Pelvic Abscess: Surgical Drainage and Inevitable Problems
Pelvic abscess is not among the common gynecologic emergencies encountered by a practicing gynecologist today. Most emergencies are obstetrical in nature. The commonest cause of acute abdomen encountered by a gynecologist is probably ectopic pregnancy followed by ovarian torsion. Therefore, pelvic abscess requires a high index of suspicion for diagnosis. In addition, inappropriate antibiotic therapy may have masked abdominal pain, fever and leukocytosis. Whenever there is a significant collection of pus, drainage is the rule. Conservative treatment can lead to the pus getting organized causing chronic PID and intestinal obstruction. Also glycemic control in diabetic patients is not possible till pus is drained. Image-guided drainage may not be available in all centers. Surgical exploration not only facilitates drainage of pus but also the release of bands, which eventually get organized and can cause intestinal obstruction. While operating, one has to keep in mind that visceral organs are inflamed and dissection has to done very gently and preferably by the sharp method. Presence of pus makes the bowel walls friable and more prone to injury. The result of repair of a bowel rent is likely to be poor, when the bowel wall is inflamed. The peritoneal cavity has to be thoroughly explored and all locules of pus have to be drained. Temptation of excising any organ (uterus, fallopian tubes or the ovaries) has to be resisted. The dissection planes will not be delineated due to induration and chances of ureteric injury and profuse bleeding are high. One has to thoroughly drain all the collection and give a good lavage to remove all the necrotic material and debris. The abdomen should be closed by delayed primary closure with a drain in situ. The skin closure can be done after anemia and hypoproteinemia have been corrected and diabetes controlled, and healthy granulation tissues have formed all along the wound.