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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 176-178

Incidental finding of an accessory ovary at laparoscopic surgery


Department of Obstetrics and Gynecology, Tomakomai City Hospital, Tomakomai, Hokkaido, Japan

Date of Submission28-Sep-2018
Date of Decision21-Jan-2019
Date of Acceptance31-Jan-2019
Date of Web Publication24-Oct-2019

Correspondence Address:
Dr. Toshio Fujimoto
Department of Obstetrics and Gynecology, Tomakomai City Hospital, 1-5-20 Shimizu-Cho, Tomakomai, Hokkaido 053-8567
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_92_18

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  Abstract 


An accessory ovary is one of the rare gynecologic abnormalities of the female genital tract. The etiology of accessory ovary has been reported to be acquired origin, such as postsurgical or postinflammatory implants, and true embryologic origin. However, as in the present case with unremarkable medical history and no urogenital abnormalities, there are accessory ovaries that cannot be explained by these etiologies. In such cases, the etiology of accessory ovary might possibly be torsion of functional ovarian cyst during the fetal period or asymptomatic torsion of the functional ovarian cyst at some time after birth.

Keywords: Accessory ovary, asymptomatic torsion, ectopic ovary, fetal functional ovarian cyst, laparoscopic surgery


How to cite this article:
Fujimoto T, Tanaka K, Yamada K, Shimahata K. Incidental finding of an accessory ovary at laparoscopic surgery. Gynecol Minim Invasive Ther 2019;8:176-8

How to cite this URL:
Fujimoto T, Tanaka K, Yamada K, Shimahata K. Incidental finding of an accessory ovary at laparoscopic surgery. Gynecol Minim Invasive Ther [serial online] 2019 [cited 2019 Nov 12];8:176-8. Available from: http://www.e-gmit.com/text.asp?2019/8/4/176/269831




  Introduction Top


Ectopic ovary, either accessory or supernumerary, is among the rarest gynecologic abnormalities.[1] The incidence for these abnormalities is estimated to occur in 1 in 29,000 to 1 in 70,000 gynecologic admissions.[2] In addition, when limited to infertile women, incidences for accessory and supernumerary ovaries are 2 in 3811, respectively.[3] An accessory ovarian tissue has the functional and pathological abilities of normal ovary.[4] We report a case of an accessory ovary incidentally discovered during laparoscopic hysterectomy.


  Case Report Top


A 46-year-old woman, gravida 0, para 0, presented to our hospital with the complaint of atypical genital bleeding. Menstrual cycle was regular with no clinical symptom of dysmenorrhea. She had no history of acute abdominal pain, surgery, or pelvic inflammatory disease. Her family history was uneventful. The clinical examination of the external genitalia and vagina was normal. On pelvic examination, the uterus was anteverted and was of fist size. Bilateral adnexa was not palpated. Transvaginal ultrasonography and preoperative magnetic resonance imaging [Figure 1]a revealed multiple uterine leiomyoma. The left ovary was able to be confirmed behind the uterus, but not the right ovary. Preoperative drip infusion pyelography revealed no urinary tract abnormalities [Figure 1]b. Laboratory data showed no abnormal findings. Cervical and endometrial cytology was both negative. The patient decided to undergo laparoscopic hysterectomy after receiving an explanation about the condition and treatment of the disease.
Figure 1: (a) Horizontal T2-weighted image showing multiple uterine myoma and normal-sized left ovary behind the uterus. The right ovary cannot be confirmed (b) Urinary tract abnormality was not observed in the drip infusion pyelography

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At laparoscopy, the patient was found to have a 2-cm white structure adhered to the omentum and right side of the abdominal wall [Figure 2]a. Macroscopically, the white structure resembled ovarian tissue. After excising the adhesion between the white structure and the omentum, the white structure and the scarred ectopic right ovary were found to be connected by 1-mm wide ligamentous tissue [Figure 2]b. The scarred ectopic right ovary was connected to the utero-ovarian ligament and infundibulopelvic ligament. There was no abnormal finding on the right  Fallopian tube More Details. The film-like adhesion and ligamentous tissue were easily cut with scissors. The left ovary and fallopian tube were normal [Figure 2]c. Total laparoscopic hysterectomy, bilateral salpingectomy, and resection of the white structure were performed. There were no intra- or post-operative complications, and the patient was discharged on the 5th day after the surgery.
Figure 2: (a) At laparoscopy, 2-cm white structure was adhered to the omentum and right side of the abdominal wall. Macroscopically, the white structure resembled ovarian tissue. (b) The white structure and the scarred ectopic right ovary were connected by 1-mm-wide ligamentous tissue. (c) The left ovary and fallopian tube were normal

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Histopathological examination of the resected white structure revealed corpus albicans and interspersed follicles, which was diagnosed with an accessory ovary [Figure 3].
Figure 3: Microscopic findings of the white structure. Normal-appearing cortex, corpus albicans, and interspersed follicles were confirmed (HE-stain, ×100)

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  Discussion Top


Ectopic ovary, either accessory or supernumerary ovary, is a very rare ovarian abnormality. The accessory ovary is a structure containing normal ovarian tissue located in the vicinity of a ectopic ovary with which it has a direct or ligamentous attachment.[4] Whereas, supernumerary ovary was defined as ovarian tissue entirely separate from the normally placed ovary. There is no ligamentous or direct connection with the ectopic ovary, the broad ligament, the utero-ovarian ligament, or the infundibulopelvic ligament.[4] The etiology of accessory and supernumerary ovary is still unclear and may cause substantial confusion. Lachman and Berman described the accessory and supernumerary ovary reported in the past and suggested that 50% of the cases were postsurgical or postinflammatory implants.[5] Apart from this acquired origin, true embryologic origin is also suggested for the etiology of the ectopic ovary.[5] It is thought to result from the abnormal separation of a small portion of the developing and migrating ovarian primordium.[4],[6] Thus, there are two types of ectopic ovary, namely, acquired origin and true embryologic origin.

In the present case, since there was no history of surgery and pelvic inflammatory disease, the etiology of accessory ovary according to Lachman's classification might be the true embryologic origin. However, accessory ovary associated with true embryologic origin complicates the mesonephric and Müllerian duct-derived systems on the affected side such as the horn of uterus, round ligament, broad ligament, fallopian tube, kidney, and ureter.[7] Because the patient did not complicate any of these urogenital abnormalities, the etiology of the accessory ovary in the present case is unlikely to be the true embryologic origin. In such case with unremarkable medical history and no urogenital abnormalities, there are two conceivable explanations for the etiology of the accessory ovary. First, it might be the torsion of functional ovarian cyst during the fetal period. Since fetal supporting ligaments are less tense and the fetal pelvis is shallow compared to the postpubertal women, the fetal ovary is more susceptible to torsion than the postpubertal ovary. The incidence of fetal ovarian cysts is estimated to be 1/2500.[8],[9] Although the fetal ovary is usually dormant, the follicular cyst may develop by exposure to placental human chorionic gonadotropin and maternal estrogen. After delivery, when the fetal ovary is isolated from maternal hormones, it disappears spontaneously. Second, it might be asymptomatic torsion of the functional ovarian cyst at some time after birth. In most cases, the torsion of ovarian cyst interferes with the blood supply and causes necrosis of the tumor. As a result, subsequent autoamputation may occur. However, in the present case, the torsion might have been insufficient to interfere with the blood supply to cause necrosis and autoamputation of the ovarian cyst. Evidence of the scarred ectopic right ovary and adhesion between the accessory ovary and the omentum in the present case may suggest the torsion of the functional ovarian cyst and subsequent inflammation.

In summary, the present case report illustrates the accessory ovary incidentally found during total laparoscopic hysterectomy. The etiology of the accessory ovary has been reported to be acquired origin or true embryologic origin. However, among patients who do not have a history of acquired origin without complications of urogenital abnormalities, torsion of functional ovarian cyst during the fetal period or asymptomatic torsion of the functional ovarian cyst at some time after birth might be the conceivable explanations for the etiology of the accessory ovary.

Ethical Statement

The institutional review board committee of Tomakomai city hospital has approved this study. The IRB Project No.2019-5 was obtained on 30th August in 2019.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wharton LR. Two cases of supernumerary ovary and one of accessory ovary, with an analysis of previously reported cases. Am J Obstet Gynecol 1959;78:1101-19.  Back to cited text no. 1
    
2.
Vendeland LL, Shehadeh L. Incidental finding of an accessory ovary in a 16-year-old at laparoscopy. A case report. J Reprod Med 2000;45:435-8.  Back to cited text no. 2
    
3.
Chen T, Li J, Yang X, Huang H, Cai S. Ultrasound manifestations of lobulated ovaries: Case report. Medicine (Baltimore) 2018;97:e0550.  Back to cited text no. 3
    
4.
Clement PB. Nonneoplastic lesions of the ovary. In: Kurman RJ, editor. Blaustein's Pathology of the Female Genital Tract. 5th ed. New York: Springer Press; 2002. p. 675-728.  Back to cited text no. 4
    
5.
Lachman MF, Berman MM. The ectopic ovary. A case report and review of the literature. Arch Pathol Lab Med 1991;115:233-5.  Back to cited text no. 5
    
6.
Printz JL, Choate JW, Townes PL, Harper RC. The embryology of supernumerary ovaries. Obstet Gynecol 1973;41:246-52.  Back to cited text no. 6
    
7.
Eustace DL. Congenital absence of fallopian tube and ovary. Eur J Obstet Gynecol Reprod Biol 1992;46:157-9.  Back to cited text no. 7
    
8.
Trinh TW, Kennedy AM. Fetal ovarian cysts: Review of imaging spectrum, differential diagnosis, management, and outcome. Radiographics 2015;35:621-35.  Back to cited text no. 8
    
9.
Bryant AE, Laufer MR. Fetal ovarian cysts: Incidence, diagnosis and management. J Reprod Med 2004;49:329-37.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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