Conservative management of a urachal remnant perforation during laparoscopic ovarian cystectomy

Abstract

Complications associated with persistent urachal remnant disease have been well documented in neonates and more recently in adults. These include laparoscopic perforation. The case has previously been made for conservative management of small symptomatic urachal remnants in young infants and also for conservative management of iatrogenic cystotomies in the absence of overt sepsis using assisted bladder drainage and prophylactic antibiotics. However, to our knowledge, there has been no recent case of successful conservative management of laparoscopically perforated urachal remnant in an adult. This case describes the incidental perforation of a suspected urachal remnant in an adult female which resulted in an infected anterior abdominal wall collection. The patient was treated with assisted bladder drainage and intravenous antibiotics. Evidence of healing was demonstrated 4 weeks later using a cystogram.A 29-year-old female with no previous medical or surgical history presented with dysmennorrhoea and hirsutism. Ultrasound demonstrated a 6-cm cyst on her right ovary, with appearances suggestive of a dermoid. She was referred to secondary care for right-sided abdominal pain and admitted for laparascopic ovarian cystectomy. A 6-7-cm right-sided dermoid cyst was removed via the suprapubic port with copious washout. The procedure was otherwise uneventful.Post-operatively, she was unable to pass urine and required catheterisation. The next day, she developed a right-sided, erythematous and oedematous rash involving the right labia majora. This was initially thought to be an allergic chemical peritonitis from the washout fluid which was treated with chlorpheniramine and steroids. She then became pyrexial and was treated with co-amoxiclav for urinary tract infection and cellulitis. She experienced delayed return of voiding until day 5 post-operatively when she was discharged on oral antibiotics with some improvement in her rash.She then presented 2 days later with abdominal pain and distension with vomiting. Examination revealed a grossly distended abdomen with features of tense ascites and a persistent rash. A clear fluid exudate was noted at the umbilical port scar. Laboratory analysis was consistent with a sample of urine. She was recatheterised due to ongoing voiding difficulties.