Laparoscopic Excision of a Gastric Lymphatic Malformation

Abstract

Lymphatic malformations occurring within the abdominal cavity are rare benign lesions predominantly affecting the pediatric population. We report an acute presentation of an unusual and extensive lymphatic malformation, arising in the lesser sac, in a 15-year-old girl. After imaging, the cystic mass was thought to be of adnexal origin. A laparoscopic resection of this presumed adnexal mass was planned. A supra-umbilical, 12-mm trocar was placed by Hasson technique. A 5-mm, 30-degree scope was used to examine the abdominal cavity, revealing a large abdominal cyst that was mobile. Two more 5-mm trocars were then placed in the left lower and right lower quadrant regions. Manipulation of the mass demonstrated a nonpelvic origin and normal adnexae. The mass was connected by a twisted pedicle traveling over the transverse colon through the greater omentum. An omental origin was suspected at this point, but the superior border of the mass could not be delineated. Another 5-mm trocar was placed in the left upper quadrant to allow manipulation of the stomach. Further examination demonstrated the omentum to be simply adherent to the twisted pedicle, and not the source of it. These adhesions were taken down by Ligasure^® (Covidien, Mansfield, MA). As we continued to free the cystic pedicle from the omentum, we discovered its connection to another large cyst. It became clear that this component of the mass was attached to the gastric wall at the lesser curvature. The mass extended posterior to the stomach into the lesser sac. The Ligasure was used to separate the mass from the gastric wall at the junction of the two. Traction on the stomach and counter-traction on the mass facilitated the identification of the plane of dissection. The posterior wall of the stomach could be clearly seen as the lesser sac was opened further. The mass was finally separated from the gastric mesentery, again using the Ligasure. After excision, the greater curvature was seen to be completely intact and uninvolved. The superior extent of the mass was clearly arising from the lesser curvature mesentery, and occupying the lesser sac. A lymphatic pedicle, twisted multiple times, attached this superior component to a large intra-abdominal lymphatic cyst. The stomach was tested for leak after the installation of dilute methylene blue through the nasogastric tube. None was identified. The mass was easily removed through the 10-mm supra-umbilical port. Her postoperative recovery was uneventful and, at 1-year follow-up, there was no recurrence. The case demonstrates the benefits of laparoscopy, and the techniques used to accomplish a safe, complete resection.

No competing financial interests exist.

Runtime of video: 5 mins

Video presentation at IPEG's 19th Annual Congress for Endosurgery in Children, Waikoloa, Hawaii, June 8–12, 2010.