Supernumerary ovary is a rare gynecological anomaly and is generally excised due to its potential malignant transformation. We report a case of a patient who was referred for excision of a probable duodenal duplication cyst that was subsequently identified as a paraduodenal supernumerary ovary. Pediatric surgery was consulted on an adolescent patient due to a presumed congenital anomaly of the intestinal tract based on imaging studies

Richard J. Scriven

Spyridon Pagkratis

Thomas Lee

Yousef El-Gohary

Journal of Pediatric Surgery Case Reports

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Supernumerary ovary presenting as a paraduodenal duplication cyst

AbstractSupernumerary ovary is a rare gynecological anomaly and is generally excised due to its potential malignant transformation. We report a case of a patient who was referred for excision of a probable duodenal duplication cyst that was subsequently identified as a paraduodenal supernumerary ovary. Pediatric surgery was consulted on an adolescent patient due to a presumed congenital anomaly of the intestinal tract based on imaging studies

El-Gohary, Yousef

Pagkratis, Spyridon

Lee, Thomas

Scriven, Richard J.

Elsevier - Publisher Connector 

Supernumerary ovary presenting as a paraduodenal duplication cyst 

Contents lists available at ScienceDirect
J Ped Surg Case Reports 3 (2015) 316e319Journal of Pediatric Surgery CASE REPORTS
journal homepage: www.jpscasereports.comSupernumerary ovary presenting as a paraduodenal duplication cyst
Yousef El-Gohary, Spyridon Pagkratis, Thomas Lee, Richard J. Scriven*
Department of Surgery, Division of Pediatric Surgery, Stony Brook Children’s Hospital, Stony Brook University Medical Center, 100 Nicolls Road, Stony
Brook, NY 11794, USAa r t i c l e i n f o
Article history:
Received 9 April 2015
Received in revised form
5 May 2015
Accepted 9 May 2015
Key words:
Supernumerary ovary
Accessory ovary
Duplication cyst* Corresponding author. Tel.: þ1 631 444 1791; fax:
E-mail address: richard.scriven@stonybrookmedici
2213-5766/ 2015 The Authors. Published by Elsevier
http://dx.doi.org/10.1016/j.epsc.2015.05.001a b s t r a c t
Supernumerary ovary is a rare gynecological anomaly and is generally excised due to its potential ma-
lignant transformation. We report a case of a patient who was referred for excision of a probable
duodenal duplication cyst that was subsequently identiﬁed as a paraduodenal supernumerary ovary.
Pediatric surgery was consulted on an adolescent patient due to a presumed congenital anomaly of the
intestinal tract based on imaging studies.
 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Ectopic ovaries, whether accessory or supernumerary, are an
extremely rare gynecological anomaly.Winckel et al. [1] reported the
ﬁrst case of supernumerary ovary in 1890. Since then about 44 cases
have been reported in the literature. The exact incidence is unknown
withWharton et al. [2] reporting one accessory ovary case in 93,000
gynecological admissions and ﬁnding only one supernumerary ovary
case in 29,000 autopsies performed. Patients are usually asymp-
tomatic, but may occasionally present with chronic abdominopelvic
pain, as was the case with the current case report. The pain pre-
sumably arises as a result of cystic or neoplastic transformation.1. Case report
A 20 year old female presented to the emergency department
(ED) with a two day history of epigastric and left upper quadrant
abdominal pain. Patient described the pain as non-radiating con-
stant pain that is associated with nausea and non-bloody diarrhea.
There were no associated fevers and patient was otherwise he-
modynamically stable. Patient’s last menstrual period was 2 weeks
prior to presenting to the ED. Lab work did not reveal any evidence
of leukocytosis or pancreatitis. Abdominal examwas unremarkable
apart from mild tenderness with no guarding in the epigastric re-
gion. An abdominal ultrasound was obtained in the ED, which
revealed an avascular cystic structure in the region of the tail of theþ1 631 444 7689.
ne.edu (R.J. Scriven).
Inc. This is an open access article upancreas (Fig. 1). For better characterization of the cystic structure,
an abdominal computed tomography was obtained (Fig. 2).
In view of the patient having persistent abdominal pain, asso-
ciated with an abnormal mass, a decision was made to surgically
excise the retroperitoneal cyst. A transverse left upper quadrant
was made and the mass was found to be palpable through the
transverse mesocolon. A Mattox maneuver was then performed to
reﬂect the colon to the right. The cystic structure was then visual-
ized in the retroperitoneal location adherent to the duodenum, butFig. 1. Ultrasound image revealing a 3.4  2.8  2.6 cm avascular cystic structure in the
pancreatic tail region.
nder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Fig. 2. CT axial (A), coronal (B) and sagittal (C) images revealed a 3.5 cm probable duplication cyst abutting the posterior wall of the third segment of the duodenum. No evidence of
bowel obstruction or bowel wall thickening.
Table 1
Published cases of supernumerary ovary.
Case Author(s) Year Age (years) Location Neoplasm/Histopathology
1 Winckel [1] 1890 77 Anterior uterine wall N
2 Falk [17] 1891 37 Omentum N
3a Kriss [18] 1947 49 Infront of uterus to the right Y/Granulosa cell carcinoma
3b Kriss [18] 1947 34 Lateral to the right ovary Y/Serous cystadenoma
4 Nicols and Postoloff et al. [19] 1951 36 Area of congenitally absent right kidney N
5a Wharton [2] 1956 37 Retroperintoneal right pelvic wall N
5b Wharton [2] 1957 39 Retroperitoneal sigmoid mesentery N
6 Wharton [2] 1959 20 Left of aorta N
7 Burnett [20] 1961 e Retroperitoneal between left ureter and rectosigmoid N
8 Pearl and Plotz [13] 1963 34 Inferolateral to left uterosacral ligament N
9 Hogan et al. [21] 1967 21 Omentum Y/Cystic teratoma
10 Williams et al. [22] 1971 26 Retroperitoneal in right iliac fossa N
11 Printz et al. [14] 1973 23 Omentum Y/Cystic teratoma
12 Arzapalo et al. [23] 1974 19 Left adnexal area N
13 Huhn [24] 1975 e Omentum Y/Cystic teratoma
14 Abrego [25] 1975 38 Distal ileal mesentery N
15 Kosasa et al. [26] 1976 31 Retroperitoneal left pelvic side wall N
16 Roth and Ehrlich [27] 1977 48 Left retroperitoneal space Y/Papillary Mucinous
cystadenocarcinoma
17 Cruikshank and Van Drie [28] 1982 33 Pelvic mass attached to descending colon N
18 Cruikshank and Van Drie [28] 1982 36 Left retroperitoneal, para-renal area Y/Mucinous cystadenoma
19 Poma [29] 1982 50 Left infundibulopelvic ligament N
20 Lee and Gore [30] 1984 30 Attached between left tubal ﬁmbria and rectosigmoid N
21 Hahn-Pedersen
and Munkholm [31]
1984 20 Connected by ﬁbrous ring to left ovary N
22 Mercer et al. [32] 1987 36 Broad ligament, 2 cm caudad to right ovary N
23 Mercer et al. [32] 1987 34 Omentum Y/Cystic teratoma
24 Harlass et al. [33] 1987 37 Anterior descending colon N
25 Navarro et al. [34] 1990 38 Left paracolic gutter N
26 Alpern [35] 1990 40 Retroperitoneal right pelvic side wall N
27 Cruikshank [36] 1991 37 Retroperitoneal left pelvic side wall N
28 Barik et al. [37] 1991 e e Y/Adenocarcinoma
29 Besser and Posey [38] 1992 47 Omentum Y/Cystic teratoma
30 McCullough [39] 1992 27 Serosal surface at junction of uterus and cervix N
31 Badawy et al. [40] 1995 32 Left pelvis side wall over liopsoas muscle N
32 Levy et al. [41] 1997 51 Right upper renal pole N
33 Kini et al. [42] 1998 5 Left upper renal pole N
34a Kuga et al. [15] 1999 1/12 Omentum N
34b Kuga et al. [15] 1999 1/12 Omentum N
35a Kamiyama et al. [43] 2001 47 Omentum Y/Fibroma
36b Kamiyama et al. [43] 2001 28 Anterior wall of uterus N
37 Litos et al. [44] 2003 32 Retroperitoneal medial aspect of descending
colon anterolateral psoas muscle
N
38 Sonntag et al. [45] 2005 30 Retroperitoneal, caudal pole left kidney Y/Mucinous adenocarinoma
39 Hartigan et al. [16] 2006 32 Right intrarenal upper pole N
40 Imir et al. [46] 2006 30 Sigmoid colon N
41 Zhigang and Wenlu [47] 2007 43 Intrarenal upper pole right N
42 Matsubara et al. [48] 2009 31 Mesentery of rectum N
43 Nomelini et al. [49] 2013 64 Retrouterine Y/Serous papillary cystadenocarcinoma
44 Bae et al. [12] 2013 31 Retroperitoneal left pelvic side wall Y/Serous papillary carcinoma
Y. El-Gohary et al. / J Ped Surg Case Reports 3 (2015) 316e319 317
Y. El-Gohary et al. / J Ped Surg Case Reports 3 (2015) 316e319318did not appear to be a duplication cyst. Pathology revealed benign
ovarian parenchyma, with hemorrhagic corpus luteum and cystic
follicles consistent with a supernumerary ovary.2. Discussion
There are numerous examples of congenital anomalies pre-
senting beyond the adolescent period such as malrotation [3],
foregut duplication cysts [4], Morgagni hernia [5,6], choledochal
cyst, and Hirschsprung’s disease [7]. Adult surgeons infrequently
encounter these congenital anomalies. This sometimes necessitates
the expertise of pediatric surgeons, who are more accustomed to
these anomalies compared with adult surgeons. Infantile hyper-
trophic pyloric stenosis (IHPS), which is the most common surgical
condition causing emesis in infancy, is an example of a pediatric
surgical condition that has been reported to be operated on by adult
surgeons in peripheral hospitals [8,9]. However, it has been
demonstrated that when IHPS is operated on in a specialized ter-
tiary center, that the infection rate and hospital stay are signiﬁ-
cantly less [10].
Here we report a case of a patient found to have a supernu-
merary ovary resembling a paraduodenal duplication cyst. Super-
numerary and accessory ovaries are an extremely rare
gynecological anomaly [11]. Although rare, they need to be excised
due to their malignant potential [12]. The term ‘supernumerary
ovary’ is deﬁned as a third ovary that is entirely separate from the
normally placed ovaries. Whereas the term ‘accessory ovary’ is
deﬁned as excess ovarian tissue that is invariably situated near the
normally placed ovary, which may or may not be connected to it
[12]. Histological diagnosis of an accessory or supernumerary ovary
requires demonstration of ovarian follicles. Imaging studies of the
cystic structure around the third portion of the duodenum were
interpreted in this 20 year old patient as most probably a duodenal
duplication cyst. Pediatric surgery was consulted for excision for a
presumed intestinal congenital malformation.
There have been two theories that have been postulated with
regards to the development of the supernumerary ovary. Firstly, the
“arrested gonocyte migration” theory, where the gonocyte’s
migration arrests as they migrate retroperitoneally through the
dorsal mesentery [13]. Secondly, the “transplantation” theory of the
germinal ridge following incorporation of the gonocyte [14]. From
these proposed mechanisms, supernumerary ovaries tend to be
located retroperitoneally as is the case with our current case report.
Other reported locations include the pelvis, para-aortic, omentum,
intrarenal, bladder and colonic mesentery [15,16]. Supernumerary
ovaries are often incidentally found, and thus underreported,
however they may also be painful, functional, multiple or associ-
ated with other congenital malformations of the genitourinary
system [12]. Table 1 lists the previously reported case reports on
supernumerary ovaries along with their location and histopatho-
logical description, whether benign or malignant.3. Conclusion
Although this is a rare gynecological anomaly, we recommend
complete excision of these cysts for accurate pathologic diagnosis
and to eliminate risk of malignant transformation (See Table 1).References
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Supernumerary ovary presenting as a paraduodenal duplication cyst

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