Case Report of Endometrioma in Layers of Broad Ligament.
Condition: Theca Lutein Cyst of Left Ovary
MeSH terms: Endometriosis
Study type: Interventional

Summary: 
      Objective:To present an extremely rare site of occurrence of endometriotic cyst in the layers
      of Broad Ligament.

      Patient:A 32 yrs.old woman,married 4 yrs.,presented to OB-GY Dept.with acute,gnawing pain in
      lower abdomen and history of sub-fertility.Diagnostic Laparoscopy and pelvic ultrasound were
      performed in emergency.Oblong cyst structure,41x21x23mm in the left adnexa,away from ovary
      and uterus was identified and excised by Four Port laparoscopic interventional surgery.
    

Detailed description: 
      Endometriosis is the second most common finding in the pelvis of females in their
      reproductive age, frequently associated with primary infertility. Endometrioma, within layers
      of broad ligament has been reported, but only in four cases, so far.

      Contributing factors in the etiopathogenesis of endometriosis and endometriomas are
      retrograde menstrual flow, metaplasia, genetic predisposition, lymphatic/ vascular
      distribution, immune dysfunction and environmental influences. Etiopathogenesis of
      endometriosis is still poorly understood, the main theories being embryonic, migratory and
      immunologic. Embryonic theories suggest that endometriosis develops from the remnants of
      wolffian ducts or the Mullerian ducts or may develop from the metaplasia of the peritoneal or
      the ovarian tissue. Migratory theories suggest transportation of endometrial tissue to
      distant places via fallopian tubes or, lymphovascular structure and subsequent implantation
      as the cause of endometriosis. Immunologic theory implies that altered immune response may
      help in ectopic endometrial implantation. However, all these mechanisms may act
      synergistically and not in exclusion of each other. Endometrial alterations in the eutopic
      endometrium have also been demonstrated in women with endometriosis. These alterations
      involve progesterone receptors co - activator, Hic - 5 resulting in resistance to
      progesterone. Endometriosis commonly involves ovaries, POD, uterosacral ligaments and
      rectovaginal septum, all within the pelvis. This accounts for the retrograde menstruation
      being the most popular theory of pathogenesis for endometriosis. But endometriosis may
      develop at many unusual locations incl. abdominal wall, urinary system, gastrointestinal
      system, thorax, inguinal canal, large muscular or in few cases, within the layers of broad
      ligament.

      Endometriosis, within the layers of broad ligament presents with classical symptoms of pelvic
      endometriosis, triad of chronic pelvic pain, dysmenorrhea and dyspareunia. Our patient, under
      reporting, presented with throbbing pain in lower abdomen. Other descriptions of pain being
      gnawing pain or dragging pain to the legs. Compared to women with superficial endometriosis,
      those with deep disease are more likely to report dyschezia. All the four cases of
      endometriosis of broad ligament reported so far, had one or more of these symptoms, the most
      common being episodic or continuous in low abdomen. All these cases reported were 27 - 34yrs
      old. Although, endometriosis is strongly associated with infertility no association between
      broad ligament endometrioma and infertility has been reported so far. Previously reported
      cases have been either parous or nulliparous females not desirous of childbearing, our
      patient under reporting, is the first case being reported as a female presenting with
      subfertility. This association needs to be explored in future because apart from localized
      endometrioma, there were no other locations of endometriosis anywhere in the pelvis, in
      ovarian fossa, in POD or anywhere else. Could it be that implantation is the prerequisite in
      endometriomas causing infertility? Complete excision of cyst wall is preferred over drainage
      and ablation. The female patient was posted for operative laparoscopy in the post - menstrual
      period. Four port laparoscopy was preferred to visualize oblong cystic structure, measuring
      4x3cms within the layers of left mesosalpinx. A small incision was applied on the most
      prominent part of the cyst on the posterior leaf of mesosalpinx and thick chocolate fluid was
      suctioned out. Cystectomy was performed, dissecting the cyst wall from the leaves of
      mesosalpinx, using harmonic. Posterior leaf of mesosalpinx was repaired with three
      interrupted sutures using vicryl no.1. Through peritoneal lavage with normal saline was
      given. Patient was discharged on the same day after uncomplicated post - operative period.
    

Intervention name(s): Laparoscopic
Intervention type(s): Procedure
Intervention description(s): Four Port Laparoscopic cystectomy
Other intervention name(s): cystectomy
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Endometriosis; Mesosalpinx; Broad Ligament; Laparoscopy