Presentation
Sudden onset of right iliac fossa pain.
Patient Data
Well-defined adnexal lesion mainly of fat density with soft tissue element, measures about 90 x 87 x 69 mm, noted at the Douglas pouch, looks originating from the right ovary at which its (ovarian) remaining parenchyma appears edematous, hypodense, surrounded by pelvic fat smudging, minimal pelvic free fluid reaching right iliac fossa and a few reactionary lymph nodes.
Whirlpool sign is noted at the right adnexa suggestive of twisted ovarian pedicle. Right ovarian dermoid cyst complicated by ovarian torsion is the most likely diagnosis.
No obvious abnormalities regarding uterus, left ovary and appendix.
Operative notes:
Right ovarian cyst with sebaceous content and hairs, measured about 9 x 8 cm and twisted thrice around its pedicle. Right ovary appeared bluish. Right tube was edematous and stretched over the cyst. De-torsion and cystectomy. Color improved after de-torsion. Cyst debulked, plane identified, and cyst wall was peeled off. Redundant cyst wall was excised. Hemostatic sutures. Normal ovarian tissue reconstructed.
Normal uterus, left ovary and left tube.
Histopathology report:
Gross:
Brownish cyst measuring 7.5 x 7.0 x 3.0 cm. Opening showed tuft of hair and cheesy material. Container also showed separate flat, brownish tissue.
Diagnosis:
Right ovarian cyst: Mature cystic teratoma with hemorrhage. Sections from the separate pieces showed ovarian tissue with extensive hemorrhage. No malignant cells.
Case Discussion
The patient complained of vague colicky lower abdominal pain for more than 3 weeks and then sudden onset of sharp right iliac fossa pain for several hours, referred initially to rule out appendicitis. According to the CT findings and suggested diagnosis, she was referred for immediate laparoscopy, confirmed to have a large right ovarian dermoid cyst with twisted pedicle three times. Luckily, due to rapid diagnosis and immediate referral, the ovary was rescued, and perfusion was restored on de-torsion.
Ovarian torsion can be found at any age with an increased percentage of suspicion if underlying ovarian cyst such as dermoid cyst was found.
Ultrasound and CT can be of great value in diagnosis, especially if radiological features are present such as adnexal cyst existence, enlarged swollen ovary, pelvic free fluid, pelvic fat stranding, and the characteristic whirlpool sign.
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