding of a serious borderline tumour in a patient with hypogonadotropic hypogonadism.