{"paper_id":"aad3d075-d34d-4ccd-8f9c-df38aac4e924","body_text":"Review began\n 07/26/2024 \nReview ended\n 08/01/2024 \nPublished\n 08/06/2024\n© Copyright \n2024\nKaya et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.66315\nLaparoscopic Management of an Early\nPostoperative Pelvic Abscess Caused by Prevotella\nbivia Following a Deep Infiltrating Endometriosis\nSurgery\nBaris Kaya \n, \nAlperen Ince \n, \nMerve Sam Ozdemir \n, \nSercan Yuksel \n1.\n Obstetrics and Gynecology, Basaksehir Cam ve Sakura City Hospital, Istanbul, TUR \n2.\n Radiology, Basaksehir Cam ve\nSakura City Hospital, Istanbul, TUR \n3.\n General Surgery, Basaksehir Cam ve Sakura City Hospital, Istanbul, TUR\nCorresponding author: \nBaris Kaya, \nmdbariskaya@gmail.com\nAbstract\nSurgery for deep-infiltrating endometriosis (DIE) carries a high risk of complications, including pelvic\nabscesses. We would like to present the laparoscopic management of a pelvic abscess caused by \nPrevotella\nbivia\n following a radical hysterectomy in a DIE laparoscopic surgery. A 43-year-old G2P2 lady underwent a\nlaparoscopic hysterectomy, bilateral ureterolysis, bilateral parametrial nodule extirpation, and rectal\nshaving following complaints of severe dysmenorrhea, dyspareunia, and chronic pelvic pain due to deep-\ninfiltrating endometriosis (ENZIAN score: P2; 02/3; T2/2; A3; B3/2; C2; FA) (American Association of\nGynecologic Laparoscopists (AAGL) score: 72, Stage 4). She received intravenous antibiotic treatment at the\nhospital with a diagnosis of pelvic inflammatory disease one month before the endometriosis surgery. After\nthe extensive laparoscopic surgery, the early postoperative period was uneventful; however, starting on the\nfourth postoperative day, she was complaining of abdominal pain. On the seventh postoperative day, severe\nleft-sided abdominal pain, fever, nausea, vomiting, rising levels of C-reactive protein (CRP > 200 mg/dL), and\nsigns of septicemia were observed. The vaginal examination revealed a purulent discharge. Bacterial cultures\nwere obtained from the vaginal cuff and peripheral vein. On the computerized tomography scan, neither a\nbowel nor ureter injury was found, but a pelvic abscess above the vaginal cuff and left ureteral compression\nbelow the pelvic brim were observed. Due to the clinical deterioration of the patient despite receiving\npiperacillin/tazobactam antibiotic therapy, the decision was made to perform a repeat laparoscopy to\nprevent septic shock and ureteral stent application for urinary tract obstruction. During the laparoscopy,\npurulent fluid was discovered around the pelvic peritoneum, and it was noted that the rectosigmoid colon\nwas edematous and tightly adherent to the pelvic sidewalls. The rectosigmoid colon was carefully detached\nfrom the pelvic sidewalls; the left ureter was released, and the purulent abscess material from the vaginal\ncuff was aspirated. Every effort was made to remove as many yellowish plaques covering the pelvic\nperitoneum and rectum serosa as possible. Recovery following surgery was rapid. \nP. bivia \nwas detected in the\nblood culture, and the patient was treated with piperacillin/tazobactam for an additional seven days,\nresulting in a complete resolution of the illness. Pelvic abscess is a rare but serious complication that can\noccur following laparoscopic deep-infiltrating endometriosis surgery. To prevent ending up with septicemia\nand septic shock, further laparoscopic surgery may be necessary.\nCategories:\n Obstetrics/Gynecology\nKeywords:\n diagnostic laparoscopy in acute abdomen, prevotella bivia, deep pelvic abscess, vaginal cuff abscess, deep\ninfiltrating endometriosis (die)\nIntroduction\nSurgery for deep-infiltrating endometriosis (DIE) carries a high risk of complications \n[1,2]\n; however, a pelvic\nabscess can be seen as a very rare complication. Pelvic abscess following laparoscopic hysterectomy for\ndeeply infiltrating endometriosis was reported between 1.3% and 3% \n[1,3]\n. While most can be treated with\nparenteral antibiotics, with/without drainage, some need further major surgery \n[1,3]\n. Here, we would like to\npresent a laparoscopic management of a pelvic abscess caused by \nPrevotella bivia\n following a radical\nhysterectomy of a DIE laparoscopic surgery.\nCase Presentation\nA 43-year-old G2P2 (VD) lady underwent a laparoscopic hysterectomy, bilateral ureterolysis, bilateral\nparametrial nodule extirpation, and rectal shaving with the complaining of severe dysmenorrhea (VAS\nscore: 10/10), dyspareunia (VAS score: 6/10), and chronic pelvic pain (VAS score: 5/10) due to deeply\ninfiltrating endometriosis (ENZIAN score: P2; 02/3; T2/2; A3; B3/2; C2; FA) (AAGL score 72, Stage 4). In her\nhistory, she was hospitalized with a diagnosis of pelvic inflammatory disease one month before the\nendometriosis surgery.\nThe early postoperative period was uneventful; the Jackson-Pratt drain was removed on the third day, and\n1\n1\n2\n3\n \nOpen Access Case Report\nHow to cite this article\nKaya B, Ince A, Sam Ozdemir M, et al. (August 06, 2024) Laparoscopic Management of an Early Postoperative Pelvic Abscess Caused by\nPrevotella bivia Following a Deep Infiltrating Endometriosis Surgery. Cureus 16(8): e66315. \nDOI 10.7759/cureus.66315\n\nthe gas-gaita discharge was positive. Discharge from the hospital was delayed due to abdominal pain,\nstarting on the fourth postoperative day. Her complaints peaked at the top on the seventh postoperative day\nwith severe abdominal pain, especially on the left side, fever, nausea, vomiting, and rising levels of C-\nreactive protein (CRP > 200 mg/dL), signs of septicemia. The vaginal examination revealed a purulent\ndischarge. Bacterial cultures were obtained from the vaginal cuff and blood. The ultrasound revealed the\npresence of free fluid, particularly above the vaginal cuff. On the computerized tomography (CT) scan,\nneither bowel nor ureter injury was found, but a pelvic abscess above the vaginal cuff and left ureteral\ncompression below the pelvic brim were observed (Figure \n1\n). Due to the clinical deterioration of the patient\ndespite receiving piperacillin/tazobactam antibiotic therapy, the decision was made to perform a repeat\nlaparoscopy to prevent septic shock and ureteral stent application to relieve ureter compression.\nFIGURE\n 1: Sagittal view of left ureter compression and renal\nhydronephrosis in a contrast-enhanced computerized tomography scan\nDuring laparoscopy, purulent, free fluid was observed around the pelvic peritoneum, and the rectosigmoid\ncolon was densely attached to the pelvic sidewalls (Video \n1\n). First, the rectosigmoid was released from the\nright side of the pelvic wall, and the vaginal cuff was revealed with the purulent abscess material. The\nvaginal cuff, pelvic peritoneum, and rectum serosa (especially the shaved area) were covered with sticky\nyellowish plaques. Next, the right ureter, densely attached to the rectosigmoid colon, was released using the\natraumatic forceps and aspirator with the traction-counteraction method. Continuous irrigation with sterile\nsaline was performed to avoid organ injuries that were already infected and fragile. The rectosigmoid\nattached to the left pelvic sidewall was released on the left side. The rectum, which was causing compression\non the left ureter, was detached. Purulent abscess material was aspirated. The infective fibrotic yellowish\nplaques were removed from the vaginal cuff, pelvic peritoneum, and rectum serosa as much as possible. The\npelvis was washed with sterile saline, and a Jackson-Pratt drain was placed.\n \n2024 Kaya et al. Cureus 16(8): e66315. DOI 10.7759/cureus.66315\n2\n of \n4\n\nVIDEO\n 1: Laparoscopic management of postoperative pelvic abscess\nfollowing a deep infiltrating endometriosis surgery\nView video here: https://youtu.be/3YHZ-gWzO4Y?si=dtQj7KmY1h6C2Wfm\nRecovery was rapid following surgery. In the blood culture, \nP. bivia\n was detected, and the patient was treated\nwith piperacillin/tazobactam for seven days more with complete resolution of the illness.\nDiscussion\nPelvic abscess following laparoscopic hysterectomy requiring surgery is a very rare circumstance. In this\ncase, the significant risk factor for vaginal cuff abscess was the history of hospitalization for pelvic\ninflammatory disease one month before the surgery. Hysterectomy for deep infiltrating endometriosis is\naccepted as a radical hysterectomy as the surgery extends to the parametrium, vagina, and rectum, and\nusually bilateral ureterolysis is performed \n[4]\n. In our case, the pelvic abscess compressed the left ureter,\nwhich was already skeletonized. In addition to the patient’s clinical deterioration, left ureter compression\nnecessitated the surgical intervention. Another risk factor for the severity of the case was the \nP. bivia\nobtained in the blood culture. \nP. bivia\n is a Gram-negative anaerobic bacteria found in the vaginal microbiota\nand may be linked to bacterial vaginosis, endometritis, and pelvic inflammatory disease \n[5,6]\n. Moreover, it\nhas been identified as the cause of severe cases of peritonitis \n[7]\n and pelvic abscess following hysterectomy\n[8]\n. Although reported cases were treated with adequate antibiotic therapy, repeat laparoscopy was\nmandatory due to the rapid clinical deterioration of our patient, who showed signs of severe sepsis in the\nearly postoperative period. Koskov et al. \n[7]\n reported \nP. bivia\n generalized peritonitis unresponsive to broad-\nspectrum antibiotic therapy (gentamicin, cefazolin, metronidazole). In our case, the patient's deterioration\nled to the decision to perform a laparoscopy after 48 hours. The surgical procedure revealed the presence of\n300 mL of purulent fluid and fibrinous adhesions in the peritoneal cavity. Additionally, slight bowel dilation,\nan edematous left fallopian tube, and fibrinopurulent exudate on the serosa of the appendix were identified\nduring the surgery. The abscess material was removed from the pelvis and left salpingectomy, and an\nappendectomy was performed; however, contrary to our case, the surgery turned into open surgery. The\npatient showed complete recovery after the surgery and was treated with oral metronidazole one week after\nhospital discharge \n[7]\n. Sang-Min Shim and Yun-Sook Kim \n[8]\n reported a pelvic abscess following a\nlaparoscopic supracervical hysterectomy caused by Prevotella. In their case, interestingly, the pelvic abscess\noccurred two months after the laparoscopic supracervical hysterectomy, which was longer than ours. The\npelvic infection and cuff abscess were revealed immediately after the surgery in our case. Their case was\nmanaged medically with 14-day cefoxitin, metronidazole, and doxycycline.\nContrary to Sang-Min Shim and Yun-Sook Kim \n[8]\n, our case was handled with laparoscopy due to clinical\ndeterioration despite receiving piperacillin/tazobactam. In some cases, minimally invasive management of\npelvic abscesses is necessary \n[9]\n. As reported by Koskov et al. \n[7]\n, pelvic infection with \nP. bivia\n may be\nresistant to some antibiotics, and removing the abscess material from the pelvis by surgical intervention\nmay help recovery.\nThe history of being hospitalized due to pelvic inflammatory disease one month before the surgery for deep\ninfiltrating endometriosis was a significant risk factor for pelvic abscess. The patient received clindamycin\nand gentamycin as prophylaxis, and there was no evidence of infection during laparoscopy. It is reported\nthat \nP. bivia\n can be resistant to clindamycin \n[10]\n, as we have seen in our case. In this case, using\nmetronidazole instead of clindamycin as a prophylaxis could prevent pelvic abscesses caused by \nP. bivia\n.\nBefore the repeat laparoscopy, the infectious disease department changed the antibiotic therapy due to\nbeing unresponsive to clindamycin plus gentamicin. The clinical response remained unobserved, prompting\nthe need for surgical intervention. The results of the bacterial culture were obtained after the surgery. She\nwas treated with piperacillin/tazobactam one week after the operation for complete recovery.\nPelvic abscess following endometriosis surgery might be severe compared with benign gynecologic\nhysterectomy due to extensive surgical removal of the nodules from the parametrium and other pelvic\norgans, such as the rectum. Further, early surgical management with minimally invasive gynecology has\nadvantages, such as high success and low readmission rates \n[11]\n, as proven in our case.\n \n2024 Kaya et al. Cureus 16(8): e66315. DOI 10.7759/cureus.66315\n3\n of \n4\n\nConclusions\nPelvic abscess is a rare but serious complication that can occur following laparoscopic deep infiltrating\nsurgery and may require further laparoscopic surgery. In our case, laparoscopic management of the pelvic\nabscess was successful and prevented septic shock. Historically, surgical management of abscesses has\nrepeatedly proven its effectiveness.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nBaris Kaya, Merve Sam Ozdemir\nAcquisition, analysis, or interpretation of data:\n  \nBaris Kaya, Sercan Yuksel, Alperen Ince\nDrafting of the manuscript:\n  \nBaris Kaya\nCritical review of the manuscript for important intellectual content:\n  \nBaris Kaya, Merve Sam Ozdemir,\nSercan Yuksel, Alperen Ince\nSupervision:\n  \nBaris Kaya\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nRoman H, Bridoux V, Merlot B, et al.: \nRisk of bowel fistula following surgical management of deep\nendometriosis of the rectosigmoid: a series of 1102 cases\n. 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