INFECTED ENDOMETRIOMA LEADING TO CUTANIOUS FISTULA FORMATION

Problem Statement:

Endometriomas present as adnexal masses which can be densely adherent to surrounding structures, such as fallopian tubes, pelvic sidewalls, and bowel. Infection of endometriomas is a rare complication which may occur after an invasive procedure or may also be local extension of an inflammatory process or hematogenous dissemination. Patients with infected endometriomas typically present with pelvic pain and a low-grade fever, a nonspecific presentation that begets an extensive differential diagnosis.

Methods:

A 44 year-old patient was seen for an enlarged, tender abdomen with a history of progressive abdominal distention over the past two months. Her history was significant for abdominal myomectomy. On ultrasound there was a 6 x 6 x 5.5 cm complex left adexal mass and a fibroid uterus measuring about 20 cm. After counseling she opted to have an abdominal hysterectomy, left salpingo-oophorectomy, right salpingectomy.

Results:

Exam under anesthesia was notable for erythematous, warm abdomen, cracking skin, and palpable mass to the umbilicus (Figure 1a). Intraoperatively, copious purulent material with significant necrosis was encountered within the subcutaneous tissue and rectus abdominus muscles requiring extensive debridement. A fistula tract was identified from the subcutaneous tissue through the fascia and rectus muscle into an ovarian cyst with small bowel adhered circumferentially (Figure 1b). The bowel was carefully dissected away, and a left salpingo-oophorectomy was performed. The uterus and other adnexa were left in situ, to minimize the amount of surgery. ABTHERA open abdomen negative pressure therapy devise was placed and patient underwent additional washout the following day with abdominal wall closure using biologic XenMatrix. Post operatively, patient was managed on vancomycin, piperacillin-tazobactam, and clindamycin. She was discharged on postoperative day seven with one additional week of amoxicillin-clavulanic acid and wound V.A.C. use to assist with her abdominal wound closure. Cultures collected intraoperatively grew Peptoniphilus harei group. Pathology confirmed that the ovarian cyst and tissue from debridement was an infected endometrioma that perforated and fistulized through this space.

Conclusion:

Spontaneous infection of an ovarian endometrioma is extremely rare. In patients with adnexal mass and suspected abdominal wall endometriosis, presence of cutaneous fistula should be considered for better surgical planning.