Unusual Case
Rectus sheath abscess after laparoscopic appendicectomy Vishwanath Golash Department of Surgery, Sultan Qaboos Hospital, P. O. Box 98, Salalah - 211, Sultanate of Oman Address for correspondence: Dr. Vishwanath Golash, Department of Surgery, Sultan Qaboos Hospital, P. O. Box 98, Salalah - 211, Sultanate of Oman. E-mail:
[email protected]
m o Clinically, Fothergill signrand Carnett’s sign help in fintrabdominal pathology. differentiating it from d Port site wound infection, abdominal wall hematoma s a tomography Ultrasound, computerized (CT) scan and n and intraabdominal abscess formation has been o l o magnetic resonance imaging are accurate in localizing i reported after laparoscopic appendicectomy. We t n the abscess w and excluding a intraabdominal pathology. describe here a rectus sheath abscess which c i o occurred three weeks after the laparoscopic d ubl appendicectomy. It was most likely the result of CASE REPORT e P . secondary infection of the rectus sheath hematoma e ) with the history of lower due to bleeding into the rectus sheath from damage r Af26-year-old male presented w to the inferior epigastric arteries or a direct tear of m rabdominal vomiting and increasing o pain, o fever, the rectus muscle. As far as we are aware this fo n c swelling over the lower abdomen for the last one . complication has not been repor ted after k e l d Heowhad laparoscopic appendicectomy week. laparoscopic appendicectomy. b e n three weeks ago and was discharged home la M elsewhere i k on the a y ed third postoperative day. He had been feeling v with lower abdominal pain since his discharge a d b munwell from the and was given a week’s course of s te w. antibioticshospital i and analgesic in a private clinic. His INTRODUCTION s F w abdominal examination revealed: the laparoscopic o w D h P per ( not port site scar noticed at the umbilicus, left iliac fossa Laparoscopic appendicectomy se does e t s and the suprapubic area [Figure 1], generalized Abdominal increase the incidence of i i complications. s h abdominal tenderness and guarding, visible and wall vessel injuries may occur during trocar insertion T a palpable spherical mass in the left side of abdomen
in laparoscopy leading to rectus sheath hematoma Abstract
[2]
Keywords: Appendicetomy, laparoscopy, rectus sheath abscess
[1]
although infection of hematoma is a rare occurrence. The usual presentation is chills and rigor, acute abdominal pain associated with palpable painful, firm, abdominal mass corresponding to the rectus sheath. The hematoma takes the shape according to its location in the rectus sheath; above the arcuate line it appears as unilateral spindle shape and below the arcuate line it appears spherical in shape. Signs of urinar y bladder and peritoneal irritation with rebound tenderness and involuntary guarding may be present. Rarely, a rectus sheath hematoma/abscess may rupture into the peritoneum, causing peritonitis.
occupying the left paraumbilical and suprapubic area with signs of inflammation. Laboratory tests showed leukocytosis and neutrophilia. Coagulation profile was within the normal range. An abdominal
Figure 1: CT scan shows loculation with air pockets in the left lower rectus sheath and displacement of urinary bladder
Journal of Minimal Access Surgery | April-June 2007 | Volume 3 | Issue 2
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Golash: Rectus sheath abscess after laparoscopic appendicectomy
ultrasound revealed air fluid level in the left anterior abdominal wall with a cavity 9 x 5 cm in size suggestive of an abscess. The CT scan of the abdomen showed extraperitoneal collection, loculation with air pockets in the left lower rectus sheath, rectus muscle was infiltrated. The collection was displacing the urinar y bladder with no intraperitoenal communication and no intraperitoneal fluid collection [Figure 2]. A diagnosis of rectus sheath abscess was made. The rectus sheath abscess was opened by a long left paramedian incision. The rectus muscle and the inferior epigastric vessels were found macerated; 300ml of offensive smelling pus was evacuated. There was a deep abscess cavity extending behind the pubis symphysis but not communicating with the peritoneal cavity. The necrotic bits of rectus muscle were debrided. The wound was left open and secondar y suturing was done after two weeks. Culture grew Escheria coli.
infection of the rectus sheath hematoma leading to abscess formation. A hematoma within the rectus sheath occurs when the epigastric vessels or the rectus muscle are lacerated during trocar insertion. A large amount of blood or pus can accumulate within the rectus sheath and would only be noticed once the swelling becomes obvious. Trauma to abdominal wall blood vessels has been reported in up to 3.4% of laparoscopic procedures.[4] Most commonly injured vessels in laparoscopic procedures are the epigastric vessels. The epigastric vessels are usually located in the area between 4 and 8 cm from the midline. Staying away from this area, either medially or laterally, will determine the safety zone of entry the abdominal wall. [5] Proper understanding of the abdominal wall anatomy is essential in avoiding the injury to vessels.
m o fr d s a o ion l n at w c REFERENCES do ubli e P . e fr w m) r DISCUSSION
fo kno .co le ed ow Rectus sheath hematoma/abscess is a potentially b serious condition with significant morbidity a and M kn l i mortality. Most likely this patient had secondary a y ed v a db m is te w. F os w D P e h (w is sit h T a 1.
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3.
[3]
4.
5.
Minne L, Varner D, Burnell A, Ratzer E, Clark J, Haun W. Laparoscopic vs open appendectomy. Prospective randomized study of outcomes. Arch Surg 1997;132:708-12. Maharaj D, Ramdass M, Teelucksingh S, Perry A, Naraynsingh V. Rectus sheath haematoma: A new set of diagnostic features. Postgrad Med J 2002;78:755-6. Cherry WB, Mueller PS. Rectus sheath hematoma: Review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105 10. López-Tomassetti E, Martín Malagón A, Artega I, Díaz H, Carrillo A. Conservative treatment of huge abdominal wall hematoma after laparoscopic appendectomy: Report of a case. J Laparoendosc Adv Surg Tech A 2005;15:634-7. Saber AA, Meslemani AM, Davis R, Pimentel R. Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 2004;239:182-5.
Cite this article as: Golash V. Rectus sheath abscess after laparoscopic appendicectomy. J Min Access Surg 2007;3: 64-5. Date of submission: 17/08/06, Date of acceptance: 16/10/06
Figure 2: Patient picture showing spherical mass left lower abdomen, port sites of appendicetomy (left) and operative findings (right)
Source of Support: Nil, Conflict of Interest: None declared.
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Journal of Minimal Access Surgery | April-June 2007 | Volume 3 | Issue 2
