Laparoscopic Excision of an Abdominal Lymphatic Malformation

When lymphatic malformations occur within the abdominal cavity, they can be discovered incidentally or become acutely symptomatic due to torsion, hemorrhage, rupture, or sudden enlargement. We present a video of a laparoscopic excision of an unusual and extensive lymphatic malformation arising from the mesentery of the gastric lesser curvature. A 15 year old girl presented with several days of non-localizing abdominal pain. Ultrasound followed by a CT scan demonstrated a large cystic mass thought to be of adnexal origin extending into the upper abdomen. We intended to perform a laparoscopic resection of this presumed adnexal cystic mass. Initial laparoscopic exploration supports the presumptive diagnosis of a cystic mass arising from the pelvis. However, further manipulation demonstrates in non-pelvic origin, the adnexa are in fact normal. The mass is connected by a torchd pedicle. Traveling over the transverse colon. Through the greater omentum. An omental origin is suspected at this point. However, further dissection demonstrates the momentum to be simply adherent to the torsd pedicle and not the source of it. These adhesions are taken down with a ligature device. As we continue to free the cystic pedicle from the omentum, we discover its connection to another large cyst. It becomes clear that this component of the mass is attached to the gastric wall. The mass extends posterior to the stomach into the lesser sac. The extent of gastric wall involvement is seen. The momentum is retracted to reveal the full extent of the mass. The ligature is 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 facilitates identification of the plane of dissection. The posterior wall of the stomach can be clearly seen as the lesser sac is opened further. Next, the mass is separated from the gastric mesentery. The last remaining attachments of the mass to the gastric mesentery are now taken. Following excision, the greater curvature is seen to be completely intact and uninvolved. The mass is clearly seen to have arisen from the lesser curvature mesentery and occupied the lesser sac. The pancreas can be clearly seen. The ligature dissection line is also clearly seen. The stomach is tested for leak after the installation of dilute methylene blue through the nasogastric tube. None is identified. The mass is easily removed through the 10 millimeter umbilical port. The patient was started on oral intake a few hours after the operation and discharged the following day. All her symptoms resolved. A screening ultrasound one year after excision showed no recurrence. An lymphatic malformation was diagnosed grossly and histologically. This case demonstrates a significant benefit of laparoscopy. Had this lesion been approached by a fanning steel incision, as some surgeons prefer, a correct diagnosis and excision would not have been possible without a second laparotomy incision.