{"paper_id":"60456e33-6c19-4488-8cf0-ab2935c53cca","body_text":"Submit Manuscript | http://medcraveonline.com\nCase presentation\nA 30 year old woman was presented to us with a history of her \nrecurrent discharging sinus in the lower abdomen just lateral to the \nright end of her pfannensteil scar and intermittent lower abdominal \npain for one year. There was no history of dysuria or white discharge \nper vagina. She gave history of recurrent fever followed by discharge \nfrom the sinus. The discharge was purulent, and had not yielded any \nbacteriological growth. The patient had two Caesarean sections; the last \nchild birth was six years ago. She had undergone multiple explorations \nof the sinus, and polypropylene suture was removed from the depth of \nthe sinus, showing some granulation tissue in histopathology. Despite \nthree excisions, the sinus recurred. She was a known Diabetic and \nhypertensive for four years on regular medications.\nOn examination, her general condition and vitals were normal. \nAbdominal examination revealed a 2* 3 cm induration in the right \niliac fossa with tenderness and a discharging sinus from the right \nend of the pfannensteil scar (Figure 1) from which a pus culture was \ntaken. On per speculum examination, her cervix was hypertrophied \nwith erosion and mild discharge. On per vaginal examination, uterus \nwas bulky with right forniceal tenderness. An ultrasonogram was \ntaken which showed a 4*5 cm right ovarian cyst with multiple small \nfibroids. MRI screening had shown a tract that extended from the right \ntubo ovarian area upto the skin. Other investigations like blood count \nand chest x-ray revealed no evidence of tuberculosis. In view of the \nradiographic findings, possible tubocutaneous fistula was diagnosed, \nand we decided to take up for diagnostic laparoscopy. \nFigure 1 Right end of the Pfannensteil scar.\nOn laparoscopy the findings were: \na. Uterus was bulky with adhesions and stuck to anterior \nabdominal wall, \nb. Right tubo-ovarian mass of 4*5cm seen with an adherent tract \nrunning from the right tube and ovary all the way up to the \nanterior abdominal wall, \nc. Left tube and ovary were normal (Figure 2). \nFigure 2 Left tube and ovary were normal.\nSmall bowel and omentum were adherent to the right ovary, \nsame separated and small bowel and omentum freed. The uterus \nwas adherent to anterior abdominal wall with adhesions but separate \nfrom the fistula. By using the vessel sealer and bipolar cautery, the \nmedial aspect of the tube and the broad ligament were separated from \nthe uterus. The infundibulo-pelvic ligament was taken as well. The \ntube, ovary, inflammatory mass and the tract going up to the anterior \nabdominal wall were excised in-toto laparoscopically (Figures 3a, \n3b) and the distal part of the tract on the abdominal wall was excised \nexternally and closed with 1-0 vicryl (Figures 4,5). The blood loss was \nObstet Gynecol Int J. 2018;9(6):419‒421. 419\n© 2018 Rajkumar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , \nwhich permits unrestricted use, distribution, and build upon your work non-commercially.\nLaparoscopic Excision of T ubocutaneous Fistula: \nCase Report\nVolume 9 Issue 6 - 2018\nJS Rajkumar, Deepa Ganesh, Akbar Syed, \nAnirudh Rajkumar, Jayakrishna Reddy\nLifeline Institute of Minimal Access Surgery, India\nCorrespondence: Deepa Ganesh, Lifeline Institute of Minimal \nAccess Surgery, 47/3, New Avadi road,kilpauk chennai-600010, \nTamilnadu, India, T el 9841257779, Email \n \nReceived: April 29, 2017 | Published: November 16, 2018\nAbstract\nGynecological fistulas that are familiar are vesicovaginal, rectovaginal and \nureterovaginal fistulas, which may be due to childbirth, operative injury, tumour or \nradiation. Tubocutaneous fistula, is as a very rare condition secondary to tuberculosis, \nendometriosis, and complications of child birth and gynecological surgeries. We \nreport a 30 year old woman with a tuberculous tubocutaneous fistula, arising from \nthe right salphingeal tube and discharging in the lower abdomen cutaneously, who \nunderwent laparoscopic right salpingo oophorectomy, and excision of the tract upto \nthe skin, and the abdominal wall, with open excision of the distal part. The case is \nbeing published for its rarity, and to remind gynecologists to consider this possibility \nin a non-healing sinus in the lower abdomen. The authors believe this to be the first \nsuch case in literature.\nObstetrics & Gynecology International Journal\nCase Report\n Open Access\n\n\nLaparoscopic Excision of Tubocutaneous Fistula: Case Report\n420\nCopyright:\n©2018 Rajkumar et al.\nCitation: Rajkumar JS, Ganesh D, Syed A, et al. Laparoscopic Excision of T ubocutaneous Fistula: Case Report. Obstet Gynecol Int J. 2018;9(6):419‒421. \nDOI: 10.15406/ogij.2018.09.00378\nnegligible. Closure was done in layers after washing out the abdominal \nwall thoroughly. The specimen was sent for histopathology.\nFigure 3a Medial part of dissection of the tube, inflammatory mass and the \ntract going upto the anterior abdominal wall.\nFigure 3b Dissection of distal portion of ovary, inflammatory mass and the \ntract upto anterior abdominal wall.\nFigure 4 Excision of Fistulous tract.\nPost-operatively, the patient was put on antibiotics and analgesics. \nShe had no infection of the wound and was back to normal in a few days. \nHistopathology revealed simple serous ovarian cyst with fistulous tract \nrunning from the inner lining of the right fallopian tube up to the skin, \nand this was surrounded by granulation tissue with epithelioid cells, \nLanghans giant cells, lymphocytes, highly suggestive of tuberculosis. \nPus cultures were negative for growth of mycobacterium, but the PCR \nof the fluid was positive for Mycobacterium tuberculosis. The patient \nwas subsequently started on anti-tuberculous therapy, and at follow \nup was asymptomatic. \nFigure 5 Final appearance.\nDiscussion\nWittich et al in 1982 first reported a tubocutaneous fistula. 1 This \ncase on retrospect is a tuberculous tuboctaneous fistula, commencing \nin a tuberculous tubo- ovarian abscess, and finding its way to the skin. \nIs it a fistula? \nYes, because both epithelial surfaces were clearly connected, the \ntubal and the cutaneous. \nWhere did the infection begin?\nTubo- ovarian tuberculosis is well known, although its presentation \nas a fistula is extremely rare.\nA pathological communication between the fallopian tube and skin \nis quite rare. Causes described in literature are pelvic inflammatory \ndisease, Crohn’s disease, tuberculosis, endometriosis, inflammatory \nbowel disease and pelvic surgeries.2–5 The current literature advocates \nsalpingectomy or salpingo-oophorectomy and complete excision \nof the tract as definitive treatment. 6 Nayini et al reported a case \nwithout any specific disease process. The best imaging modality \nrecommended is MRI or CT scan. 7 A high index of suspicion in a \npersistently discharging sinus of the lower abdomen is required. Belli \net al reported a persistent ischiorectal fistula of tubo-ovarian origin.8\nAll the available reports, intra-operative details are of open surgery \nonly.2–11 In our case, we used the ‘medial to lateral’ approach. As the \nmedial end of the fallopian tube and broad ligament were unaffected \nin the inflammatory process, we disconnected the medial attachments \nfirst. The next step was to devascularise the inflammatory phlegmon \ncompletely, and the ovarian vessels were sealed and cut. The rest \nof the dissection consisted of removing the entire fistula up to the \nperitoneum. Perhaps a PCR testing in the early stages of her disease \nmight have yielded results for aggressive antitubercular therapy.\n A small number of cases have been reported of fistulas between the \nfallopian tube and the neighbouring colon, small bowel, or bladder, all \nthese fistulas managed by laparotomies. To our knowledge, this is the \nfirst ever case report of a Total Laparoscopic excision of a tuberculous \ntubocutaneous fistula.\n Conclusion\nThis article highlights the need to consider the possibility of an \nunderlying Tubocutaneous or Uterocutaneous fistula as a cause \n\n\nLaparoscopic Excision of Tubocutaneous Fistula: Case Report\n421\nCopyright:\n©2018 Rajkumar et al.\nCitation: Rajkumar JS, Ganesh D, Syed A, et al. Laparoscopic Excision of T ubocutaneous Fistula: Case Report. Obstet Gynecol Int J. 2018;9(6):419‒421. \nDOI: 10.15406/ogij.2018.09.00378\nfor a non-healing lower abdominal sinus, especially after multiple \nexplorations. Early diagnosis and adequate surgical clearance will \nserve to prevent complications in the long term. This case, a Totally \nLaparoscopic excision of a Tubocutaneous Tuberculous fistula, \nis being published, as it is the first of its kind in literature, to our \nknowledge. \nAcknowledgments\nNone. \nConflict of interest\nThe authors declare that they have no conflict of interest.\nReferences\n1. Wittich AC, Morales H, Braeuer NR. Tubocutaneous fistula. Am J Obstet \nGynecol. 1982;144(1):109–110.\n2. Shukla D, Pandey S, Pandey LK, et al. Repair of uterocutaneous fistula. \nObstet Gynecol. 2006;108(3 Pt 2):732–733.\n3. Ogbeide OU, Ukadike IA, Ehigiamusoe FO, et al. Acquired salpingo-\nenteric fistula—a case report. Afr J Reprod Health. 2010;14(1):139–143.\n4. Abasiattai AM, Ibanga GJ, Akpan A, et al. Post caesarean section \nuterocutaneous fistula: a case report. Women’ s Health, Issues & Care. \n2014;3(5).\n5. Sheikh MA, Begum J, Balasubramanian G. Tuboenterocutaneous fistula \nfollowing caesarean section. International J Reproduction Contraception, \nObstetrics & Gynecology. 2014;3(1).\n6. Palnaes-Hansen C, Bülow S, Karlsen J. Tubocutaneous fistula,Case \nreport. Acta Chir Scand. 1987;153(7–8):465–466.\n7. Krishnaveni Nayini, Clive Gie. Tubocutaneous fistula a case report. Case \nReports in Obstetrics & Gynecology. 2015.\n8. Belli EV , Landmann RG, Koonce SL, et al. Persistent ischiorectal fistula \nwith supralevator origin secondary to a chronic tubo-ovarian abscess: \nreport of a case and review of the literature. Female Pelvic Med Reconstr \nSurg. 2012;18(1):66–67. \n9. Lopes EN, Dam ásio LC, Passos LS. Tubocutaneous fistula due to \nendometriosis-a differential diagnosis in cutaneous fistulas with cyclic \nsecretion. Rev Bras Ginecol Obstet. 2017;39(1):31–34.\n10. Choe SA, Lee HJ, Moon KY , et al. A tubocutaneous fistula in a patient \nwith Chro’s disease after multiple laparotomies: a case report. J of \nWomen’ s Med. 2008;1(2);188–189.\n11. London AM, Burkman RT. Tuboovarian abscess with associated rupture \nand fistula formation into the urinary bladder: report of two cases. Am J \nObstet Gynecol. 1979;135(8):1113–1114.","source_license":"CC0","license_restricted":false}