Minimally Invasive Surgical Approach to Tubo-Ovarian Abscess in Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) Syndrome

Abstract

<h3>Study Objective</h3> We present a case of an acute presentation of tubo-ovarian abscess in the setting of Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) syndrome in a non-sexually active adolescent, and demonstrate the surgical principles and techniques used int the management of the tubo-ovarian abscess and obstructed hemivagina/septum. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> Vaginoscopy and four port laparoscopy. <h3>Patients or Participants</h3> An adolescent female who has never been sexually active, presenting with a tubo-ovarian abscess on a background of OHVIRA syndrome. <h3>Interventions</h3> Vaginoscopy for identification of patent cervix and vaginal septum, laparoscopic drainage of tubo-ovarian abscess, adhesiolysis, and right salpingectomy, vaginoscopic septal resection with monopolar Collins knife. <h3>Measurements and Main Results</h3> A 15-year-old female, who had never been sexually active, presented with lower abdominal pain, fevers and malodorous vaginal discharge. Imaging of the pelvis demonstrated a right tubo-ovarian abscess of 5.8 × 4.7 × 5.8cm, uterine didelphys, obstructed right vaginal cavity, and right renal agenesis, suggesting OHVIRA syndrome. Medical management with intravenous antibiotics was unsuccessful, and the patient was managed surgically in a minimally invasive manner. Vaginoscopy identified a normal left cervix, and a small perforation was noted in the vaginal septum. Laparoscopy revealed a right sided tubo-ovarian complex adherent to the right pelvic side wall, bowel, and omentum. Blunt dissection and electrosurgical techniques were used to adhere to tissue planes. Drainage of multiple collections and a subsequent right salpingectomy was performed. A monopolar Collins knife was used with the vaginoscopy to resect the vaginal septum. The patient recovered well and was discharged shortly after her procedure. <h3>Conclusion</h3> Vaginoscopic septal resection is feasible in the setting of OHVIRA syndrome and in non-sexually active patients. Pre-operative imaging allows correct diagnosis of OHVIRA and assist in surgical planning. Care must be taken in tissue dissection to avoid injury.