Design and Methods: TF, a 12-year-old male, presented to the surgical outpatient clinic with a 3 month history of abdominal pain
and distention. Examination of the abdomen revealed mild tenderness in the epigastric region and an abdominal mass. CT scan of the
abdomen and pelvis showed two mesenteric cysts with the largest being 15cm x 10cm x 6 cm.
Results: Both cysts originated from the small bowel mesentery and they were resected laparoscopically, placed in an endocatch bag and
removed by way of the 12mm umbilical port site. Histologic evaluation of the specimen confirmed cystic lymphangioma.
Conclusion: Minimally invasive surgery has been found to be an excellent approach in the surgical management of mesenteric cysts.
The operation was executed without complications, an unremarkable recovery, short hospital stay and quick return to normal activity.
The laparoscopic approach should always be considered as a feasible option for this pathology
laparoscopic,resection, mesenteric, cyst.
Mesenteric cysts are benign lesions that are found within the
abdomen. They have an incidence that is less than 1 in 100,000
patients. While they were first described as an autopsy finding in
1507, less than 1000 have been described in the literature1.
Most lesions are asymptomatic but can present with symptoms
such as abdominal pain, nausea, vomiting, anorexia, and a change
in bowel habits. Although most mesenteric cysts are benign, these
lesions do occasionally cause complications, including intestinal
obstruction, volvulus, torsion, or even hemorrhagic shock
secondary to bleeding or rupture1. We present a case, which was
successfully treated with minimally invasive surgery.
TF, a 12-year-old male presented with a three (3) month history
of abdominal pain and a mass. The pain was intermittent in nature
and located in the epigastric region. The pain was non-specific in
nature and there was no alleviating/aggravating factors. There was
no associated nausea, vomiting or change in bowel habits. The
patient had an insignificant past medical and surgical history and
no family history of malignancy.
On physical examination, his abdomen was asymmetrical, soft and
non- tender and he was noted to have a mass in the mesogastric
region. The rest of the general examination was insignificant.
Haematological and biochemical investigations were noted to be
within normal limits. CT scan of the abdomen and pelvis illustrated
two thin walled multiloculated cysts arising from the small bowel
mesentery; one in the midline of the abdomen (10cm x 7cm x 8cm)
and another (7cm x 5cm x 4cm) was noted to be to the right of the
midline, anterior to morrisons pouch and extending into the right
subhepatic region [figure 1].
Figure 1: Transverse section view of a CT scan of the abdomen showing two separate cystic
lesions of the small bowel mesentery. The arrow points at the larger of the two cysts.
A decision to undertake a minimally invasive approach was chosen
to resect the cyst. A total of four trocars were used for the surgery.
Initially, a 12 mm trocar (camera port) was placed at the umbilicus
via the open Hasson technique, with two additional 5mm trocars
(working ports) placed under direct vision in the bilateral lower
quadrants and another 12mm trocar (assistant/working port)
placed at the left upper quadrant.
During the laparoscopic exploration, it was noted that the larger
mesenteric cyst was in the midline of the abdomen attached to the ileal mesentery. Whereas the other cyst was located in the right
lower quadrant, also attached to the ileal mesentery. It was a thin
walled structure and was fixed to the mesentery posteriorly, with
no other points of attachment [figure 2].
Figure 2: Intra-operative photograph showing a large mesenteric cyst.
is frequently associated with a history of a previous pelvic
inflammatory process, surgery or endometriosis1.
The majority of the lesions are asymptomatic but they can also
present with abdominal pain, nausea, vomiting, anorexia, and a
The cysts were mobilized from the mesentery using blunt and
harmonic dissection. Once free, the cysts were placed singly in an
endoscopic retrieval bag and the contents were aspirated completely,
with the remaining cyst wall removed from the abdomen via the
12mm umbilical port site within a surgical retrieval bag.
mesenteric peritoneal defects were approximated with 3-0 vicryl
sutures to decrease the formation of adhesions.
The patient had an uneventful recovery and was discharged after
two days tolerating a regular diet. Pathological examination of
the cyst revealed the fluid to be benign and the histology was
consistent with a cystic lymphangioma.
Mesenteric cysts are benign lesions found within the abdomen.
The first report of a mesenteric cyst was found during an autopsy
by Benevenni in 1507 whereas the first surgical resection of a
mesenteric cyst was performed by Tillaux in 18802. Mesenteric
cysts are rare abdominal lesions and the incidence varies from 1
per 100,000 to 250,000. Thus far there has been less than 1000
cases described in the literature1.
Mesenteric cysts are usually found in the mesentery of the small
bowel (66%), mesentery of large intestine (33%), usually in the
right colon. Very few cases have been reported of cysts presenting
in the mesentery of the descending colon, sigmoid or rectum
(approximately 1%)3. They are classified as 1) cysts of lymphatic
origin, 2) cysts of mesothelial origin, 3) enteric cysts, 4) cysts of
urogenital origin, 5) dermoid cysts and 6) pseudocysts. Mesenteric
cysts occur with very small incidence, usually occurring in the
fifth decade of life and with a female predominance4. Cystic
lymphangioma is the only exception that mostly occurs in the first
decade of life (up to 12 years of age) with a male predominance4,
as in our case.
The etiology of mesenteric cyst is variable. They usually arise from
developmental abnormalities of the mesenteric lymphatics or from
their traumatic rupture. Simple lymphatic and mesothelial cysts
are most likely congenital, while the benign cystic mesothelioma change in bowel habits. The most common physical finding for a
mesenteric cyst is Tillaux’s sign2. This is described as a mass lesion
of the abdomen only mobile in the horizontal plane. Most of these
cysts are discovered incidentally during an abdominal imaging
done for another reason. Ultrasound and CT scan can distinguish
between solid and cystic characteristics of the abdominal mass,
and CT scan is usually sufficient in making an acurate diagnoses
in all cases1.
Surgical excision of mesenteric cysts is the preferred method of
treatment and may or may not involve resection of the adjacent
bowel. Procedures such as marsupialization and drainage are
associated with high recurrence rates and are best avoided. Though
the operating time is longer with laparoscopy, it has advantages
of minimal access, which includes less postoperative pain, shorter
hospital stay, early return to normal activity and better cosmesis5,6.
Mesenteric cysts have a good prognosis and no recurrence
have been reported following complete excision of the cyst5,6.
Depending on the size and site of the mesenteric cyst, where
difficulty of ease of handling may be accounted, aspiration of the
cyst may be done initially or at a later stage to ensure safe and
complete excision in order to prevent recurrences7. Minimally
invasive surgery has been found to be an excellent approach in the
surgical management of mesenteric cysts8.
Minimally invasive surgery has been found to be an excellent
approach in the surgical management of mesenteric cysts. The
operation was executed without complications, an unremarkable
recovery, short hospital stay and quick return to normal activity.
The laparoscopic approach should always be considered as a
feasible option for this pathology.
The patient and his parents’ approval was taken.
Conflicts of interest:
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