1. Huge Abdominal Mass– a
diagnostic dilemma
Case history

2. • Name of patient – Mrs XYZ
• 28years/female
• Address- Amravati

3. COMPLAINTS
• c/o lump in abdomen since 5-6 months
Progressively increasing in size
• c/o irregular menses since 2-3 months
• No c/o pain in abdomen or any urinary
complaints

4. MENSTRUAL HISTORY
• LMP: 2/12/12
• PMC( since 2-3 months):2-3days/30-40
days/irregular/ scanty/ no dysmenorrhea
• PMC(before2-3 months)- 2-3 days/30
days/regular/scanty/ no dysmenorrhea

5. OBSTETRIC HISTORY
• DOM-2 ½ years
• A1: spontaneous abortion of 1 ½ month
around 1 ½ year back/ d&c done

6. EXAMINATION
• GC fair
• Afebrile
• P-80/min
• B.P-110/70 mm hg
• P/A- firm, fixed mass arising from pelvic
cavity, around 26 weeks size gravid
uterus, non –tender with irregular margins

7. • P/S- cervix not visualised, pulled up
• P/V- mass deviated to right side, and could be
felt in right side of anterolateral fornix, uterus
could not be felt separated from the
mass, other fornices were free
• P/R- POD free, parametrium not involved

8. INVESTIGATIONS
1) Blood investigations- normal
2) CA-125- 10.8 IU/ml
3) AFP, LDH,b-HCG(NOT AFFORDING)
4) USG – large mix echogenic mass in lower abdomen
separate from uterus.
5) USG- heterogenous mass in pelvis and abdomen
extending upto supraumbilical region measuring
about 21x12x24 cm in size with solid and cystic
component. Mass extending in to cul-de-sac and in
left peri- rectal space displacing the rectum towards
right side and also causing encasement of uterus.
f/s/o possibility of malignant ovarian mass

9. 4)CT scan- heterogenous mass in pelvis and
abdomen extending upto supraumbilical region
measuring about 21x12x24 cm in size with
irregular enhancing solid component and
peripherally enhancing cystic component. Mass
extending in to cul-de-sac and in left peri- rectal
space displacing the rectum towards right side.
f/s/o possibility of malignant ovarian mass

10. 5) FNAC- fragments of spindle cell
f/s/o benign spindle cell leison

11. • Clinical diagnosis: ? Ovarian tumor
? Fibroid uterus

12. Questions asked
• Are we dealing with a malignancy?
• Is fertility preserving surgery possible?

14. • Pre-opertaive :
Patient was posted for exploratory lapratomy on
26/12/12.

15. PROCEDURE
Intra-operative findings:
• Mid- line vertical incision was given extending above the umbilicus.
• No evidence of ascites.
• Omentum was free and uninvolved.
• Huge mass arising from and filling the pelvic cavity, was
retroperitoneal and displaced the rectum to the right. Size was
approx. 25x25 cms with a lobulated fleshy appearance and firm to
soft consistency.

16. Questions asked
• Are we dealing with a malignancy?
• Is fertility preserving surgery possible?

17. Intraop……continued
• Mass extended upto the left lateral pelvic wall
and fell short of the right.
• Bilateral ovaries were normal and the tubes were
stretched out over the mass, only a portion of the
uterine fundus and right lateral portion could be
made out and the tumor was seen surrounding it
both anteriorly and posteriorly.

18. Intraop……..continued
• Dissection was begun from the left side where the mass
was seperated from the left pelvic wall and postero-
superiorly, where it was seperated from the adhesions to
the bowel mesentry and retroperitoneum.
• The mass was seperated from the external iliac vessels and
upper ureter. The lower portion of the left ureter was seen
entering the tumor.

20. Intraop………continued
• At this juncture, dissection was begun on the right side and
right infundopelvic ligament was cut and ligated. Course of
the right ureter was traced and safeguarded.
• Seperation of the bladder was begun anteriorly. There was
no visible plane and in the process the dome of the bladder
was opened.
• In looking for the proper plane between uninvolved bladder
wall and the tumor, the pseudocapsule was opened.

21. Intraop………continued
• The wall of the tumor was glistening and white with
surprising lack of vascularity.
• The diagnosis and plan of management was reviewed.
• Frozen section?
• Enucleation of the mass was attempted. Though there
were multiple extensions and lobules, this was
accomplished with relative ease.

22. Intraop……….continued
• After removing the mass the anatomy became much clearer with the uterus
being displaced to the right side and being highly mobile so reconstruction of
the anatomy was undertaken.
• Right tubovarian stump was reattached , broad ligament opening was closed.
• Bladder was repaired using 2-0 vicryl in two layers.
• The left sided reconstruction was more difficult, given the loss of peritoneal
tissue with the mass.
• However, the broad ligament was reconstituted by attaching it to the lateral
pelvic wall and abdomen closed after inserting a drain in the pelvis.

30. POST OPERATIVE
• Post-operative period was uneventful.
• Patient received 2 units of blood transfusion.
• Drain was kept and removed 5th day.
• Catheter has been retained.

31. HISTOPATHOLOGY REPORT
• Histopathology report:
s/o leiomyoma

34. FINAL DIAGNOSIS
TRUE BROAD LIGAMENT FIBROID