TheFirstReportofanIntraperitoneal Free-FloatingMass...

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2012, Article ID 615734, 7 pagesdoi:10.1155/2012/615734

Case Report

The First Report of an IntraperitonealFree-Floating Mass (an Autoamputated Ovary)Causing an Acute Abdomen in a Child

Ibrahim Uygun, Bahattin Aydogdu, Mehmet Hanifi Okur, and Selcuk Otcu

Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280 Diyarbakir, Turkey

Correspondence should be addressed to Ibrahim Uygun, [email protected]

Received 28 July 2012; Accepted 18 September 2012

Academic Editors: M. Gorlitzer and R. Mofidi

Copyright © 2012 Ibrahim Uygun et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

A free-floating intraperitoneal mass is extremely rare, and almost all originate from an ovary. Here, we present the first case withan intraperitoneal free-floating autoamputated ovary that caused an acute abdomen in a child and also review the literature. A4-year-old girl was admitted with signs and symptoms of acute abdomen. At surgery, the patient had no right ovary and the righttube ended in a thin band that pressed on the terminal ileum causing partial small intestine obstruction and acute abdomen. Acalcified mass was found floating in the abdomen and was removed. The pathological examination showed necrotic tissue debriswith calcifications. An autoamputated ovary is thought to result from ovarian torsion and is usually detected incidentally. However,it can cause an acute abdomen.

1. Introduction

An autoamputated ovary (AO) is a very rare cause of anintraabdominal mass [1–25]. The primary pathological eventof an AO is torsion of a normal ovary or an ovarian cyst andthe adnexa, followed by infarction and necrosis [17, 21, 26,27]. Typically, the AO is found incidentally while investigat-ing an unrelated disease, on antenatal ultrasonography, or atsurgery [1–25].

Here, we present a patient who underwent surgery for anacute abdomen and was observed to have a free-floating AOin the abdominal cavity. We also review the occurrence of thisextremely rare free-floating mass in children and discuss itsdiagnosis and management.

2. Case Presentation

A 4-year-old girl was admitted with nausea, vomiting, andabdominal pain. On physical examination, the right lowerabdominal quadrant was tender. Abdominal guarding andrebound were detected. The abdominal plain X-ray was nor-mal. Emergency ultrasonography (US) showed minimal free

fluid. The patient underwent surgery for an acute abdomen.At surgery, a 28 mm diameter, brown, soft, calcified mass wasfound floating in the right lower abdomen (Figure 1). Thepatient had no right ovary and the right tube ended in a thinband that extended to the cecum and pressed on the terminalileum causing partial small intestine obstruction and acuteabdomen (Figure 2). The appendix was hyperemic. The free-floating mass was removed from the abdomen, the rightfallopian tube and band were excised, and an appendectomywas performed. The patient was discharged on the secondpostoperative day. The pathological examination showedlong standing necrotic tissue debris with calcifications. The6-year follow up showed no problems.

3. Discussion

A free-floating intraperitoneal mass is extremely rare, andalmost all originate from an ovary. To date, there have beenonly two cases in the literature that originated from otherorgans [28, 29]; one such mass in a geriatric woman was fromthe gallbladder, due to torsion, and caused acute abdomen,while the other was from appendix epiploica, due to torsion,

2 Case Reports in Surgery

Figure 1: The right tube (RT) ended in a thin band (arrow) attached to the cecum and pressed on the terminal ileum. The patient had noright ovary. The left ovary (LO) and tube (LT) and uterus (U) were normal.

Figure 2: The brown, soft, calcified free-floating autoamputated right ovary (right) and the excised right tube ending with a thin band (left).

in a man [28, 29]. A free-floating intraperitoneal AO in achild was first reported by Lester and McAlister in 1970 [1].Our case is the first report of an intraperitoneal free-floatingmass causing an acute abdomen in a child.

There have been only 36 reported cases of intraperitonealfree-floating AO involving children ranging in age from 1day to 12 years of age, including our case (Table 1) [1–25].Twenty-five cases were younger than 1 year of age. Although23 of these infants were diagnosed with a cystic abdominalmass, ranging in diameter from 2.2 to 8 cm on antenatalUS, only 12 of the newborns were operated on during theneonatal period.

Six cases were symptomatic, including our case. One ofthe newborns had abdominal distention, intestinal obstruc-tion, and respiratory distress syndrome due to an 8 cm diam-eter cyst [24]. Four children, ages 14 and 17 months, 2 years,and 12 years, had a history of abdominal pain without anacute abdomen and were diagnosed during routine phys-ical examinations [1, 3, 7]. Only our 4-year-old patient

developed an acute abdomen, with signs and symptomsthat included tenderness in the right abdominal quadrant,nausea, and vomiting.

Nine of the masses could be palpated on physical exam-ination. Only three cases were diagnosed as an AO preop-eratively. Characteristically, an AO is seen as a free-floatingintraabdominal mass on antenatal US [13, 19, 25]. Eightcases were diagnosed incidentally. Two had no abdominalpain but were diagnosed based on palpating an abdominalmass during a routine physical examination [3]. The othersix patients were diagnosed with a calcified mass seen onplain X-rays obtained for an unrelated reason [2, 3, 6, 10, 12].The AO was the right ovary in 17 cases, the left in 11, bilateralin two, and unknown in six cases.

Ultrasonography is safe and sufficient for diagnosingmost ovarian cysts and AO. Computed tomography andmagnetic resonance imaging may be performed if the massis complex [22]. In our case, emergency US showed minimalfree fluid, but no AO, perhaps because our patient had an

Case Reports in Surgery 3

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intestinal obstruction and a dilated intestine with intralu-minal gas. A plain X-ray may also be sufficient, especiallywith a calcified AO [1–3, 5, 7, 10]. In the literature, 25 of36 cases of AO were diagnosed prenatally with antenatal US.We believe that this is because antenatal US is performed verycommonly worldwide.

Pathologically, necrosis was seen in all cases, and 20 hadcalcifications. Small amounts of ovarian tissue were seen inseven specimens [3, 7, 18, 20, 23, 25]. In four of these cases,the AO was attached to the retroperitoneum and ascendingcolon by vessels [3], the omentum [23], the mesentery ofthe transverse colon via a long pedicle [7], or to the livervia a hemorrhagic twisted pedicle of omentum [7]. Nonecontained malignant tissue. In adults, Ushakov et al. reporteda remarkable characteristic of AO: an AO teratoma becamereimplanted as an omental mass in 22 cases of teratoma ofthe omentum that they reviewed [26]. This adult review andour review of children suggest that an AO may reimplant,develop into omentum or peritoneum, and possibly undergomalignant transformation. Therefore, we suggest that all AOsshould be excised instead of taking a wait and see approach.

An AO is very rare and thought to result from ovariantorsion. Most free-floating AOs are detected incidentally.However, clinicians should remember that it can cause anacute abdomen, and should always make sure there are twoovaries on US in a small child with acute abdomen.

Conflict of Interests

The authors declare that there is no conflict of interests.

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[2] G. W. Nixon and V. R. Condon, “Amputated ovary: a causeof migratory abdominal calcification,” American Journal ofRoentgenology, vol. 128, no. 6, pp. 1053–1055, 1977.

[3] L. A. Kennedy, L. E. Pinckney, G. Currarino, and T. P. Votteler,“Amputated calcified ovaries in children,” Radiology, vol. 141,no. 1, pp. 83–86, 1981.

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[15] P. A. Decker, J. Chammas, and T. T. Sato, “Laparoscopic diag-nosis and management of ovarian torsion in the newborn.,”Journal of the Society of Laparoendoscopic Surgeons, vol. 3, no.2, pp. 141–143, 1999.

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[18] C. Tsobanidou and G. Dermitzakis, “Ovarian cyst as a pelvicmass in an infant,” European Journal of Gynaecological Oncolo-gy, vol. 24, no. 6, pp. 582–583, 2003.

[19] S. Visnjic, M. Domljan, and B. Zupancic, “Two-port lapar-oscopic management of an autoamputated ovarian cyst in anewborn,” Journal of Minimally Invasive Gynecology, vol. 15,no. 3, pp. 366–369, 2008.

[20] R. J. H. Herrera, L. F. R. Sanchez, R. C. Flores, J. R. AcunaReyes, and G. Carmona Martınez, “Prenatal diagnosis ovariancyst with an amputation at three months of age: a case report,”Ginecologia y Obstetricia de Mexico, vol. 77, no. 8, pp. 372–375,2009.

[21] Y. Koike, M. Inoue, K. Uchida et al., “Ovarian autoamputationin a neonate: a case report with literature review,” PediatricSurgery International, vol. 25, no. 7, pp. 655–658, 2009.

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[23] J. Amodio, A. Hannao, E. Rudman, F. Banfro, and E. Garrow,“Complex left fetal ovarian cyst with subsequent autoamputa-tion and migration into the right lower quadrant in a neonate:case report and review of the literature,” Journal of Ultrasoundin Medicine, vol. 29, no. 3, pp. 497–500, 2010.

[24] S. Marinkovic, R. Jokic, S. Bukarica, A. N. Mikic, N. Vuckovic,and J. Antic, “Surgical treatment of neonatal ovarian cysts,”Medicinski Pregled, vol. 64, no. 7-8, pp. 408–412, 2011.

[25] T. Kuwata, S. Matsubara, and K. Maeda, “Autoamputation offetal/neonatal ovarian tumor suspected by a ”side change” ofthe tumor,” Journal of Reproductive Medicine for the Obstetri-cian and Gynecologist, vol. 56, no. 1-2, pp. 91–92, 2011.

[26] F. B. Ushakov, D. Meirow, D. Prus, E. Libson, A. BenShushan,and N. Rojansky, “Parasitic ovarian dermoid tumor of the


omentum-a review of the literature and report of two newcases,” European Journal of Obstetrics Gynecology and Repro-ductive Biology, vol. 81, no. 1, pp. 77–82, 1998.

[27] S. Schmahmann and J. O. Haller, “Neonatal ovarian cysts:pathogenesis, diagnosis and management,” Pediatric Radiol-ogy, vol. 27, no. 2, pp. 101–105, 1997.

[28] F. J. Laso, C. Procel, I. Pastor, G. Vasquez, and R. M. Ramos,“Gallbladder torsion: report of a case,” Anales de MedicinaInterna, vol. 6, no. 3, pp. 149–150, 1989.

[29] F. J. L. Murat and M. T. Gettman, “Free-floating organized fatnecrosis: rare presentation of pelvic mass managed with lapar-oscopic techniques,” Urology, vol. 63, no. 1, pp. 176–177, 2004.

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