37: A 20-centimeter peritoneal inclusion cyst presenting as vaginal prolapse

Abstract

This video shows the surgical evaluation and excision of a peritoneal inclusion cyst with laparoscopic repair of the pelvic floor. Our case is that of a 44-year-old female referred to urogynecology for pelvic organ prolapse. The patient reported bulge sensation for six months. On examination, a vaginal mass descended four centimeters outside of the introitus. The mass was reducible and unchanged while standing or straining. Dynamic MRI demonstrated a 20-centimeter intraabdominal cystic mass located between the uterus and the rectum and extending into the vagina. Robotic assisted laparoscopic evaluation showed endometriosis and a large peritoneal inclusion cyst extending from the pelvic brim to the rectovaginal septum. After the fluid was drained, redundant peritoneal tissue was excised. The distended posterior vaginal wall was then laparoscopically reduced using interrupted sutures of 2-0 PDS to imbricate the posterior vagina down to the perineal body. Uterosacral ligaments were plicated at the apex of the vagina with interrupted 2-0 PDS, suspending the posterior vaginal apex and uterus. Given the large peritoneal defect from the dissection, a culdoplasty was performed with purse string sutures using 2-0 monocryl. On repeat vaginal exam, restoration of normal anatomy was confirmed. At the six-week post-operative visit, the patient denied further bulge symptoms and had a normal vaginal exam. Pathology revealed benign simple mesothelial cyst without malignancy. We present a unique presentation of a large peritoneal inclusion cyst presenting as vaginal prolapse. Laparoscopic repair can be performed similarly to closing an enterocele. Consideration for laparoscopic repair of a high rectocele can be performed in specific cases when already working laparoscopically to avoid vaginal incisions. Further studies are needed to determine the efficacy of laparoscopic versus transvaginal rectocele repair.