Ovarian Surgery
7 min read

Stepwise Approach to Complex Tubo-Ovarian Abscesses

Last updated:

Table of Contents

Video Description

This video demonstrates a systematic surgical approach to managing intricate tubo-ovarian abscesses, emphasizing precision and patient care.

Presented By

Female doctor avatar
Dr. Kinshuk Kumar
Female doctor avatar
Dr. Sarah Freeman
Female doctor avatar
Dr. Mary Melchior
male doctor avatar
Dr. Brian Liu

Affiliations

University of Toronto St. Joseph’s Unity Health Toronto

Watch on YouTube

Click here to watch this video on YouTube.

What is Stepwise Approach to Complex Tubo-Ovarian Abscesses?

The stepwise approach to managing complex tubo-ovarian abscesses involves a systematic method to ensure effective treatment and resolution:

  • Initial Assessment: Begin with a thorough history and physical examination to identify symptoms such as abdominal pain, fever, or masses.
  • Diagnostic Imaging: Utilize ultrasound for initial detection and assessment of the abscess. A CT scan may be employed for detailed visualization and to guide treatment planning.
  • Laboratory Tests: Perform blood tests to evaluate infection markers and obtain cultures from the abscess to identify pathogens and tailor antibiotic therapy.
  • Antibiotic Therapy: Initiate broad-spectrum antibiotics to cover common pathogens, adjusting based on culture results and sensitivities for targeted treatment.
  • Drainage: Attempt percutaneous drainage for accessible abscesses. If the abscess is complex or percutaneous methods are unsuccessful, surgical drainage may be required.
  • Supportive Care: Manage pain with appropriate analgesics and maintain fluid and electrolyte balance to support overall patient health.
  • Follow-Up: Monitor the patient with regular imaging and clinical evaluations to assess response to treatment and make necessary adjustments.
  • Address Underlying Causes: Investigate and treat any underlying conditions or risk factors, such as pelvic inflammatory disease (PID) or endometriosis, to prevent recurrence and ensure comprehensive care.

What are the Risks of Stepwise Approach to Complex Tubo-Ovarian Abscesses?

The stepwise approach to complex tubo-ovarian abscesses involves risks such as:

  • Missed Diagnosis: Symptoms may overlap with other conditions.
  • Radiation Exposure: CT scans involve radiation risks.
  • Inaccurate Cultures: Cultures might fail to identify the correct pathogen.
  • Antibiotic Resistance: Broad-spectrum antibiotics can lead to resistance.
  • Invasive Procedure Risks: Drainage may cause infection, bleeding, or injury.
  • Side Effects: Pain management and fluids can have adverse effects.
  • Inadequate Follow-Up: Poor monitoring can lead to complications.
  • Overlooked Conditions: Underlying issues might be missed or inadequately treated.

Managing these risks requires careful planning, monitoring, and adaptation of the treatment approach based on the patient’s response and any emerging complications.

Video Transcript: What are the Risks of Stepwise Approach to Complex Tubo-Ovarian Abscesses?

This video presents a stepwise approach to the management of complex tubo-ovarian abscesses. The objectives are to describe the importance of early intervention and management of TOAs, identify the role of surgery in managing TOAs and use an organised approach to surgically manage TOAs. TOAs are polymicrobial infectious masses of the adnexa and a complex sequela of PID. Failure to treat early can lead to long-term complications. Surgery is considered if the patient’s clinical status is not improving within 48 to 72 hours of conservative management, rupture of abscess is suspected or the diagnosis is unclear. Timely surgical intervention is critical to avoid encountering dense fibrotic adhesions that develop over time. Earlier intervention is associated with shorter hospitalisation, lower rates of readmission, less blood loss, shorter OR time and a fourfold higher pregnancy rate. We will begin with a case presentation. Our patient is a 26-year-old gravida 0 female, who presented with one-month history of abdominal pain and acute onset nausea, vomiting and abdominal distension. Investigations of note were a white count of 18.8.

Preoperative imaging showed underlying bowel obstruction on X-ray. A pelvic ultrasound and CT revealed large bilateral adnexal masses measuring 8.8 and 7.4 cm, consistent with TOA. An MRI showed that the masses were intimately involved with the fallopian tubes and ovaries and abutting the sigmoid colon. The patient was admitted with a small bowel obstruction secondary to extensive TOAs. An NG tube was placed and she was started on antibiotics. By post-admission day three, she continued to have lower abdominal pain and her NG outputs remained high. We advised early intervention with either image-guided drainage or surgical management. Image-guided drainage was discussed as a minimally invasive option, with the ability to drain large TOAs.

Although surgery is more invasive, it offers a higher chance of definitive management as all TOAs can be drained with minimal, persistent residual debris. The patient elected to proceed with surgical management. She was consented for laparoscopic drainage of TOAs, lysis of adhesions, methylene blue dye test with a possible risk of salpingectomy, oophorectomy or laparotomy. She was counselled on a high risk of bowel injury. We will now review the seven key steps for the surgical management of complex TOAs. Safe entry and abdominal survey. Lysis of adhesions. Identify key anatomical structures. Drain tubo-ovarian abscess and resect infected tissue. Send specimens for culture and sensitivity. Consider fertility options and tubal lavage. Irrigate abdomen thoroughly and consider intra-abdominal drain. Step one, safe entry and abdominal survey. The safest point of entry is at Palmer’s point, as the bowels will often be adherent in the interior abdominal wall. Here, matted adhesions of small and large bowel were noted on entry. We were unable to identify any gynaecological organs. Step two, lysis of adhesions. It is challenging to identify key anatomy until lysis of adhesions is completed. One port was inserted in the left upper quadrant to start lysis of adhesions and optimise remaining port placements. One technique is advised using a suction irrigator in a sweeping motion to minimise trauma to friable tissue. Ensure the pressure is directed towards the anterior abdominal wall instead of the bowel to avoid inadvertent injury. The risk of bowel injury in these cases is approximately 8 to 10%. Aqua dissection should be used concurrently to identify and separate planes. Avoid grasping organs and undue traction due to tissue oedema. Electrosurgery should be minimised on acute adhesions. Secondary ports can be safely placed as adhesiolysis proceeds. Of note, lysis of adhesions can be quite extensive and can take several hours. It is important to remain patient and precise in your surgical technique. Step three, identify key anatomical structures. The anatomy can be markedly altered due to adhesions. It is important to repeatedly identify anatomy throughout the procedure to maintain orientation and avoid injury to key structures. Although not seen in this case due to extensive bowel adhesions, an effort should be made to visualise the appendix as some TOAs may be secondary to appendicitis. Step four, drain tubo-ovarian abscess and resect infected tissue.

Gently probe the abscess cavity with the suction irrigator using blunt dissection, push and spread motion and traction-countertraction manoeuvres. Once the abscess is drained, consider a sharp dissection to trim the abscess cavity. Here, abscess cavity was attached to the bowel and was carefully resected with the general surgery team present. Then examine the pelvis further as there may be several locules that are walled off. Here, pockets of TOA were noted in multiple locations. Some of these included the right pelvic sidewall, caecum, left pelvic sidewall, left adnexa and posterior cul de sac. Step five, send specimens for culture and sensitivity. Send both aspirated fluid and tissue. In this case, the fluid aspirate grew Streptococcus anginosus and the tissue culture showed scant yeast. Step six, consider fertility options and tubal lavage. If future fertility is not desired, consider an opportunistic salpingectomy. In this case, the patient was interested in future fertility. A methylene blue dye test was used for dual purpose. One, to identify the location and patency of the tubes. And two, to irrigate residual necrotic debris in the tubes. Here, both tubes were open. The right tube was intimately buried into the right pelvic sidewall and the methylene blue dye test confirmed its location and patency. Sometimes, however, tubes may not be patent due to interstitial oedema. Step seven, irrigate the abdomen thoroughly and consider intra-abdominal drain. A thorough irrigation aids removal of any infected debris. 2 l of fluid was flushed into the upper abdomen, one on each side of the falciform, to dilute any purulent material. The patient was then placed into reverse Trendelenburg and the fluid was suctioned. Finally, two JP drains were placed through the bottom bilateral laparoscopic ports. Post-operatively, the patient’s bowel function was restored. She was discharged with a 14-day course of antibiotics. At the two-month follow-up, she remained well. Repeat imaging showed a small 4.1 cm area in the right adnexa containing simple fluid, which was not clinically significant. At seven months post-operatively, the patient has remained well without further intervention. In conclusion, we reviewed the importance of early intervention to achieving higher cure rates and when surgery should be considered. The seven key steps for surgical management of complex TOAs are safe entry and abdominal survey, lysis of adhesions, identify key anatomical structures, drain tubo-ovarian abscess and resect infected tissue.

Send specimens for culture and sensitivity. Consider fertility options in tubal lavage. Irrigate abdomen thoroughly and consider intra-abdominal drain. Thank you to our patients or collaborators and thank you for your time.