Laparoscopic Excision of Douglas Pouch Fibroma in Contact With the Sigmoid Colon

Pelvic tumors, especially those in difficult locations such as tumors in the rectouterine pouch in contact with the sigmoid colon, pose therapeutic approach difficulties due to the increased risk of complications, such as intestinal perforation. In practice, open surgical technique is often used even though laparoscopy has more advantages, due to lack of familiarity with delicate endoscopic maneuvers. This article describes the laparoscopic excision of a pelvic mass (residual fibroid after a previous myomectomy) implanted in the rectouterine pouch and in contact with the sigmoid colon. The patient is a 49-year-old woman with a history of laparoscopic excision of a 10 cm FIGO 4 (International Federation of Gynecology and Obstetrics Stage 4) fibroid three years ago. She presented to the outpatient clinic for prenatal care initiation, where the ultrasound revealed a solid mass in the pelvis measuring 6x6 cm. The MRI differential diagnosis at 28 weeks of gestation included sarcoma, ovarian cancer, and fibroid. Cancer markers were negative. Conservative management was decided until delivery. During pregnancy, the mass remained stable in size and morphology. At 39 weeks, a selective cesarean section was performed due to a history of myomectomy, during which the mass was identified between the intestinal loops. The ultrasound three months postpartum depicted the mass measuring 4.5x4.5 cm located in the rectouterine pouch. A laparoscopic approach was decided, during which the mass was initially identified and then dissected from the surrounding tissue using bipolar bovie and laparoscopic scissors. Delicate manipulation was needed when dissecting in order to avoid bowel perforation. The mass was removed from the peritoneal cavity using an endoscopic bag to prevent tissue dissemination. The histological diagnosis was fibroid. This report demonstrates that pelvic tumors in difficult locations like in contact with the sigmoid colon can be safely removed by an experienced laparoscopic surgical team.