A 65 year old Mexican patient who attended the surgery service for stabbing abdominal pain, located in the mesogastrium and of variable intensity, reaching an 8/10 on the visual analogue pain scale. She also presented dissident abdominal pain and nausea, as well as absence of actions or gas channelling since the last 24 hours prior to her evaluation. The patient has long-term chronic hypertension, G3 P3 without previous surgical interventions, and does not refer to other important clinical history.
On physical examination, she presented dehydrated mucosa, abdominal distension, slightly increased peristalsis in frequency of intensity, slightly depressible soft abdomen with diffuse pain on medium and deep palpation, and a negative rebound, without wall resistance.
Conservative management begins with gastric decompression using a nasogastric tube, fasting, and fluid replacement. We decided to perform the management with an exploratory laparotomy due to lack of improvement in the patient after the first 48 hours. The final diagnosis was an acute abdomen. The hematological and biochemical parameters were within normal limits.
Surgical Technique
Under balanced general anaesthesia, in the supine position, asepsis, antisepsis and placement of sterile curtains were performed. An incision was made in the supra and infraumbilical midline and dissected by planes with electrocautery in the opening of the abdominal cavity. A citrine free liquid leakage occurred; approximately 200 cc are aspirated, and 10 cc were sent to cytology or cytochemistry. Proximally dilated loops of the small intestine were identified.
Next, evisceration is performed, identifying two tumours at the level of the mesentery in small intestine (Figure No. 1), approximately 130 cc from Treitz angle. The first one of an estimated size of 20x15 cm, with adherence on omentum; and the second one with an ovoid shape with approximately 6.5 cm of diameter.
Adherenciolysis is performed with a cold cut and a harmonic scalpel. The tumour is skirted and dissected, nevertheless, there is an accidental breakage with leakage of purulent material and the existence of hair is observed (Figure No.2). A cross stitch is placed to close the tumour and control the secretion and the dissection continues (Figure No.3).
Consequently, the root of the tumour and the nutrient vessel from the mesentery are identified (Figs. 4 and 5). The tumour is resected with a harmonic scalpel and the surgical specimen is extracted (Figure No.6). It is sent to pathology routinely, then, haemostasis is verified with no evidence of bleeding or intestinal injury and metastatic disease in the liver is intentionally searched sliding, annexes, without alterations. A textile count is requested from the nursing staff, reporting complete, cavity closure, and anterior aponeurosis with vicryl from 1 continuous surgete, subcutaneous cellular tissue with vicryl from 2 − 0 continuous surgete, and skin with nylon from 3 − 0 medium sarnoff points. A sterile dressing is placed, ending the surgical procedure without incidents or accidents and minimal bleeding. Patient goes to recovery under residual effects of anaesthesia.
The pathology report confirms the reception of two specimens. The first one, ovoid with a smooth external surface and integrates that measures 6.5 cm in diameter. When we proceeded to cut it, it presented a cystic appearance and contains abundant thick and grey material and hair. Its internal surface was smooth, with a central area irregular and nodular 3 cm in diameter made up of bone tissue. The second one, was an ovoid specimen with a gray, rough and integral external surface measuring 15 x 11 cm; it was cystic and contained brown and thick material with hair, the internal surface is rough with solid focal areas. The lamellae were stained with H&E. Microscopic observation revealed histological sections of the wall of a cyst lined by stratified squamous epithelium with superficial keratinization and squamous cells without data of cellular atypia, supported by a fibrous and dense stroma. There was bone tissue in the minor cyst and extensive ulceration with a mixed and intense inflammatory infiltrate with congestion in the larger specimen (Figure No.7a, b, c, d, e, f). The histopathological diagnosis is as follows: Two mature cystic teratomas, with no evidence of immature elements or malignancy.