Hatching from the Myometrium: Unusual Excision of an Endometrioma

Abstract

Study Objective

To showcase a rare presentation of intra-myometrial endometrioma and demonstrate laparoscopic excision technique when faced with an unusual presentation.

Design

Video presentation

Setting

Tertiary care center

Patients or Participants

This is a case of a 21 year old female who presented with one week of right lower quadrant pelvic pain and abnormal uterine bleeding. Medical history notable for levonorgestrel intrauterine device and dysmenorrhea. Physical exam notable for right adnexal tenderness. Complete blood count was normal and pregnancy test negative. Transvaginal ultrasound and magnetic resonance imaging (MRI) pelvis findings noted a 3.2 × 2.1 cm hemorrhagic lesion within the right uterine horn at the insertion of the fallopian tube suspicious for endometriosis.

Interventions

Laparoscopy revealed a 2 × 3cm cyst in the right anterior uterine body, proximal to the right round ligament. The cyst was superficial with approximately one millimeter of overlying serosa and extended less than 50% into the myometrium. The cyst was injected circumferentially with 20 mL of vasopressin. Cyst remained intact during careful dissection using sharp and blunt technique. The cavity was closed in three layers. Hemorrhagic brown fluid was noted when drained after the case. Final pathology report consistent with endometriotic cyst.

Measurements and Primary Results

Endometriotic cyst was successfully excised without spillage or full-thickness injury to uterine wall. Patient recovered well and reported improvement in pain at postoperative visit.

Conclusion

This case highlights a rare presentation of endometriosis and demonstrates the use of multiple surgical techniques when faced with a novel finding. Intra-myometrial endometriotic cysts are rare with unknown prevalence and have been described in very few case reports, most commonly in patients with prior uterine incisions. This is a rare presentation of an intra-myometrial endometrioma in a young patient without prior surgery. Surgical techniques for cystectomy and myomectomy were applied to this unusual case. Surgical excision provided symptomatic relief without full-thickness injury to myometrium.