Retroperitoneal Approach for Recurrent Benign Multicystic Peritoneal Mesothelioma
A 32-year-old female presented with recurrent lump in right lumbar region. There were no associated urinary or bowel complaints. She was operated twice for similar lumps in a rural hospital 10 and 3 years back. Her discharge card of previous surgery showed the diagnosis of lymphangioma. Her case papers of first surgery done 10 years back were not available. On physical examination a lump in right lumbar region just lateral to previous paramedian incision was palpated. Rest of the abdomen was unremarkable.\nUltrasonography showed multicystic complex mass in right lumbar region measuring 25×8×7 cm. Computed tomography scan abdomen and pelvis () showed a 25×10×6.5 cm sized well defined non enhancing lobulated multiloculated cystic lesion in right paracolic gutter on lateral aspect of ascending colon. Inferiorly it was abutting the lateral wall of urinary bladder. Similar morphology lesions were seen in pouch of Douglas and mesentery. All these finding were suggestive of recurrent lymphangioma.\nPatient was subjected to surgery with a retroperitoneal approach as majority of the mass was retrocolic in position. Incision was taken below and parallel to 12th rib extending from posterior axillary line and going anteriorly towards umbilicus by keeping the patient in left lateral position. Initially retroperitoneal component of lesion was dissected out from kidney and ureter and lastly from retro peritoneal surface of colon. During this peritoneum was opened and the intra peritoneal component including pelvic component was completely removed. Intra operative finding showed a cystic multiloculted mass loosely attached to serosal surfaces of the ascending colon extending into pelvis with intra peritoneal extension into pouch of Douglas. The rest of the appendix, caecum, large and small bowel appeared grossly normal. Both ovaries and the uterus were visualized and found to be normal. The lesion was friable, hence care was taken to avoid rupture contamination of the pelvis with the cyst fluid. Complete resection of the lesion was performed. The diagnosis was not clear at this point, but our differential included a mucinous cystadenoma or pseudomyxoma peritonei or lymphangioma. As the diagnosis of BMPM was not established hence intraoperative hyperthermic peritoneal infusion with cisplatin was not considered. The specimen was a multicystic mass that was 22 cm wide in its greatest dimension (). The individual cysts, which ranged between 3 and 9 cm in diameter, contained serous fluid.\nPost operative recovery was uneventful. Histopathology showed cystic spaces lined by flattened cuboidal to hobnail epithelium separated by thin fibrous septa () .The lining epithelium showed strong immunopositivity for calretinin () and immunonegativity for CD31. Hence diagnosis of multilocular peritoneal inclusion cyst was confirmed. Follow up of 1 year has shown patient to be disease and symptom free.