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Blunt abdominal trauma resulting in ovarian mucinous
cystadenoma rupture
A fit and well 24-year-old nulliparous female was a restrained, rear
seat passenger in a high-speed motor vehicle accident. On arrival
by ambulance to a tertiary trauma centre emergency department,
she was alert and orientated, tachycardic (heart rate of 120) with
stable blood pressure (135/100), normal respiratory vital signs
(respiratory rate 16, oxygen saturation 99% on room air) and afe-
brile (temperature 36.9). On examination, she had a moderately dis-
tended abdomen with guarding, exquisitely tender in both lower
quadrants with signs consistent with seatbelt injury.
Laboratory investigations revealed a haemoglobin of 137 g/L,
white cell count of 14.8 × 109/L, negative human chorionic gonado-
tropin and unremarkable serum biochemistry and liver function tests.
An extended focused assessment with sonography for trauma demon-
strated a moderate amount of fluid in Morrison’s pouch and pelvis.
Chest and pelvic X-rays were unremarkable. A trauma series com-
puted tomography (CT) scan (Fig. 1) revealed lower anterior abdomi-
nal wall bruising, moderate amount of low-density intraperitoneal free
fluid, a large ovarian cystic lesion and appearance highly suspicious
of ruptured cystic lesion adjacent to this. Pneumoperitoneum was not
seen on CT, but a left L1–L3 transverse process fracture was also
noted.
Owing to ongoing tachycardia and generalized peritonism with
abdominal distension, she underwent a trauma laparotomy. Upon
breaching the peritoneum via a midline incision, there was extravasa-
tion of over 2 L of free mucin which was slightly blood-stained with
no enteric, bilious or faecal contents. A ruptured left ovarian cystic
sac was noted together with another intact large left ovarian cyst
(Fig. 2). Meticulous and systematic exploration revealed no further
abnormality nor hollow viscus injury. An ovarian cystectomy and
copious peritoneal lavage were performed. Samples of mucin and
Fig 1. Computed tomography of the abdo-
men and pelvis showing right lower anterior
abdominal wall bruising, moderate intraperito-
neal free fluid, intact large ovarian cystic lesion
measuring 9 × 8 × 11 cm (Anterior-
Posterior × Medial-Lateral × Superior-Inferior)
and multiple wavy enhancing septa (red
arrows) adjacent to the cyst in the right
iliac fossa highly suspicious of a separate
ruptured cystic lesion. (a) Axial view and
(b) coronal view.
© 2020 Royal Australasian College of Surgeons
peritoneum were taken for cytology and histology, in addition to the
cystectomy specimen. The findings were consistent with a left ovarian
mucinous cystadenoma with no evidence of malignancy.
The patient had an uneventful recovery and was discharged
4 days post-operatively with gynaecology follow-up.
In patients with blunt abdominal trauma, identification of intra-
abdominal injuries is often challenging. The most commonly
injured abdominal organs are the spleen, liver, kidneys and bowels.
To our knowledge, this is the first case report of a traumatic large
ovarian mucinous cystadenoma rupture.
Ovarian mucinous cystadenomas are benign, non-invasive intra-
epithelial tumours that display cellular atypia without stroma inva-
sion. They are considered the most common benign ovarian
neoplasm (20–25%) and comprise of approximately 80% of all
mucinous ovarian tumours.1 They are likely to be unilateral,
multicystic and large.2 Histologically, a single layer of columnar
cells with abundant intracellular mucin and small basilar nuclei
lines the cysts.1 Most of these tumours are asymptomatic and usu-
ally found incidentally or when it is given time to grow extensively
in low-resource settings resulting in late presentations.3,4 They are
associated with excellent prognosis and can be managed conserva-
tively with serial surveillance ultrasound examinations to ensure
stability and monitor for suspicious malignant changes. However,
they often require resection for histological confirmation or their
mass effect causing persisting symptoms.
In this case, the preoperative CT images raised suspicions of an
ovarian mucinous cystadenoma rupture, while the intraoperative
finding of abundant intra-abdominal mucinous material confirmed
it. Differential diagnoses include mucinous ovarian carcinoma,
appendiceal mucocele rupture and pseudomyxoma peritonei
ANZ J Surg (2020)
2 Images for surgeons

Fig 2. Ruptured left ovarian cystic sac with adjacent existing cystic structure. (a) Lateral view, black arrows indicating edges of ruptured cystic sac. (b) Fron-
tal view, white arrow showing intact ovarian cyst.

syndrome. As such, when encountering intra-abdominal mucinous 2. Hoffman MS, Hochberg L. Differential diagnosis of the adnexal mass.
fluid, it is imperative to conduct a meticulous intra-operative explo- In: Eckler K (ed). UpToDate. Waltham, MA: UpToDate, 2019. Available
ration of the abdominal cavity to identify any organ abnormalities from URL: https://www.uptodate.com/contents/differential-diagnosis-of-
or deposits, or further mucoid fluid accumulations. the-adnexal-mass
3. Gwanzura C, Muyotcha AF, Magwali T. Giant mucinous cystadenoma: a
In conclusion, this is the first described case of a traumatic ovar-
case report. J Med Case Reports 2019; 13: 181.
ian mucinous cystadenoma rupture. It highlights the importance of
4. Kamel RM. A massive ovarian mucinous cystadenoma: a case report.
the awareness of blunt abdominal traumatic injury of a Reprod. Biol. Endocrinol. 2010; 8: 24.
gynaecological nature. In addition, the presence of intra-abdominal
mucinous fluid during surgery warrants thorough examination of
the abdominal cavity and sampling of tissues for histological diag- Tze Wei Wilson Yang, MBBS, MS (Sc)
nosis. Close follow-up is necessary due to the potential for develop- Ee-Jun Ban, MBBS, FRACS
ing the morbid complication of pseudomyxoma peritonei. James C. Lee, MBBS, FRACS, PhD
Informed consent was obtained from the patient for publication Jonathan Serpell, MBBS, MD, MEd, FACS, FRACS, FRCSEd (ad
of this case study report. hom)
Karishma Jassal, MBBS, FRACS
Department of General Surgery, Breast and Endocrine Unit, Alfred
References Hospital, Melbourne, Victoria, Australia
1. Hart WR. Mucinous tumors of the ovary: a review. Int. J. Gynecol. Pat-
hol. 2005; 24: 4–25. doi: 10.1111/ans.16045

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