This video demonstrates a minimally invasive stepwise approach to surgical management of the tubo-ovarian abscess. Patient characteristics with high likelihood of requiring surgical intervention for TOA and considerations for pre-operative optimization are reviewed. Three novel surgical techniques are illustrated to help avoid intra-operative complications, particularly involving the bowel. ‘Gravity for traction’ with sharp dissection, gentle interrogation of tissue planes and ‘tissue plane surfing’ are demonstrated to achieve normalization of anatomy and surgical goals. The role of salpingectomy in fertility and non-fertility cases is also explored.
University of Calgary, McMaster University
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Video Transcript: Minimally Invasive Surgical Management of Tubo-Ovarian Abscess
This video describes the Minimally Invasive Surgical Management of the Tubo-ovarian Abscess. The objectives are to identify TOA patients’ likelihood of requiring surgical intervention, discuss pre-operative optimization, highlight novel surgical techniques unique to TOA, and review the role of salpingectomy in the prevention of long-term sequelae.
Literature on the management of TOA is sparse, with studies suggesting a wide range of success with antibiotics and drains alone. But success is poorly defined, with factors including underlying endometriomas, post-IVF treatment TOAs, and fertility desire, which are rarely taken into account as positive predictors for surgical intervention.
We divide surgical intervention into immediate or delayed, depending on risk factors and response to treatment. Immediate intervention may benefit patients with fertility desire or those presenting with TOA post-IVF or IUI. Whereas delayed surgery, from weeks to months from initial admission, is ideal for patients with endometriosis or with interim stabilization allowing for future definitive surgical intervention.
In all cases of TOA, a comprehensive management approach is required. Initial management hinges on IV antibiotics. Blood cultures should also be drawn, and consultation with Infectious Disease should be completed in the case of atypical pathogens. CT imaging is the modality of choice for diagnosis and potentially for drain insertion. The patient should be adequately resuscitated with all attempts made to correct coagulopathy, hyperglycemia and anemia. With surgical intervention, an MIS-driven laparoscopic approach is ideal, with a frank and clear discussion of realistic surgical goals.
Fertility, including the role of IVF following salpingectomy, needs to be discussed, with hysterectomy excluded in an acute situation. Planning for surgery is critical, with expectations of long operative times and required support from Anaesthesia, Colorectal Surgery and possibly our ICU colleagues. Timing should aim for a weekday, with ample support available.
We now present a stepwise approach to minimally-invasive surgery for TOA.
All cases must begin with abdominal entry at Palmer’s point. Given these abdominal findings, an umbilical entry would almost certainly result in bowel injury.
Step 2: Adhesiolysis with Modification to Traditional Techniques
The first placement of any single accessible operative port should be completed. Here we demonstrate using gravity for traction in the surgical management of TOA. Note the gentle placement of the grasper, providing almost no counter-traction and allowing the bowel to simply hang by gravity. Gentle interrogation of tissue planes allows for controlled dissection without inadvertent injury to friable tissues.
Step 3: The Normalization of Anatomy
Adhesiolysis allows safe and clear delineation of anatomy, and further port placement should not be completed until this has been achieved. Again, we show dissection using gravity for traction to allow for the normalization of anatomy. Ports are best placed as the case unfolds. As adhesiolysis is performed, space is created, revealing the anterior abdominal wall, and trocars can be safely inserted.
Step 4: Identification of Anatomic Structures
Following the normalization of anatomy and ongoing adhesiolysis, the identification of anatomic structures can be exceedingly challenging. The bladder is identified as overlying the uterus, and the boundaries of the bladder are confirmed with cystosufflation. Step 5. Drainage of pelvic abscess. Access to abscess collections and drainage is key for patient improvement. This is aided by pre-operative image-guided drain placement for localization of the abscess. Once the drains are visualized, gentle exploration of the tissues in the area often allows for drainage. Copious irrigation follows.
In another example of abscess drainage, once anatomic planes are identified, tissue plane surfing can be used to isolate known structures and access abscess cavities. This is done with the use of a blunt instrument, which is gently skimmed across the inflamed tissues in a parallel fashion to open the abscess cavity. Lastly, Step 6. Consideration of salpingectomy. Here we demonstrate the complexity of a salpingectomy in the case of a severe TOA. We recommend that a bilateral salpingectomy be considered in patients without a desire for future fertility, those who present with a post-fertility-procedure TOA, and patients with known endometriomas.
For patients with desired ongoing fertility, individualized decision-making regrading IVF and informed surgical consent is essential. Fertility may be improved for those with acute onset TOA and for those who receive early intervention. Spontaneous pregnancy rates following TOA, however, are not impressive, with data estimating this from a low of 32% to a high of 63%.
In conclusion, careful pre-operative planning by an MIS team and anticipation of populations at risk for surgical intervention in TOA are critical. The use of novel laparoscopic surgical techniques, including gravity for traction, sharp dissection with gentle interrogation of tissue planes and tissue plane surfing, helps to avoid intraoperative complications. The role of salpingectomy should be individualized, with recognition of long-term sequelae, including infertility, ectopic pregnancy and chronic pain, without dedicated surgical intervention.