Laparoscopic excision of tubocutaneous fistula: case report

Gynecological fistulas that are familiar are vesicovaginal, rectovaginal and ureterovaginal fistulas, which may be due to childbirth, operative injury, tumour or radiation. Tubocutaneous fistula, is as a very rare condition secondary to tuberculosis, endometriosis, and complications of child birth and gynecological surgeries. We report a 30 year old woman with a tuberculous tubocutaneous fistula, arising from the right salphingeal tube and discharging in the lower abdomen cutaneously, who underwent laparoscopic right salpingo oophorectomy, and excision of the tract upto the skin, and the abdominal wall, with open excision of the distal part. The case is being published for its rarity, and to remind gynecologists to consider this possibility in a non-healing sinus in the lower abdomen. The authors believe this to be the first such case in literature. Obstetrics & Gynecology International Journal Case Report Open Access Laparoscopic Excision of Tubocutaneous Fistula: Case Report 420 Copyright: ©2018 Rajkumar et al. Citation: 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. DOI: 10.15406/ogij.2018.09.00378 negligible. Closure was done in layers after washing out the abdominal wall thoroughly. The specimen was sent for histopathology. Figure 3a Medial part of dissection of the tube, inflammatory mass and the tract going upto the anterior abdominal wall. Figure 3b Dissection of distal portion of ovary, inflammatory mass and the tract upto anterior abdominal wall. Figure 4 Excision of Fistulous tract. Post-operatively, the patient was put on antibiotics and analgesics. She had no infection of the wound and was back to normal in a few days. Histopathology revealed simple serous ovarian cyst with fistulous tract running from the inner lining of the right fallopian tube up to the skin, and this was surrounded by granulation tissue with epithelioid cells, Langhans giant cells, lymphocytes, highly suggestive of tuberculosis. Pus cultures were negative for growth of mycobacterium, but the PCR of the fluid was positive for Mycobacterium tuberculosis. The patient was subsequently started on anti-tuberculous therapy, and at follow up was asymptomatic. Figure 5 Final appearance.

Wittich et al in 1982 first reported a tubocutaneous fistula. 1 This case on retrospect is a tuberculous tuboctaneous fistula, commencing in a tuberculous tubo- ovarian abscess, and finding its way to the skin. Is it a fistula? Yes, because both epithelial surfaces were clearly connected, the tubal and the cutaneous. Where did the infection begin? Tubo- ovarian tuberculosis is well known, although its presentation as a fistula is extremely rare. A pathological communication between the fallopian tube and skin is quite rare. Causes described in literature are pelvic inflammatory disease, Crohn’s disease, tuberculosis, endometriosis, inflammatory bowel disease and pelvic surgeries.2–5 The current literature advocates salpingectomy or salpingo-oophorectomy and complete excision of the tract as definitive treatment. 6 Nayini et al reported a case without any specific disease process. The best imaging modality recommended is MRI or CT scan. 7 A high index of suspicion in a persistently discharging sinus of the lower abdomen is required. Belli et al reported a persistent ischiorectal fistula of tubo-ovarian origin.8 All the available reports, intra-operative details are of open surgery only.2–11 In our case, we used the ‘medial to lateral’ approach. As the medial end of the fallopian tube and broad ligament were unaffected in the inflammatory process, we disconnected the medial attachments first. The next step was to devascularise the inflammatory phlegmon completely, and the ovarian vessels were sealed and cut. The rest of the dissection consisted of removing the entire fistula up to the peritoneum. Perhaps a PCR testing in the early stages of her disease might have yielded results for aggressive antitubercular therapy. A small number of cases have been reported of fistulas between the fallopian tube and the neighbouring colon, small bowel, or bladder, all these fistulas managed by laparotomies. To our knowledge, this is the first ever case report of a Total Laparoscopic excision of a tuberculous tubocutaneous fistula.

This article highlights the need to consider the possibility of an underlying Tubocutaneous or Uterocutaneous fistula as a cause Laparoscopic Excision of Tubocutaneous Fistula: Case Report 421 Copyright: ©2018 Rajkumar et al. Citation: 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. DOI: 10.15406/ogij.2018.09.00378 for a non-healing lower abdominal sinus, especially after multiple explorations. Early diagnosis and adequate surgical clearance will serve to prevent complications in the long term. This case, a Totally Laparoscopic excision of a Tubocutaneous Tuberculous fistula, is being published, as it is the first of its kind in literature, to our knowledge. Acknowledgments None. Conflict of interest The authors declare that they have no conflict of interest.

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