Laparoscopic Management of Tubo-Ovarian Abscess Refractory to Percutaneous Drainage

Abstract

<h3>Study Objective</h3> To demonstrate the feasibility and safety of a laparoscopic approach to a case of tubo-ovarian abscess (TOA) refractory to percutaneous drainage and antibiotic therapy. <h3>Design</h3> Case report. <h3>Setting</h3> Operating room with traditional laparoscopy. <h3>Patients or Participants</h3> 30-year-old female patient with refractory TOA. <h3>Interventions</h3> Laparoscopic lysis of adhesions, bilateral salpingectomy, right oophorectomy, wash out and drain placement. <h3>Measurements and Main Results</h3> The patient is a 30-year-old female who presented with a 16cm TOA, initially managed with parenteral antibiotics and percutaneous drainage. However, despite initial improvement, the abscess continued to re-accumulate, refractory to a total of three percutaneous drain placements over the course of 8 weeks. She was taken to the operating room for laparoscopic resection of the TOA. Four port sites were utilized, three 5mm ports and one 10mm port. Survey of the pelvis revealed dense adhesions, bilateral pyosalpinx, and residual large abscess encompassing the right ovary. Given the patient's prolonged pre-operative course and her consent for loss of future fertility, the decision was made to proceed with bilateral salpingectomy and right oophorectomy. The right adnexal structures were densely adherent to the pelvic side wall and cul de sac; therefore, retroperitoneal dissection was utilized to identify important landmarks including the medial umbilical ligament, uterine artery and ureter in order to safely remove the diseased tissue without injuring the surrounding vital structures. The pelvis was irrigated and a JP drain was placed. She was discharged home on the same day. She had an uncomplicated post-operative course. Final surgical pathology revealed chronic and active salpingitis as well as focal endometriosis. <h3>Conclusion</h3> Laparoscopy is a safe and feasible surgical approach to the management of tubo-ovarian abscess refractory to percutaneous drain placement. The surgeon should be adept and familiar with retroperitoneal dissection to ensure safety of surrounding structures in the setting of dense adhesive disease and inflammation.