Introduction
We are reporting the first case in world literature, where a full thickness parasitic piece of the sigmoid colon attached to an ovarian tumour was removed surgically.
Case Report
Mrs. SP, a 25 year old woman presented with acute pain in the left iliac fossa for 6 hours. The pain was griping in nature, continuous, non-radiating. She was married since 2 months. There was no history of vomiting or any change in her bowel habits. She had undergone an exploratory laparotomy at the age of 12 years at a Medical College Hospital in Bombay for abdominal tuberculosis. She had received antituberculous chemotherapy for 9 months after the operation.
On Examination, her pulse rate was 120/min, BP was 110/70 mm of Hg, and respiratory rate was 16/min. There was mild pallor. Systemic examination revealed no abnormality. Abdominal examination showed a midline, infraumbilical, hypertrophic scar of previous surgery, tenderness of the lower abdomen, guarding and rigidity. The tenderness was maximum in the left iliac fossa just above the mid point of the left inguinal ligament. There was no palpable mass. Speculum examination was normal. On bimanual vaginal examination transverse cervical movements were tender. The uterus was normal in size, retroverted and fixed. Left fornix had an acutely tender, 6 x 6 cm tense cystic, irregular, adhered mass. The right fornix was clear.
Her Hb was 11 gm%, Urine pregnancy test was negative. Transabdominal and transvaginal ultrasonography revealed a mixed echogenic 6 x 5.5 x 4 cm mass in the left fornix. The left ovary was not seen separately from the mass. The right ovary was normal. Th endometrial thickness was 6 mm. There was no free fluid in the pouch of Douglas. A provisional diagnosis of torsion of an ovarian cyst was made. Cefazolic 2 g IV was administered for surgical prophylaxis. A laparoscopy was performed. It showed normal right tube and ovary, normal uterus, and walling off of the left side of the pelvis by dense omental adhesions. An exploratory laparotomy was performed excising the previous scar. The adhesion of the omentum to the left ovarian cyst were separated by sharp dissection. The cyst was found to be adhered to the anterior surface of the sigmoid colon, from which it was separated by sharp dissection. Gross appearance was suggestive of a tubo-ovarian mass of about 4 x 5 cm. It was excised. There were no tubercles seen in the pelvis or in the upper abdomen. The sigmoid colon was examined by a gastrointestinal surgeon and found to be intact. There was no evidence of inflammation of the colon or diverticulitis. The patient was given oral fluids after peristalsis detected after 24 hours. She tolerated the oral liquids well and was then gradually given soft and full diet by third postoperative day. On day 4 she had a spontaneous bowel movement. She had no signs of faecal peritonitis like abdominal distension, guarding, rigidity, tenderness or febrile morbidity, in the postoperative period.
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Fig. 1 : The hollow arrow shows junction of the attachment of the ovarian dermoid epithelium and the sigmoid colon full thickness segment. The solid arrow shows the cyst.
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Histopathological examination of the specimen showed a dermoid cyst of the ovary, with a full thickness of a small piece of the sigmoid was adhered to it externally, separate from the dermoid, (Fig. 1). In view of this histopathological evidence the surgical consultant was once again consulted and asked to review the patient clinically. A CT scan was performed to look for local, perisigmoid walled up collection. The CT report was normal. On day 10 the sutures were removed and the healing was found to be satisfactory. The patient was observed for eleven more days, and was found to have no intraabdominal infection. She was discharged and called for follow up after a fortnight or earlier if any symptoms developed. After a fortnight also the patient was normal. She then followed up in March 2001, March 2002, and again in March 2004 and was found to be without any pelvic or colonic problems.
Discussion
An injury to the sigmoid colonic without prior preparation of the bowel results in faecal peritonitis, unless managed by a colostomy and peritoneal irrigation.1 This patient had a strip of sigmoid colon attached to the external surface of the ovarian dermoid cyst, which can be derived only from the sigmoid colon and not formed by the dermoid cyst, because it was outside the cyst wall, while all tissues formed by a dermoid cyst are on the inner surface of the cyst. This strip of sigmoid could not be separated at the time of the laparotomy performed by us because there was no injury to the sigmoid colon at the end of the surgery, as confirmed by the gastrointestinal surgeon, and also the subsequent uneventful recovery of the patient. Thus the strip can only have been removed at the time of the first laparotomy several years ago. That strip survived on the external surface of the ovary, deriving its blood supply from the ovarian vessels. It came to notice only because the ovary developed a dermoid cyst later and required surgery. Survival of an entire thickness strip of the bowel away from the main segment in this manner has not yet been reported in the literature, as shown by Medline and internet search of English literature.
Conclusion
A piece of the bowel, accidentally separated from it may survive if adherent to another organ and derives its blood supply from it.
References
- Damore LJ 2nd, Rantis PC, Vernava AM 3rd, Longo We : Colonoscopic perforations. Etiology, diagnosis and management. Dis Colon Rectum 1996; 39 (11) : 1308-14.
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