and Jyothi G Seshadri2
Finding pus in the abdomen and pelvis can be a surprise finding on table. Adnexal mass, torsion of a subserosal fibroid or ovarian tumor, appendicitis, etc. are conditions which can present in a similar manner and can lead to delay in the diagnosis of pelvic abscess [1, 2].
Sometimes pelvic abscess can be a confident preoperative diagnosis. Diabetics with history of poor glycemic control, history of PID, lack of asepsis during uterine evacuation or during delivery, are known causes of pelvis abscess [1, 2]. There could be fever, abdominal pain, and tenderness. Leukocytosis will always be present, unless inappropriate antibiotic treatment has been given.
So, whenever the diagnosis is uncertain, one must either take a vertical incision or must put a laparoscope and see. Colpotomy or image-guided aspiration is confirmatory; finding pus on aspiration is diagnostic of an abscess inside the peritoneal cavity, but should colpotomy be used to treat pelvic abscess? Colpotomy can only drain pus collected in the pouch of Douglas and not of the loculated pus elsewhere in the peritoneal cavity. Also, the rectum may be adherent to the posterior uterine surface, and colpotomy in such a situation may result in rectal injury [3]. Thus it is better to open and see and drain everything out.
There could be locules of pus even under the diaphragm and sub-hepatic space. The bowel loops will be agglutinated to each other if the pus has spread beyond the pelvis, and the omentum (“Policeman of the Abdomen”) would have contained the pus. So one can expect the bowel walls to be inflamed and every effort has to be made to avoid injury. The results of repair on an inflamed bowel will obviously be very poor.
When pus is seen pouring out, take samples for culture, and then irrigate the abdominopelvic cavity with copious amounts of saline. Suction the collected fluid, taking care not to traumatize any organ with the suction cannula. Even gentle rubbing movements on the bowel can lead to a bowel rent. Use sharp dissection to separate the flimsy bowel adhesions. Divide the omentum which would have localized the pus, release all the locules of pus and inflammatory fluid. Examine the paracolic gutters, sub-diaphragmatic spaces, and the under surface of the liver. Gently break all the locules of pus, and release the collected fluid. Never forget to gently probe the pouch of Douglas. The pouch of Douglas being the most dependent part of the peritoneal cavity will have collected pus, which could be in encysted locules. Do not use force, lest the rectum gets damaged, and colostomy becomes necessary. If the diagnosis has been delayed for any reason, the flimsy adhesion will start getting organized making their release even more difficult and bowels are then more prone to injury.
Never perform a hysterectomy or any destructive procedure in the presence of pus. There will be lot of edema, induration, and planes will not be well delineated. The chances of ureteric and other vital organ injuries are high. Just drain the pus and remove all the necrotic material, thoroughly irrigate the entire peritoneal cavity with copious amount of saline and close. Before closing, trace the entire small intestine from duodenojejunal flexure to the ileocecal junction. Check the caecum, transverse, sigmoid, and rectum for any injuries. If there are any bands which are still intact, gently break them; use sharp dissection if the bands are getting organized and do not separate easily. If the bands and purulent flakes get organized, it can lead to intestinal obstruction [4]. Do not leave agglutinated loops of bowel unattended on grounds that the loops appear intact; patient may have vomiting and subacute bowel obstruction in the immediate postoperative period itself. The author has an experience of a case where the patient had to be taken for reexploration because pus reappeared in the drain on the third postoperative day. On table, one large locule of pus was still found intact. In a hurry to finish the case, one locule was overlooked and had not been drained.
As a rule of thumb, the author prefers closing cases of pelvic abscess (probably the only condition in gynecology where there is a dirty/contaminated wound) by delayed primary closure [5, 6].
In this method, the peritoneum is closed, followed by rectus sheath. The author does not prefer mass closure for vertical incisions because should the suture give way at any point, it will result in burst abdomen [7]. But if the peritoneum and the rectus sheath are closed separately, even if the rectus sheath suture gives way (let us say due to tissue necrosis and infection), there will be an intact peritoneum that will prevent burst abdomen. However, if factors which raise the intra-abdominal pressure like coughing, vomiting, straining, etc. are not controlled in the postoperative period, then the risk of burst abdomen is very high irrespective of the type of closure.
The skin is not closed. The wound is packed with gauze soaked in povidone iodine and changed daily. The skin is closed after anemia, dyselectrolytemia, and hypoproteinemia have been corrected by blood and albumin transfusions, and diabetes if present is also brought under control [8]. This is usually after a week. The patient would have passed stools and would have tolerated soft diet by then.
Delayed primary closure was widely used during the pre-antibiotic era, but now with growing antibiotic resistance, it is time this approach is adopted more often in situations when the possibility of wound gape is high or almost certain. This method does not reduce the incidence of incisional hernia and late intestinal obstruction due to adhesions, but certainly reduces hospital stay, treatment costs, and the use of antibiotics. The question of wound gape does not arise since the closure is done only after control and correction of associated risk factors (like anemia, hypoproteinemia, and diabetes mellitus), and after healthy granulation tissue has formed all along the wound. Delayed primary closure should not be confused with open abdomen. Open abdomen is a defect created intentionally by not closing the incision after completion of surgery; or the abdomen is opened or reopened out of concern that the patient is developing abdominal compartment syndrome.
In delayed primary closure, the rectus sheath is closed; it is the skin closure which is deferred by a few days. The wound is dressed daily with gauze soaked in povidone iodine. This improves blood supply by hygroscopic action. Also, the act of draining pus by releasing all adhesions and braking of locules will lead to bacteremia in the immediate postoperative period. The chances of wound dehiscence will be high.
By deferring the closure of skin by a week, the chances of wound healing would have greatly improved on account of better blood supply to the wound margins and control of risk factors.
Now let us study some photographs taken during live surgery of cases of pelvic abscess. The photographs are grouped in the following sequence—precautions while opening the peritoneum, separating the loops of bowel and releasing the bands, entering the pelvis and draining locules of pus, looking for hidden pockets and locules, examining and checking for injuries before closure, and finally delayed primary closure of the abdomen.
Opening the Abdomen in a Case of Pelvic Abscess (Figs. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, and 8.7a, b)
Fig. 8.1
Fig. 8.2
Fig. 8.3
Fig. 8.4
Fig. 8.5
Fig. 8.6
Fig. 8.7a
Pus immediately below the peritoneum (Fig. 8.2), collect a sample for culture and sensitivity.
Figure 8.3 is an image from another case. The peritoneum has been opened. Purulent flakes can be seen and appreciated. The inflammatory fluid is seen pouring out. Avoid sticking the suction cannula deep inside. Bowel walls could be very friable and can get torn even by a slight jerk. Dip the suction cannula into the pool of fluid, so that the tip is visible. Take care to ensure that the omentum or the bowel wall do not get sucked into the cannula and get injured.
Figure 8.4 is another example of a pelvic abscess. Peritoneum has been opened taking care not to injure any structure. The incision length may not be enough. Extend the incision, and drain the collected fluid with the help of a suction cannula. Avoid inserting the tip of the suction cannula deep into the collection. The tip of the cannula must be visible while suctioning. There could be an inflamed friable organ deep inside the collected fluid that can get damaged by rough movements of the cannula .
The edematous loops of intestine are seen directly under the peritoneum (Fig. 8.5). The peritoneum has been opened with care. The bowel loops are agglutinated to one another and the abdominal wall. One has to gently release them lest the bands get organized and cause intestinal obstruction later.
In Fig. 8.6, the peritoneum is being opened with great care; pus is seen inside, and one must expect inflamed bowels and pelvic organs and must proceed with caution.
Pus is getting organized and the bowels have become adherent to the overlying parietal peritoneum (Fig. 8.7a).
In Figs. 8.2, 8.3, and 8.4 one can see there is a lot of fluid in the abdominal cavity. This in a way protects the bowel from getting injured during opening of the peritoneum. The bowels by virtue of floating in the collected fluid will get pushed away if subjected to some force during opening of the peritoneum. Figure 8.7a is from a patient who was obese and diabetic, and the patient had presented late. One can see that the peritoneum has not been fully opened yet, but it is obvious that there is a lot of pus inside. The omentum can be seen forming a cake. The small intestine loop with purulent flakes can be seen below, and it is stuck to the overlying peritoneum. Operating on a case of pelvic abscess means pausing at every step to carefully check what is there, and then proceeding again with caution. Injuries are almost always due to lack of caution, unlike let us say endometriosis where let us say resection anastomosis of affected bowel segment is intentionally performed to remove every visible trace of the disease.
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