Minimally invasive management of pyoperitoneum attributed by spontaneous perforated pyosalpinx and pyometra

Pyoperitoneum, apart from bowel perforation, can occur due to gynecologic causes like ruptured pyometra or ruptured tubo-ovarian abscess. Earlier, the management of pyoperitoneum included broad-spectrum antibiotics and emergency laparotomy with or without a hysterectomy and bilateral saphingo-oophorectomy. A higher rate of surgical complications like bowel or bladder injury was noted with surgery, and future fertility was also compromised in these patients. Later on, treatment strategies improved to laparoscopic drainage of pus with antibiotics without extensive surgery. However, such cases can be managed with an even more minimally invasive approach by image-guided pigtail drainage. In this report, we describe two cases of pyoperitoneum that were managed successfully with pigtail insertion and continuous drainage of pus along with antibiotics obviating the need for anaesthesia and surgery. It seems to be a promising approach for pyoperitoneum in a hemodynamically stable patient, not showing any features of severe sepsis.

Role of surgical management in invasive mole: a report of 2 cases and review of literature

Invasive mole is a rare gestational trophoblastic neoplasia with proliferative trophoblast invading into myometrium or uterine vasculature. Primary management of invasive mole is chemotherapy, but hysterectomy can be performed in selective cases. In this report, we discuss two cases of invasive mole, which required surgical intervention in the form of a hysterectomy. Both patients had a favorable outcome and are in remission.

Transmurally migrated gossypiboma rarely posing as surgical site infection: a case report and review of literature

The term gossypiboma is used to describe a retained surgical sponge or gauge after surgery. The clinical features range from being asymptomatic to frank bowel obstruction, perforation and peritonitis. Radiological modalities also do not provide a definite diagnosis. We report a case of a 30-year-old lady who presented to the emergency room with recurrent surgical site infection. She had a history of caesarean section 5 months ago. Following the caesarean section, she developed superficial wound dehiscence which was re-sutured. At the present facility, the lady underwent Computed tomography (CT) scan and was suspected to have a foreign body around the gut. She was planned for an exploratory laparotomy. Upon laparotomy, a large thick-walled ileal loop with some unusual intra luminal mass was found. Dense adhesions were present between the ileal loop and sigmoid colon. Adhesiolysis led to an iatrogenic sigmoid colon perforation, around 2 cm length. On incision over the ileal loop, surgical sponge was retrieved. Ileal loop was resected along with perforated site with end-to-end ileo-ileal anastomosis was done. Primary repair of sigmoid colon perforation was done. Patient was stable in postoperative period. Although rare, gossypiboma should be kept in mind as a differential diagnosis in postoperative cases presenting with recurrent surgical site infection.

Aggressive angiomyxoma of the vulva - a rare entity: case report and review of literature

Aggressive angiomyxoma (AA) is an extremely rare locally invasive mesenchymal tumor with a high risk of recurrence. Till date, only about 350 cases reported worldwide. Because of the rarity it should be considered as differential diagnosis whenever patient present with vulvovaginal growth. The diagnosis is clinched on histopathology. These are hormone-dependent and have estrogen and progesterone receptors. Hence sometimes GnRH agonists are used for ovarian estrogen secretion suppression but long-term use is not advocated due to side effects. A 45-year-old P4 L4 perimenopausal female presented to the GOPD with a 4×4×3 cms pedunculated painless globular mass on right labia majora. On palpation, the globular mass was firm, non-tender and with a smooth surface. Mass was excised and on gross histopathology, cut sections showed white myxoid areas. On microscopy epidermal lined tissue with stellate and spindle-shaped mesenchymal cells was found, embedded in a loose myxoid stroma with few collagen fibers. The cells were small and bland and lacked nuclear atypia. Small to medium-sized blood vessels were present with the thickened wall. Entrapped nerves and adipocytes were also present. No necrosis or mitosis was identified. All these features were suggestive of an aggressive angiomyxoma. Immunohistochemistry markers ER, PR, CD34, desmin, SMA were all positive. Imaging was done to rule out metastatic lesions and wide local excision was done around the stump with laparoscopic bilateral oophorectomy. Aggressive angiomyxoma is a rare disease. In women with asymptomatic growth in the vulvovaginal region, perineum or pelvis, aggressive angiomyxoma should be considered as a differential diagnosis. Ideal treatment is a wide local excision to prevent local recurrences, which are common and a hypoestrogenic milieu is created by either GnRH Agonists or by bilateral oophorectomy due to their hormone-sensitive nature.