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Laparoscopic transverse colectomy with excision of para‐aortic retroperitoneal leiomyoma – A video vignette

We present a case of a 45-year-old, morbidly obese patient, who presented with an adenocarcinoma of the splenic flexure. She suffered from protracted diarrhoea and underwent a colonoscopy, which showed a sub-occlusive, circular, vegetative and ulcerative lesion approximately 50 cm from the anal verge. The biopsy identified an infiltrative ulcerative adenocarcinoma. A CT scan excluded metastasis of thoracic or abdominal cavity but did show two enlarged nodules, measuring about 2 cm in the para-aortic region, cranial to the inferior mesenteric artery. Lymph node metastasis was considered the most likely differential diagnosis based on the presenting disease and nodule location. She was scheduled for operation and a laparoscopic transverse colectomy with dissection of para-aortic nodules was performed. The postoperative course was uneventful and she was discharged on the seventh postoperative day. Histological evaluation showed a moderately differentiated, ulcerated adenocarcinoma (G2, pT3 N0 M0, R0). The para-aortic nodules were identified as leiomyoma with adjacent reactive lymph nodes. She was referred to the oncology department for further treatment of adenocarcinoma. While uterine leiomyoma affects 20-30 % of women older than 35 years, extrauterine presentation, such as retroperitoneal leiomyoma, is exceedingly rare. Several pathological mechanisms are speculated in their development and may include hematogenous or lymphatic spread. Radiological diagnosis can be difficult with differential diagnosis including other tumours of the retroperitoneum, metastasis or lymphadenopathy. History of uterine leiomyoma should raise the clinical suspicion for extrauterine disease. Magnetic resonance imaging and biopsy may aid in diagnosis of difficult cases.