|Year : 2019 | Volume
| Issue : 1 | Page : 50-53
Laparoscopic resection of a giant omental cyst masquerading as ascites
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||20-Feb-2019|
|Date of Acceptance||20-Feb-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Rahul Gupta
Assistant Professor, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
A 3-year-old child presented with huge abdominal distension mimicking ascites; no obvious localized lump was detected. She was previously hospitalized multiple times for evaluation of ascites of unknown origin. Contrast-enhanced computed tomography suggested ascites with displacement of bowel loops outside the fluid without dispersion of fluid around the liver and spleen. A diagnostic laparoscopy revealed giant omental cyst. Complete laparoscopic resection of omental cyst was performed with 4-port technique. Cyst wall was removed from the umbilical port; outcome was favorable. Laparoscopy proved to be both diagnostic and therapeutic with complete relief of symptoms.
Keywords: Ascites, giant, laparoscopic surgery, omental cyst, pediatric
|How to cite this article:|
Gupta R. Laparoscopic resection of a giant omental cyst masquerading as ascites. Saudi J Laparosc 2019;4:50-3
| Introduction|| |
An omental cyst is a rare intra-abdominal lesion with <200 cases reported in the literature. Absence of characteristic clinical findings in the omental cyst makes the diagnosis difficult. A high index of suspicion is required for accurate preoperative diagnosis. The usual presentation is abdominal distension and a painless freely movable abdominal mass. Giant omental cyst presenting as pseudoascites in children has been previously reported in only a few cases.,, We describe an extremely unusual case of a 3-year-old female child with giant omental cyst who presented with huge abdominal distension mimicking ascites and was successfully treated by minimally invasive (laparoscopic surgery) approach.
| Case Report|| |
A 3-year-old female child presented to our department with complaints of abdominal distension with mild abdominal discomfort for 1.5 years. The distension was gradually increasing, and her appetite was also affected. There were no bowel, bladder, or respiratory complaints. There was no history of vomiting, fever, jaundice, and swelling over the face or lower limb. The child was previously hospitalized multiple times in different hospitals for evaluation of ascites of unknown origin. Paracentesis and diagnostic evaluation of fluid failed to improve the condition completely. On general physical examination, the patient was slightly pale; no other obvious abnormality was detected. On systemic examination, the abdomen was grossly distended extending from the epigastrium to the pelvis with dilated veins over skin; umbilicus was everted, but there was no tenderness. No obvious localized lump was detected. Percussion note was dull note all over the abdomen; fluid thrill was present mimicking ascites.
Laboratory evaluation showed that hemoglobin was 9.1 gm%, platelets were adequate, and erythrocyte sedimentation rate was 25 at 1 h; other baseline blood investigations were normal. Plain abdomen radiograph revealed haziness of the abdomen with a paucity of intestinal gas. A plain chest radiograph showed compression of the thoracic cavity, caused by the abdominal distension. Abdominal ultrasonography (USG) was suggestive of ascites; there was no evidence of hepatosplenomegaly and lymphadenopathy. Contrast-enhanced computed tomography (CT) showed displacement of bowel loops outside the fluid without dispersion of fluid around the liver and spleen [Figure 1]. The whole small intestine was displaced posteriorly by the cyst [Figure 2]. A diagnostic laparoscopy was performed through a 10-mm umbilical port using Hassan's open technique. It revealed giant omental cyst arising from the greater omentum just below the transverse colon extending bilaterally to the flanks down into the pelvis covering all abdominal organs [Figure 3]. The cyst was occupying whole of the abdominal cavity with hemorrhagic fluid inside it [Figure 3]. Then, three 5-mm trocars were inserted: two working ports in the flanks (bilaterally) and one in the right upper quadrant for retraction of the liver [Figure 4]. Controlled aspiration of the fluid was carried out. Finally, the complete resection of the collapsed cyst was done using ultrascision (harmonic scalpel), sparing small part of the omentum near the transverse colon (place of origin). The cyst wall was placed in an Endobag and finally removed from the umbilical port. No obvious abnormality was detected. Histological examination confirmed omental cyst with mesothelial lining. Postoperatively, the patient improved well and was discharged on 3rd-postoperative day with healthy port sites [Figure 4]. The patient was followed up for a period of 2 years and had no postoperative complication or recurrence of the disease.
|Figure 1: Abdominal contrast-enhanced computed tomography images showing displacement of bowel loops to outside the fluid (top left); fluid occupying nearly the whole abdomen (top left) and pelvis (bottom) without dispersion around the liver and spleen (top right)|
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|Figure 2: Abdominal contrast-enhanced computed tomography showing fluid occupying nearly the whole abdomen and pelvis (images on right) with the whole small intestine displaced posteriorly by the fluid (images on left)|
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|Figure 3: Laparoscopic view of the omental cyst with very thin lining, covering all abdominal organs and occupying whole of the abdominal cavity with hemorrhagic fluid inside it|
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|Figure 4: Intraoperative image (on the left) showing port positions: 10-mm umbilical port (laparoscope, blue arrow), 5-mm working ports in the flanks (red arrow) and right upper quadrant (liver retraction); postoperative picture (on the right) showing girl on the 2nd day|
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| Discussion|| |
Omental cyst constitutes only 2.2% of the combined mesenteric and omental cysts. The first report of an omental cyst was published in 1852 by Gairdner. Approximately 25% of cases present in children <10 years of age group. The omental cysts are comparatively more common in females than males and white than nonwhite race. Omental cysts may be congenital: (i) benign proliferations of ectopic lymphatics that lack communication with the normal lymphatic system, (ii) lymphatic obstruction, and (iii) failure of the embryonic lymph channels to join the venous system., Other etiologies are traumatic, neoplastic, or infectious in origin. Omental cysts are restricted to either greater omentum as seen in this case or sometimes lesser omentum. It may be unilocular or multilocular; contents may be serous, chylous, hemorrhagic, or infected fluid.
They may present typically as low-grade partial intestinal obstruction with freely movable abdominal lump (25%–50% cases) and sometimes as acute abdomen (rupture or torsion), especially in children. Omental cysts are usually freely movable in all directions, but mesenteric cysts are mobile transversely but have limited movement longitudinally. Presentation with pseudoascites is rare and was seen in very few reports in children.,, Omental cysts may remain asymptomatic and grow to a giant size, as seen in this case.,, Rare complications are torsion, rupture, bleeding, and infection. Compression of the portal vein and respiratory complications are caused by massive enlargement of the cyst. Similar case with pseudoascites requiring multiple hospitalizations and recurrent paracentesis was seen in earlier report.
The diagnostic procedures include USG and CT scans/magnetic resonance imaging (MRI) showing displacement of bowel loops to outside the fluid without dispersion of fluid around the liver and spleen, which are highly suggestive of giant intra-abdominal cyst occupying the abdominal cavity. It can be distinguished from ascites by the relative sparing of flank region bulge. MRI with sagittal or coronal views has been described to be very useful in the diagnosis of omental cyst. It was not performed in this case due to resource constraints. A correct preoperative diagnosis of omental cyst has been made in <1/4th of the cases., Differential diagnosis of giant omental cyst includes pseudoascites, mesenteric cyst, pseudocyst, ovarian cyst, mesothelial cyst, and lymphangioma.
The preferred treatment of omental cyst is total excision even if the patient has no symptoms. Earlier open surgery was advocated to avoid the risk of spreading the cyst contents., Laparoscopy proved to be both diagnostic and therapeutic with complete relief of symptoms in this case and other previously published reports in the literature., Giant omental cyst should be included in the differential diagnosis of pediatric patient with huge abdominal distension mimicking ascites (or large abdominal fluid accumulation).,,, Hassan's open technique is safer for giant intra-abdominal cysts, particularly in pediatric patients. Controlled aspiration of the cyst early during the surgery in this case helped in dissection of the cyst. Dissection in the omental cyst is easier as compared to other intra-abdominal cysts. Recurrence is rare and also malignant degeneration (sarcoma and adenocarcinoma) of omental cyst.
| Conclusion|| |
Omental cyst is a rare condition in pediatric age group. Giant omental cyst presenting as pseudoascites is extremely rare with only a few reports in the literature. Laparoscopic surgery proved to be both diagnostic and therapeutic with complete resection of omental cyst with excellent cosmetic results while decreasing operative morbidity and hospital stay. It is an effective replacement to open abdominal surgical procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]