Incarcerated ovarian hernia in the umbilicus
© Springer-Verlag 2007
Received: 29 September 2006
Accepted: 5 April 2007
Published: 11 May 2007
This case regards a morbidly obese lady presenting with a massive ovarian tumour herniating through the umbilicus. Six months previously she had suffered from a life-threatening pulmonary embolus requiring supportive ventilation at the same hospital. Herniation of the ovary directly into the umbilicus is very rare and here we provide pictoral evidence and advice regarding the management of this patient.
A 55-year-old post-menopausal Maori lady was admitted under the surgeons with a 7-day history of tenderness and redness in her umbilicus, with worsening abdominal pain, lethargy and urine retention. Six months previously, she had been on the intensive care unit at the same hospital with near-fatal massive pulmonary and right ventricular emboli, which were treated with streptokinase infusion and significant respiratory support. Abdominal examination at the time was reported as “nothing abnormal”.
Tumour markers were elevated, with a CA125 of 224 kU/l, haemoglobin of 7.03 mmol/l but otherwise normal renal and liver function tests. Chest X-ray did not reveal any extraperitoneal masses, and abdominal CT scan showed a 41 cm × 33 cm mass, consisting of mainly fat but also some calcified areas and septae.
Following anaesthetic review and an informed discussion regarding the significant risks associated with surgery, the patient was booked for midline laparotomy. The midline incision site was marked preoperatively (Fig. 1).
The patient made a good recovery and was able to walk into clinic unaided when seen at 6 weeks, having lost 27 kg (11.5 kg due to tumour). Histology confirmed a benign cystic teratoma (dermoid cyst) of the ovary with no malignant components.
There are numerous case reports of herniation of the ovaries through the inguinal canal (most commonly in newborn girls , but also in adults [2, 3]), the obturator foramen  or the femoral canal . Malignant ovarian tumours may present with a co-existent metastasis in the groin , or in the umbilicus . There has only been one previous report in the literature of an ovarian tumour herniating into the umbilicus , but this is the first report of an incarcerated umbilical hernia due to a massive dermoid cyst. As a pelvic organ, the ovary does not enter the abdominal cavity unless enlarged. In this case, the large nodule of tumour extending from the greater portion of the mass had become incarcerated into the base of the umbilicus, creating a hernial sac. This led to the acute presentation.
Dermoid cysts are usually benign, and may be bilateral in up to 10% of cases. Less than 2% may contain a malignant component, usually a squamous carcinoma. This is more common in women over the age of 40. The majority of benign dermoid cysts are asymptomatic, but they may undergo torsion. More rare is spontaneous rupture, which causes a chemical peritonitis, or—if slowly as is likely in this case—a chronic granulomatous peritonitis leading to adhesions and chronic pain.
Immobility due to morbid obesity, the hypercoagulable state from an inflammatory mass, and direct compression of the inferior vena cava by the mass causing venous stasis all increase the risks of thrombosis.
This case report is a reminder for all medical staff to consider investigation of the abdominal cavity with ultrasound following pulmonary embolism, particularly in obese women.
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