Peritoneal inclusion cysts, also known as benign multicystic mesotheliomas or peritoneal pseudocysts, represent a challenging gynecological condition often mistaken for ovarian pathology. These cysts are fluid-filled collections within the peritoneal cavity, typically arising in women of reproductive age with a history of prior pelvic surgery, endometriosis, pelvic inflammatory disease, or trauma. Although benign, they can cause significant discomfort and diagnostic dilemmas. With the advancement of minimally invasive techniques, laparoscopic management has become the preferred approach, offering both diagnostic accuracy and therapeutic benefit.

Understanding Peritoneal Inclusion Cysts

A peritoneal inclusion cyst is formed when normal peritoneal fluid becomes trapped by adhesions or fibrotic bands. Since the peritoneum continues to produce fluid, it accumulates within these confined spaces, giving rise to multiloculated cystic structures. Unlike true ovarian cysts, the ovary is typically trapped within the cyst or seen adjacent to it, a key feature on imaging.

Clinical presentation includes:

Chronic pelvic pain.

Palpable abdominal or pelvic mass.

Abdominal distension or bloating.

Menstrual irregularities.

Rarely, urinary or bowel symptoms due to pressure effects.

Diagnostic Evaluation

The diagnosis of peritoneal inclusion cysts is often complex because they mimic ovarian neoplasms. A careful combination of history, imaging, and intraoperative assessment is required.

Ultrasound: Shows multiloculated cystic structures surrounding a normal ovary, often with a “spider in a web” appearance.

MRI/CT Scan: Helps distinguish peritoneal inclusion cysts from neoplastic ovarian masses by identifying the entrapped ovary and absence of solid nodules.

Tumor Markers (CA-125, CEA, etc.): Usually normal, but checked to rule out malignancy.

Despite advanced imaging, many cases are definitively diagnosed only at laparoscopy.

Indications for Surgical Management

While some asymptomatic cysts may be managed conservatively with observation, laparoscopic management is indicated when:

The cyst is symptomatic (pain, distension, mass effect).

There is rapid increase in cyst size.

Malignancy cannot be confidently excluded.

Fertility preservation is desired but ovarian function is compromised by adhesions.

Laparoscopic Management: Surgical Technique

Patient Preparation and Positioning
The patient is placed under general anesthesia in lithotomy position. Pneumoperitoneum is established, and three to four laparoscopic ports are inserted depending on the size and complexity of the cyst.

Initial Exploration
The peritoneal cavity is inspected. Multiloculated, translucent cystic structures are seen, often encasing or surrounding the ovary. Adhesions are carefully noted.

Adhesiolysis
Adhesions trapping the ovary and peritoneal folds are released meticulously. Draining the cyst without proper adhesiolysis can lead to recurrence, so careful dissection is crucial. Energy sources such as bipolar cautery, harmonic scalpel, or cold scissors may be used depending on the density of adhesions.

Cyst Drainage and Excision

The cyst is punctured, and fluid is aspirated for cytological analysis.

Cyst walls are excised or fenestrated widely to prevent reaccumulation.

Whenever possible, complete removal of cystic walls is performed, though this may be limited if the ovary or vital structures are densely adherent.

Ovarian Preservation
In reproductive-age women, the ovary is preserved. The ovary is gently freed from surrounding adhesions, restoring its normal anatomy and mobility.

Specimen Retrieval
Excised tissue is retrieved in an endoscopic bag to prevent spillage and allow histopathological confirmation.

Hemostasis and Adhesion Prevention
Meticulous hemostasis is ensured. Anti-adhesion barriers and copious irrigation are used to reduce recurrence risk.

Postoperative Care

Recovery following laparoscopy is rapid. Patients are mobilized within hours, and oral intake resumes the same day. Hospital stay is typically 24–48 hours. Postoperative pain is minimal, managed with oral analgesics.

Follow-up involves:

Clinical assessment of symptoms.

Periodic imaging (ultrasound) to monitor for recurrence.

Counseling about the possibility of recurrence, which remains significant despite surgery due to ongoing peritoneal fluid production.

Advantages of Laparoscopic Management

Superior visualization of pelvic anatomy.

Accurate differentiation from ovarian malignancy.

Fertility preservation by conserving ovaries and fallopian tubes.

Minimal postoperative pain and faster recovery.

Reduced hospital stay compared to laparotomy.

Lower adhesion formation with meticulous technique.

Challenges and Recurrence

One of the main challenges in managing peritoneal inclusion cysts is recurrence. Even with complete laparoscopic excision, recurrence rates can be as high as 30–50% due to the persistent peritoneal fluid environment. Strategies to minimize recurrence include:

Wide fenestration of cyst walls.

Complete adhesiolysis.

Use of anti-adhesion agents.

Hormonal suppression (oral contraceptives or GnRH analogs) in select cases to reduce ovarian fluid production.

Conclusion

Peritoneal inclusion cysts, though benign, pose significant diagnostic and therapeutic challenges. They often mimic ovarian tumors and cause chronic pelvic symptoms. Laparoscopy serves as both a definitive diagnostic tool and the most effective therapeutic modality. Through careful adhesiolysis, cyst excision, and ovarian preservation, laparoscopic management restores normal pelvic anatomy and alleviates symptoms. While recurrence remains a concern, minimally invasive surgery ensures reduced morbidity, faster recovery, and better quality of life. Thus, laparoscopy remains the gold standard in the management of peritoneal inclusion cysts in modern gynecology.