A mesenteric cystic mass causing chronic abdominal pain. It was compressing the posterior gastric wall and was abutting from the mesentery at the origin of the middle colic artery, making it is excision a surgical challenge.

1. Dr. Majd AlHaddadin, MBChB,MS,MRCS
Consultant General & Laparoscopic Surgeon
Al Hammadi Hospital – Riyadh – Nuzha
- Jordanian Board and Arab Board in General Surgery.
- Member of The Spanish Association of Surgery (AEC).
- Member of The Royal College of Surgeons – Ireland (MRCSI).
- Associate Fellow of the American College of Surgeon (AFACS).

2. Challenge Surgery
Dr. Majd AlHaddadin, MBChB, MS, MRCS, FACS
Consultant General & Laparoscopic Surgery
Al Hammadi Hospital - Nuzha
Compressive Mesenteric Cystic Mass

3. Introduction
• Mesenteric mesothelial cysts are rare lesions of the peritoneum.
• Incidence of 1 for 250 000 of admissions.
• Less than 1000 cases were reported in the literature.
• Presumably, they result from incomplete fusion of the mesothelial-lined peritoneal
surfaces.
• The most common locations are the mesentery of the small bowel and the
mesocolon, but these cysts may also arise from the omentum and, in woman, from
the paraovary.

4. Introduction
• Mesothelial cysts occur mainly in children and in young adults as
asymptomatic abdominal masses. However, they can cause chronic
abdominal pain or acute pain secondary to torsion, rupture, hemorrhage,
infection or GI obstruction due to compression.
• In 1507, the first case report during an autopsy… by Benevenni.
• In 1880, the first successful surgical resection… by Tillaux.
• In 1993, the first successful laparoscopic resection… by Mackenzie.

5. Case Presentation
• File No. 1741987
• A 41 year — old, female
• PMH: Goiter
• PSH: cesarean section
• Visited the clinic on February 2022
• Complaint of:
- Persistent upper abdominal pain since 2 months.
- Pain aggravating after meals.
- Persistent nausea.
- Post prandial vomiting.
- Significant weight loss .

6. Cont…
Visited multiple hospitals.
Multiple empirical medical treatment given…No improvement.
 Initial differential diagnosis:
- Gastritis and peptic ulcer disease.
- GERD and reflux.
- Gallbladder stones.
- H. Pylori infection.

7. Investigations:
• Upper GI endoscopy:
- The distal third of the esophageal mucosa shows mild hyperemia with small mucosal breaks less than 5 mm
confined to folds with no masses or ulcers.
- Incompetent cardia.
- Antral mucosa shows mild hyperemia.
- Compression at the greater curvature mostly from outside.

8. Investigations:

9. Coronal
- Cystic mass
- Pancreas
- Stomach
Sagittal

10. DDx:
- Pancreas serous
cystadenoma.
- Pancreas mucinous
cystadenoma.
- Mesenteric cyst.
- Pancreatic Pseudocyst.
To operate OR to do
more investigation ??
If Surgery:
- Distal pancreatectomy?
- Cystic mass excision?
- Cyst-enteric bypass ?

11. DYNAMIC MRI OF THE PANCREAS

12. Coronal Sagittal

13. Intraoperative findings :
• During induction of anesthesia… Foleys catheter and NG tube inserted
• Midline laparotomy…opening of the gastro-colic ligament…mobilization of
the splenic flexure.
• Findings:
- A mass raising from the transverse mesocolon.
- Adherent to the antero-inferior surface of the pancreas.
- Compressing the greater curvature of the stomach.
- Intimal adherence to the middle colic vessels at it’s origin from the SMA.

14. Access to the lesser sac :

16. Meticulous Surgery
Main Middle
Colic Vessel
Left Branch
of Middle
Colic Vessel
M

17. Post operative
• Developed pancreatitis … expected…conservative.
• Discharged in day 4 .
• Good general condition.
• OPD follow up…asymptomatic.

18. Discussion
 Rare lesions of the peritoneum, happens mainly in children and in young adults
 Clinical presentation is commonly indolent. Symptoms are non-specific, mostly abdominal pain and an
increase in abdominal girth, but also include nausea and vomiting, constipation and diarrhea.
 Symptoms are unveiled as a result of mass effect, since these masses can reach large sizes (a range of a few
centimeters to 30 cm), or when other complications arise such as rupture, hemorrhage, torsion or infection.

19. Classification
According to their etiology characteristics mesenteric cysts are classified as:
 Fetal and developmental cysts.
 Traumatic or acquired cysts.
 Neoplastic cysts.
 Infectious or degenerative cysts

20. Histopathological classification:

21. Discussion
 Though a benign clinical suspicion, surgery is highly recommended for large and symptomatic mesenteric
cysts, as this excludes malignant transformation and avoids complications.
 Metastatic potential is not consensual, but malignant evolution of BCM has been documented
 The prognosis is excellent, since surgery is usually curative if a total resection is accomplished.
 Close long-term follow-up of these patients is advisable because of the high rates of local recurrence.

22. CONCLUSION
Mesenteric mesothelial cysts are rare lesions of the peritoneum and need high
index of suspicion.
Abdominal ultrasound and CT scan can be accurate in the diagnosis as well as
it can delineate the relation to the surrounding organs.
Despite the majority of those lesions are benign , surgical resection is advised
to rule out malignancy and to avoid possible complications.
Surgical resection (either open or laparoscopic) is associated with good
outcomes if properly planned.

23. Thank You…