LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 2 | Page : 196-197
Laparoscopic excision of a lipoma of parietal peritoneum
Hrishikesh P Salgaonkar, Ramya Ranjan Behera, Avinash N Katara, Deepraj S Bhandarkar
Department of Minimal Access Surgery, Hinduja Hospital, Mumbai, Maharashtra, India
|Date of Submission||04-Aug-2015|
|Date of Acceptance||13-Aug-2015|
|Date of Web Publication||11-Mar-2016|
Deepraj S Bhandarkar
Department of Minimal Access Surgery, Room 2103, Hinduja Hospital, Veer Savarkar Road, Mahim, Mumbai - 400 016, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Salgaonkar HP, Behera RR, Katara AN, Bhandarkar DS. Laparoscopic excision of a lipoma of parietal peritoneum. J Min Access Surg 2016;12:196-7
A 79-year-old man presented with right upper abdominal pain of 8 months' duration. He also gave history of episodes of pain in the left iliac fossa and occasional constipation. There was no fever, jaundice, or loss of weight or appetite. Abdominal examination was unremarkable. All the haematological and biochemical investigations were normal. Abdominal ultrasound examination revealed multiple gallstones and a slightly thickened gall bladder. Colonoscopy was normal except for a few sigmoid diverticula. Abdominal computed tomography (CT) showed a well-defined intraperitoneal lipomatous lesion of 6.3 × 3.8 × 5.3 cm 3 in the left iliac fossa [Figure 1] and confirmed the presence of multiple gallstones. The patient was offered laparoscopic surgery, which was performed with two 10-mm ports in infra-umbilical and epigastric locations along with two 5-mm ports on the right side of the abdomen. A standard cholecystectomy was performed. The laparoscope was then shifted to the epigastric port, with the monitor to the left side of the patient and the surgeon as well as the cameraperson moved towards the right shoulder. A large lipomatous lesion that appeared to be arising in the extraperitoneal layer was observed in the left iliac fossa [Figure 2]a. This lesion was excised completely using an ultrasonic shears (Harmonic Scalpel, Ethicon Endosurgery, Cincinnati, Ohio, USA) [Figure 2]b. Both the gallbladder and the lipoma were placed in a plastic pouch and extracted from the umbilical port site. The fascia at the 10-mm ports and the skin were approximated. The patient made an uneventful recovery and was discharged the day after surgery. Histopathology showed chronic cholecystitis, and the excised fat mass was confirmed to be a well-encapsulated lipoma composed of mature adipose tissue. The patient remains asymptomatic 1 year after the surgery.
|Figure 1: CT scan showing a well-circumscribed mass deep in the peritoneum (arrow)|
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Lipomas are common benign soft-tissue tumours composed of mature fat and are prone to occur throughout the body. Superficial lipomas commonly affect the neck, trunk or extremities, and deep ones can occur in the thorax, mediastinum or retroperitoneum. In the gastrointestinal tract they tend to occur in the submucosa or subserosa of the small and large intestines. Lipoma of parietal peritoneum (LPP) is an extremely rare entity. The origin and pathogenesis of a LPP remain obscure, and it is considered that the tissue of origin may be either the peritoneal fat tissue or fat seeding from peritoneal fluid. Similarly, there is no unanimity regarding the pathogenesis of these tumours. Theories put forth include:
- Development from misplaced embryonic adipose tissue
- Hyperproliferation of adipose tissue and
- Trauma-related herniation of fat through tissue planes followed by trauma-induced cytokine release triggering pre-adipocyte differentiation and maturation.
Whether obesity, hypercholesterolaemia or hypertriglyceridemia predispose to the formation of LPP is unknown. More often than not, a LPP is seen as an incidental finding at laparotomy or laparoscopy. It can present with obscure abdominal pain, as in our patient, or it may mimic acute appendicitis, as has been described in two previous reports., Ultrasound examination may or may not help arrive at the diagnosis of this rare entity. However, a CT scan that demonstrates a well-circumscribed mass of uniform fat attenuation attached to the parietal wall is diagnostic of LPP. Other fat-containing masses such as angiomyolipoma, myelolipoma or trauma should be considered in the differential diagnosis. If symptomatic, the treatment of choice is excision of the LPP, and this is generally quite straightforward. In all the four previously reported cases, LPPs were excised at laparotomy;,,, ours is the only reported case of laparoscopic resection of a LPP. Once excised completely, the chances of recurrence are extremely low.
This case highlights the fact that LPP, being extremely rare, is unlikely to be considered in the differential diagnosis of abdominal pain. However, it can be easily picked up on CT imaging and when considered symptomatic, is amenable to laparoscopic excision.
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Conflicts of Interest
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| ¤ References|| |
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Barut I, Tarhan OR, Cerci C, Ciris M, Tasliyar E. Lipoma of parietal peritoneum: An unusual cause of abdominal pain. Ann Saudi Med 2006; 26:388-90.
[Figure 1], [Figure 2]