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Peritoneal inclusion cysts are complex cystic adnexal masses consisting of a normal ovary entrapped in multiple fluid-filled adhesions. The cysts usually develop in women of reproductive age who have a history of previous pelvic surgery or pelvic infection. This unusual but benign mass, which has a distinct sonographic appearance, has also been referred to as benign encysted fluid, inflammatory cyst of the peritoneum, peritoneal pseudocyst, entrapped ovarian cyst, multilocular peritoneal cyst, and postoperative peritoneal cyst. The development of peritoneal inclusion cysts depends on the presence of peritoneal adhesions and active ovaries. During the reproductive years, ovaries are the main source of peritoneal fluid. Fluid normally produced by the ovaries during ovulation is absorbed by the peritoneum. However, if the peritoneum has been disrupted by previous surgery, inflammation, or infection, its absorptive properties diminish, thus trapping this physiologic fluid. Also, inflammation of the peritoneum can contribute to production of a more exudative fluid, which is less adequately absorbed by the peritoneum. Previous surgery, infection, or inflammation often leads to the development of adhesions within the abdomen and pelvis. With extensive peritoneal adhesions, the fluid produced by normal ovaries is trapped by the scarred peritoneum. As the normal ovary continues to produce fluid and the fluid becomes entrapped by surrounding adhesions, a complex cystic pelvic mass develops. Other causes of peritoneal inclusion cysts include trauma, pelvic inflammatory disease, and endometriosis.

Peritoneal inclusion cysts (PICs), also known as benign multicystic mesotheliomas, are rare cystic lesions that arise from the peritoneal lining. They are usually seen in women of reproductive age and are often associated with prior abdominal or pelvic surgeries, endometriosis, pelvic inflammatory disease, or trauma. These cysts are typically benign but can present with symptoms such as abdominal pain, pelvic discomfort, bloating, or a palpable mass. Accurate diagnosis and minimally invasive management are crucial for optimal outcomes.

Pathophysiology
Peritoneal inclusion cysts form when reactive mesothelial cells proliferate in response to peritoneal inflammation, adhesions, or fluid accumulation. They often trap ovarian fluid within peritoneal adhesions, leading to multilocular cystic formations. Although benign, these cysts may recur if not completely excised, especially if the underlying adhesions are not addressed.

Clinical Presentation
Patients with peritoneal inclusion cysts may present with:

• Chronic lower abdominal or pelvic pain

• Abdominal distension or bloating

• Palpable pelvic mass

• Occasionally, urinary or bowel symptoms due to compression

Diagnosis often requires imaging studies, as clinical examination alone is insufficient. Ultrasound typically shows multilocular cystic masses, while MRI or CT scans provide better delineation of cysts and adhesions.

Laparoscopic Management
Laparoscopic surgery has become the preferred approach for managing peritoneal inclusion cysts due to its minimally invasive nature, faster recovery, and lower complication rates compared to open surgery. The main goals of laparoscopic management include cyst excision, adhesion release, and preservation of ovarian and reproductive function.

Preoperative Considerations

• Detailed imaging to assess the extent and location of cysts

• Laboratory evaluation to rule out malignancy

• Counseling regarding risks of recurrence and fertility implications

Surgical Technique

1. Patient Positioning: The patient is placed in a lithotomy or supine position with Trendelenburg tilt for optimal pelvic exposure.

2. Port Placement: Standard laparoscopy ports are used, typically including a 10-mm umbilical port and two or three accessory 5-mm ports in the lower abdomen.

3. Adhesiolysis: Careful dissection of adhesions is performed using blunt and sharp techniques, often assisted by energy devices.

4. Cyst Identification and Excision: The cysts are carefully dissected from surrounding structures, including the ovary, bowel, and bladder, ensuring complete excision to minimize recurrence.

5. Specimen Retrieval: Cysts are placed in an endoscopic retrieval bag and removed to prevent spillage.

6. Peritoneal Lavage: The peritoneal cavity is irrigated to remove debris and prevent postoperative adhesions.

Postoperative Care

• Early ambulation to prevent adhesions and venous thrombosis

• Pain management with analgesics

• Monitoring for complications such as bleeding, infection, or recurrence

• Follow-up imaging in 6–12 months to ensure no residual or recurrent cysts

Advantages of Laparoscopy

• Minimally invasive with smaller scars

• Shorter hospital stay and faster recovery

• Reduced postoperative pain

• Better visualization of pelvic structures, allowing precise excision

• Preservation of fertility

Challenges and Considerations

• Dense adhesions may complicate dissection

• Risk of cyst rupture and fluid spillage

• Possibility of recurrence if adhesions are not adequately managed

• Requires advanced laparoscopic skills, especially in complex or large cysts

Conclusion
Laparoscopic management of peritoneal inclusion cysts offers a safe, effective, and fertility-preserving option for women affected by this condition. Thorough preoperative evaluation, meticulous surgical technique, and careful follow-up are key to reducing recurrence and ensuring optimal outcomes. With advancements in minimally invasive surgery, laparoscopy has become the gold standard for managing these challenging cystic lesions.