Laparoscopic Management of Post-cesarean Uterovesical Abscess: A New Approach to an Old Problem
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CASE REPORT
Laparoscopic Management of Post‑cesarean Uterovesical Abscess: A New Approach to an Old Problem Kusum Lata1 · Amenda Ann Davis2 · Akshita Panwar2 · Isha Kriplani1 · Alka Kriplani2 Received: 29 May 2020 / Accepted: 29 October 2020 © Federation of Obstetric & Gynecological Societies of India 2020
Introduction
Case
A uterovesical abscess, also called a bladder flap hematoma, is a rare complication of cesarean delivery. It refers to an enclosed collection between the lower uterine segment and bladder [1]. These cases present any time from day 2 of cesarean to several weeks postpartum with fever unresponsive to antibiotics, anemia, suprapubic pain, and a visible pelvic collection between the uterus and bladder on ultrasound, CT, or MRI. The various described methods of treating such patients include conservative medical management, percutaneous or transvaginal drainage, laparoscopy, or, traditionally, for significant collections, laparotomy. We describe a case of bladder flap hematoma whom we treated by laparoscopy and conclude that minimally invasive techniques applied to obstetric practice may significantly reduce maternal and neonatal morbidity. Institute review board approval and informed patient consent were taken for this case.
A 24-year-old woman presented with the history of highgrade fever with chills since 11 days. She was having these symptoms since an elective lower segment cesarean section (LSCS) done 11 days ago in view of previous cesarean with the patient not willing for vaginal birth. She had two children, with the first LSCS done 1.5 years ago for nonprogress of labor. The intraoperative records of her LSCS were unnoteworthy. The cesarean was performed by the traditional method, with closure of the visceral peritoneum. The baby was born healthy with a weight of 3.2 kg. The catheter was removed after 12 h. However, she had been suffering from fever from postoperative day 2 and was hospitalized since then. Urine culture showed infection with Klebsiella pneumoniae, and she had been administered intravenous piperacillin/tazobactam according to culture sensitivity. She was referred to our hospital due to nonresolution of her symptoms. On examination, the patient was pale, tachycardic, and febrile (temperature 102.3° F). Her hemoglobin was 6.8 g/dL, and c-reactive protein was elevated. The transverse abdominal scar was healthy and well healed. She had suprapubic tenderness, and transabdominal sonogram was suggestive of pelvic hematoma. MRI revealed a loculated fluid collection of size 7.2*3.1*4.2 cm in the uterovesical pouch, indenting the dome of the bladder, suggesting an infected hematoma (Fig. 1). We proceeded for laparoscopic adhesiolysis, drainage of pus, and peritoneal lavage. We gave preoperative antibiotic prophylaxis with piperacillin/tazobactam and metronidazole. Laparoscopy was done with a supraumbilical 10 mm port and three accessory 5 mm ports. Intraoperatively, the omentum was found densely adhered to the anterior abdominal wall as well as the uterine scar. The bladder could
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