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CASE REPORT  
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 226-230
 

Ectopic ovary with dermoid cyst as a result of possible asymptomatic autoamputation


Department of Minimally Invasive Surgery, Credence Hospital, Trivandrum, Kerala, India

Date of Web Publication12-Oct-2017

Correspondence Address:
Bimal Mathew John
Director of Minimally Invasive Surgery, ART Program Director, Department of Minimally Invasive Surgery, Credence Hospital, Ulloor, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrs.JHRS_67_17

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   Abstract 

A 32-year-old woman, who presented for laparoscopic sterilization after two full-term normal deliveries, was incidentally diagnosed to have a left-sided complex cyst in the pouch of Douglas (POD). She had no history of previous surgeries or any symptoms of lower abdominal pain, nausea, or vomiting in the past. She underwent laparoscopy, and the left ovary and distal portion of the fallopian tube were absent in their normal position. An ectopic left ovary with dermoid cyst was noted in the POD. The right ovary and tube were in their normal position. I attribute this to be a very rare case of asymptomatic torsion and autoamputation of the ovary resulting in an ectopic ovary.


Keywords: Asymptomatic autoamputation, ectopic ovary, ovarian autoamputation, ovarian dermoid cyst, wandering ovary


How to cite this article:
John BM. Ectopic ovary with dermoid cyst as a result of possible asymptomatic autoamputation. J Hum Reprod Sci 2017;10:226-30

How to cite this URL:
John BM. Ectopic ovary with dermoid cyst as a result of possible asymptomatic autoamputation. J Hum Reprod Sci [serial online] 2017 [cited 2020 Jul 2];10:226-30. Available from: http://www.jhrsonline.org/text.asp?2017/10/3/226/216607



   Introduction Top


Ovarian autoamputation is an extremely rare phenomenon of uncertain etiology, with very few cases reported in literature.[1] I report a rare case of possible asymptomatic autoamputation of the left ovary containing a dermoid cyst, along with the distal part of the  Fallopian tube More Details, presenting as an ectopic ovary in the pouch of Douglas (POD) of a 32-year-old patient.


   Case Report Top


A 32-year-old patient presented for laparoscopic sterilization after two previous normal deliveries. She did not have any history of surgeries or significant symptoms such as abdominal pain, nausea, or vomiting. On routine ultrasound, a left-sided complex cyst measuring around 6 cm was noted in the POD region. Laparoscopy was performed under general anesthesia. The uterus and right adnexa were normal. Left adnexal adhesions were noted [Figure 1], and after adhesiolysis [Figure 2], the left ovary and the distal portion of the ipsilateral fallopian tube were found to be absent. The left ovary was found in the POD, buried in adhesions to the pelvic sidewall and the rectum [Figure 3] and [Figure 4]. The ovary was released, and no major vessels or ligamentous attachments were noted on the ovary [Figure 5]. Adhesion to the rectum was most difficult to release and showed a few strands of hair within the adhesion bands [Figure 6] and [Figure 7]. After releasing the ovary, it was bisected to reveal a large dermoid cyst [Figure 8]. The specimen was extracted in toto using an endobag. The postoperative period was uneventful.
Figure 1: Release of left adnexal adhesions

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Figure 2: Absent left ovary and distal portion of the left Fallopian tube

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Figure 3: Ectopic left ovary in the cul-de-sac

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Figure 4: Left ovary with dermoid cyst in the POD with adhesions over it

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Figure 5: Adhesiolysis of left ectopic ovary

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Figure 6: Release of adhesions between rectum and ectopic ovary

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Figure 7: Left ectopic ovary in POD after adhesiolysis

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Figure 8: Bisected ovary containing dermoid cyst

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   Discussion Top


Autoamputation of the ovary is a rare event potentially induced by infarction subsequent to ovarian torsion or torsion of a dermoid cyst. The torsion of the pedicle, occurring in 16.1% of ovarian dermoid cyst cases, has been reported to be a pivotal factor for the development of new ectopic ovary.[1]

Ultrasonography and color Doppler may be useful in diagnosing ovarian torsion in symptomatic cases. However, in cases with obscure clinical signs and symptoms, a definitive diagnosis of torsion remains challenging.[2],[3]

The pathophysiology of ovarian torsion involves the twisting of the vascular pedicle in the suspensory ligament causing obstruction to vascular and lymphatic outflow. This leads to diffuse ovarian edema and enlargement, which over a period may result in ischemia and infarction of the ligament. Some of the common predisposing factors causing the ovary to swing on its vascular pedicle include ovarian enlargement as seen in ovarian tumors or ovarian hyperstimulation syndrome, excessive mobility of fallopian tubes or mesosalpinx, elongated pelvic ligaments, fallopian tube spasm, strenuous exercise, or abrupt intra-abdominal pressure changes.[3]

Dermoid cysts are the most common germ cell tumors and account for up to 25% of all ovarian tumors.[2] Parasitic dermoid cysts, an extremely rare entity, develop due to autoamputation of the ovaries following subacute or chronic torsion, and implantation elsewhere. Consequently, an inflammatory response might occur, resulting in the adherence of the dermoid cyst to adjacent structures and the development of new microvasculature. Parasitic dermoid cysts might also occur when it grows within a supernumerary or ectopic ovary, which develops subsequent to the implantation of ovarian tissue after surgery or inflammatory response. It has to be noted that supernumerary ovaries might also occur as a congenital defect.[24]

A search of articles from 1949 to 2012 in the PUBMED database was conducted to find the number of reported cases with the absence of adnexa. Out of the 27 cases identified, 24 unilateral and three bilateral absences of adnexa were documented. The current case study’s clinical findings of the unilateral absence of adnexa associated with ectopic ovarian dermoid cyst were compared with other reported cases [Table 1]. The number of cases reported with unilateral absence of adnexa associated with ectopic ovarian dermoid cyst was nil. Only one case of bilateral absence of the ovaries and fallopian tubes with the ectopic ovary containing a dermoid cyst present in the omentum was found. Thus, the absence of the left ovary and the fimbrial portion of the left fallopian tube with ectopic ovary present in the POD as in this case has not been reported yet.
Table 1: List of reported cases on unilateral or bilateral absence of adnexa with or without ectopic ovarian cyst

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A review of literature suggests that this case is also unique compared to other reported cases of ovarian tumors present in POD [Table 2] owing to the unilateral absence of adnexa and the presence of cyst within the ovary.
Table 2: List of reported cases of autoamputated ovary associated with dermoid cyst or teratoma

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In the current case study, the absence of apparent nourishing vessels in the ectopic dermoid cyst would explain its existence to torsion or inflammation rather than a developmental defect.[24],[25] However, the autoamputated ovary with the dermoid cyst found to be adherent to the retroperitoneum with minor adhesions may explain its existence as a parasitic ovarian dermoid cyst.[1]

This case did not have symptoms of lower abdominal pain, nausea, or vomiting. In such cases, the diagnosis of ovarian and fallopian tube torsion should be considered if there is an incidental finding of absent adnexa during exploratory laparoscopy. In the above-presented case, an ovary with a large dermoid cyst, densely adherent to the rectum, was removed by laparoscopy, and the postoperative period was uneventful.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Peitsidou A, Peitsidis P, Goumalatsos N, Papaspyrou R, Mitropoulou G, Georgoulias N. Diagnosis of an autoamputated ovary with dermoid cyst during a Caesarean section. Fertil Steril 2009;91:1294.e9-12.  Back to cited text no. 1
    
2.
Medeiros LR, Rosa DD, Bozzetti MC, Fachel JM, Furness S, Garry R et al. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev 2009:CD004751.  Back to cited text no. 2
    
3.
Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics 2008;28:1355-68.  Back to cited text no. 3
    
4.
Tanaka Y, Koyama S, Kobayashi M, Kubota S, Nakamura R, Isobe M et al. Complex Müllerian malformation without any present classification: Unilateral ovarian and tubal absence with an arcuate uterus. Asian J Endosc Surg 2013;6:55-7.  Back to cited text no. 4
    
5.
Pabuccu E, Kahraman K, Taskın S, Atabekoglu C. Unilateral absence of fallopian tube and ovary in an infertile patient. Fertil Steril 2011;96:e55-7.  Back to cited text no. 5
    
6.
Nishiyama S, Hirota Y, Nishizawa H, Tada S, Udagawa Y. Bilateral interruption of mid-fallopian tubes and ovarian anomalies including ectopic ovary and cystic teratoma, a previously unreported combination. J Minim Invasive Gynecol 2010;17:534-7.  Back to cited text no. 6
    
7.
Uckuyu A, Ozcimen EE, Sevinc Ciftci FC. Unilateral congenital ovarian and partial tubal absence: Report of four cases with review of the literature. Fertil Steril 2009;91:936.e5-8.  Back to cited text no. 7
    
8.
Olufowobi O, Sorinola O, Afnan M, Papaioannou S, McHugo JM, Sharif K. Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary. Obstet Gynecol 2002;100:1136-8.  Back to cited text no. 8
    
9.
Dueck A, Poenaru D, Jamieson MA, Kamal IK. Unilateral ovarian agenesis and fallopian tube maldescent. Pediatr Surg Int 2001;17:228-9.  Back to cited text no. 9
    
10.
Gold MA, Schmidt RR, Parks N, Traum RE. Bilateral absence of the ovaries and distal fallopian tubes. A case report. J Reprod Med 1997;42:375-7.  Back to cited text no. 10
    
11.
Kriplani A, Takkar D, Karak AK, Ammini AC. Unexplained absence of both fallopian tubes with ovary in the omentum. Arch Gynecol Obstet 1995;256:111-3.  Back to cited text no. 11
    
12.
Eustace DL. Congenital absence of fallopian tube and ovary. Eur J Obstet Gynecol Reprod Biol 1992;46:157-9.  Back to cited text no. 12
    
13.
Sharony A, Nseir T, Bronshtein M, Eibschitz I. Transvaginal sonographic diagnosis of suspected tubal pregnancy and contralateral missing adnexa. Int J Fertil 1991;36:212-4.  Back to cited text no. 13
    
14.
Chan CL, Leeton JF. A case report of bilateral absence of fallopian tubes and ovaries. Asia Oceania J Obstet Gynaecol 1987;13:269-71.  Back to cited text no. 14
    
15.
Sivanesaratnam V. Unexplained unilateral absence of ovary and fallopian tube. Eur J Obstet Gynecol Reprod Biol 1986;22:103-5.  Back to cited text no. 15
    
16.
Sinha MR. Unexplained absence of a fallopian tube and an ovary. J Indian Med Assoc 1983;80:103-4.  Back to cited text no. 16
    
17.
Ali V, Lynn S, Schmidt W. Unilateral absence of distal tube and ovary with migratory calcified intraperitoneal mass. Int J Gynaecol Obstet 1980;17:328-31.  Back to cited text no. 17
    
18.
Sirisena LA. Unexplained absence of an ovary and uterine tube. Postgrad Med J 1978;54:423-4.  Back to cited text no. 18
    
19.
Nissen ED, Kent DR, Nissen SE, Feldman BM. Unilateral tuboovarian autoamputation. J Reprod Med 1977;19:151-3.  Back to cited text no. 19
    
20.
Georgy FM, Viechnicki MB. Absence of an ovary and uterine tube. Obstet Gynecol 1974;44:441-2.  Back to cited text no. 20
    
21.
Burge ES. Absence of left ovary and portion of left fallopian tube in 19-year-old student; Case report. Q Bull Northwest Univ Med Sch 1958;32:4-5.  Back to cited text no. 21
    
22.
Stone ET. Absence of tube and ovary, congenital or acquired. Am J Obstet Gynecol 1949;57:596-8.  Back to cited text no. 22
    
23.
Peh WC, Chu FS, Lorentz TG. Painful right iliac fossa mass caused by a migrating left ovary. Clin Imaging 1994;18:199-20.  Back to cited text no. 23
    
24.
Kusaka M, Mikuni M. Ectopic ovary: A case of autoamputated ovary with mature cystic teratoma into the cul-de-sac. J Obstet Gynaecol Res 2007;33:368-70.  Back to cited text no. 24
    
25.
Khoo CK, Chua I, Siow A, Chern B. Parasitic dermoid cyst of the pouch of Douglas: A case report. J Minim Invasive Gynecol 2008;15:761-3.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2]



 

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