Recurrent massive ascites due to mossy endometriosis

Hemorrhagic ascites associated with endometriosis is rare. This video article depicts the laparoscopic treatment of a 26-year-old woman with 7 L of ascites and diffuse moss-like endometriosis and reviews the current literature.

Volume 106, Issue 6, Pages e14-


Erica C. Dun, M.D., M.P.H., Serena Wong, M.D., Nisha A. Lakhi, M.D., Ceana H. Nehzat, M.D.



To report the medical and surgical management of a rare case of recurrent moss-like endometriosis and associated hemorrhagic ascites.


Video description of the case, demonstration of the surgical technique, discussion of the histology, and review of endometriosis-associated ascites.


Tertiary referral center.


A 26-year-old nulliparous woman of Nigerian heritage with recurrent hemorrhagic ascites due to endometriosis. Three years previously she underwent an exploratory laparotomy for similar symptoms, and 7 L of hemorrhagic ascites were evacuated from her abdomen. Friable lesions covering the peritoneum of the uterus, bladder, and pouch of Douglas were biopsied and consistent with endometriosis. After her initial surgery, the patient was hormonally suppressed with goserelin for 3 months and oral medroxyprogesterone for 1 year. She then stopped the medications to attempt pregnancy but was unsuccessful. She used clomiphene for 3 months, and the ascites reaccumulated. The patient was started on depot leuprolide and oral norethindrone, but the ascites persisted.


The patient underwent small-diameter laparoscopy using a multipuncture technique, evacuation of 7.8 L of hemorrhagic ascites, enterolysis, appendectomy, chromopertubation, and treatment of the endometriosis.

Main Outcome Measure(s)

Diffuse olive-green “mossy” endometriosis lesions blanketed the pelvic and abdominal peritoneum. The endometriosis was surgically resected with a combination of peritoneal stripping, excision with carbon dioxide laser, and ablation with neutral argon plasma. Examination of the ascites showed scattered hemosiderin-laden macrophages in a background of red blood cells. Histology of the olive-green mossy lesions revealed dense sheets of hemosiderin-laden macrophages and rare foci of endometriosis. Surgical reports in deidentified patients are exempted from Institutional Review Board approval. The patient gave consent to use photography and images for the video article.


No postoperative hormone suppression was given to the patient because she desired pregnancy. At 6 months after her second surgery, the patient had not achieved pregnancy, but the ascites had not reaccumulated. She was referred for further infertility care.


This rare form of mossy endometriosis often mimics ovarian cancer, pelvic tuberculosis, and other gynecologic conditions, but when identified, the endometriosis can be treated and symptoms can subside with drainage of the ascites, thorough ablation of the diffuse, superficial lesions, and restoration of anatomy.

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