A 52-year old woman was referred to the Department of Gynecology at Sirai Hospital, Carbonia, Italy with a 4-hour history of abdominal pain that started in the left lower quadrant and subsequently spread to the whole abdomen. She was pale and in obvious discomfort. Her temperature was 39°C, blood pressure was 100/60 mmHg and heart rate was 120 beats/min. Her past medical history was unremarkable except for intermittent episodes of abdominal discomfort and a sensation of abdominal heaviness during the preceding months.
Physical examination revealed a mass that occupied almost the entire abdomen, extending from the lower abdomen to above the umbilicus and restricting mobility. The uterus and adnexae could not be assessed on bimanual pelvic examination.
Pelvic ultrasonography showed ascites throughout the abdomen and an anteverted, enlarged uterus (67 × 54 × 64 mm) with a slightly non-homogeneous myometrial echostructure. The maximum endometrium thickness was 16 mm. The adnexal structures were not recognizable. A non-homogeneous mass (184 × 121 × 184 mm) adjacent to the uterus occupied almost the entire abdomen, extending from the hypogastric region to the epigastric region. No flow was detected in the mass on color Doppler or power Doppler ultrasonography. Contrast-enhanced computed tomography showed a large solid left adnexal mass, ascites and bilateral pleural effusions; a thickened and twisted Fallopian tube with a whirlpool sign was also observed, suggesting adnexal torsion. Contrast-enhanced computed tomography did not show enhancement of the adnexal structures, confirming the hypothesis of torsion and necrosis.
The patient's hematological parameters at admission are shown in Table 1 . She had severe anemia, total bilirubin level of 4.13 mg/dl, indirect bilirubin level of 3.33 mg/dl, elevated CA-125 level and elevated levels of inflammatory markers including the total white blood cell count, percentage of neutrophils, C-reactive protein (CRP) and fibrinogen.
Considering the patient's serious clinical condition and assuming that she had Meigs' syndrome with a twisted large ovarian mass and possible hemolytic anemia, we implemented intensive medical therapy to prepare her for surgery. She received 5 units of packed red blood cells to correct the anemia. In accordance with the accepted international recommendations for the treatment of hemolytic anemia,[5,6] she received intravenous methylprednisolone 500 mg/day (Solu-Medrol®; Pfizer, Latina, Italy) for 3 days. She also received subcutaneous low-molecular-weight heparin, antibiotic therapy, albumin infusion and diuretics to avoid progression of her ascites and pleural effusions. Her hematological parameters improved significantly after 3 days, as shown in Table 1 . The temporal association between the cessation of hemolysis and glucocorticoid therapy supported our hypothesis of an association between the ovarian tumor and the hemolytic anemia.
After improvement of the patient's condition, we performed laparoscopic surgery on day 4. A port was placed 5 cm above the umbilicus and a pneumoperitoneum of 10–14 mmHg was established and maintained throughout the surgery. Intra-abdominal visualization was achieved using a 10 mm, 0° telescope (Karl Storz, Tuttlingen, Germany) and three 5-mm trocars were introduced under laparoscopic visualization through ports in each lower quadrant and in the suprapubic region. A large amount of ascites was aspirated and a large solid mass was observed. The mass was covered by omentum (Figure 1) and adherent to parts of the bowel wall (Figure 2). The liver, gallbladder, stomach and diaphragm were normal in appearance. The mass was carefully freed from the surrounding adherent structures and was found to arise from the twisted left adnexa (Figures 3 and 4). Malignancy was excluded by intraoperative histological examination without the use laparoscopic power morcellator.
The utero-ovarian ligament, Fallopian tube and infundibulopelvic ligament, which were twisted together, were coagulated using BiClamp LAP forceps (ERBE GmbH, Tubingen, Germany) and the ovarian fibroma was resected using monopolar forceps. In accordance with the recent FDA recommendation regarding the use of internal laparoscopic power morcellation for removal of uterus or uterine fibroids, the ovarian fibroma was removed from the abdominal cavity with external morcellation through the supraumbilical port, which was enlarged to approximately 6 cm, with the placement of the "Endopath Dextrus", to avoid tumor spillage.
The operating time was about 120 min. There was no significant blood loss and no anesthesia-related complications were observed ( Table 1 ). Postoperative pathologic examination of the surgical specimen showed complete hemorrhagic necrosis of an ovarian fibroma with evidence of stromal edema (weight 1,930 g) and a 10-cm long necrotic Fallopian tube. Peritoneal cytology showed inflammation but no malignant cells.
The patient was discharged 5 days after surgery ( Table 1 ) with a small pleural effusion which resolved approximately 2 weeks after discharge. Seven days after discharge she reported a satisfactory return to her normal social and working activities. One month later she had recovered well and was asymptomatic.
BMC Surg. 2014;14(38) © 2014 BioMed Central, Ltd.
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