PREOPERATIVE DIAGNOSIS: Pelvic mass thought to be ovarian with low risk OVA1 test.

POSTOPERATIVE DIAGNOSIS: Pelvic mass in the posterior cul-de-sac ? peritoneal inclusion cyst.

PROCEDURES PERFORMED: Operative +laparoscopy, bilateral salpingo-oophorectomy, pelvic washings, resection of pelvic masses (3) and posterior cul-de-sac TAP block.

FINDINGS: Normal appearing fallopian tubes and ovaries consistent with age, a normal uterus, 3 cystic lesions in the posterior cul-de-sac adherent to the posterior aspect of the uterus, uterosacral ligaments, particularly on the right and the pouch of Douglas. They measured approximately 3 cm, 4 cm and 6 cm individually.

PATHOLOGY SPECIMENS: Bilateral fallopian tubes and ovaries, pelvic masses.

DESCRIPTION OF PROCEDURE: The patient was brought into the operating room, placed supine on the operating room table where general anesthesia via oral endotracheal tube was administered in the usual fashion. She was then placed in the dorsal lithotomy position, prepped and draped in the usual fashion for operative laparoscopy, A 5 mm umbilical incision was made, 0.25% Marcaine with Epinephrine was instilled into this incisional site. A disposable 5 mm trocar with a )-degree 5 mm scope was entered under direct visualization placed within the abdominal cavity. The patient was placed in Trendelenburg and the abdomen was insufflated with carbon dioxide gas. Next, 2 stab wounds were made, one in the left paramedian and the other in the right paramedian line approximately one hand breadth lateral and one and a half hand breadth inferior to the umbilicus. Under direct visualization, 0.25% Marcaine with Epinephrine was instilled into these incisional sites. Next, a 12 mm trocar was placed under direct visualization into the left paramedian incision and a 5 mm into the right paramedian incision. The operative laparoscopy instruments included the Covidien LigaSure hook, a grasper and the Nezhat suction irrigator. Grasping from the contralateral side superiorly and medially, the LigaSure hook bipolar device was placed across the infundibulopelvic ligament, cauterized doubly and cut, followed by the mesovarium and the round ligament just beneath the fallopian tube up to the level of the cornu. The fallopian tube was then severed from its attachment to the uterus at the cornu using the LigaSure bipolar device. This process was repeated on the contralateral side.

Next, attention was directed towards removing pelvic masses. The Nezhat suction irrigator was initially used to hydrodissect. The smallest mass easily was removed in this manner. With gentle traction on these pelvic masses which appeared to be peritoneal inclusion cysts, the cysts were separated from the pelvic sidewall. They were brought out through the 12 mm port. Irrigation was performed and hemostasis was noted. The 2 adnexa were placed in the EndoCatch bag and brought out with the left paramedian port. All instruments were removed.

Any help would be greatly appreciated!