Scrotal Abscess Postemergency Laparotomy for Noniatrogenic Pneumoretroperitoneum from Colonic Diverticular Perforation

Abstract

An otherwise healthy, 55-year-old adult male of average height and build presented to the emergency department of a tertiary care teaching hospital with complaints of abdominal pain, abdominal distension, and absolute constipation for two days. His pain began in the lower abdomen and was now generalized. On arrival, he seemed distressed and was tachycardic. Examination revealed lower abdominal tenderness with guarding. Bowel sounds were sluggish. His initial laboratory investigations revealed a raised total leukocyte count of 12.6 · 10/L. All other laboratory parameters were within normal limits. A CT scan was performed (Fig. 1). It revealed air in the retroperitoneum with multiple noninflamed colonic diverticula in the sigmoid colon and mild thickening at the rectosigmoid junction. There was no hydronephrosis, perinephric, or periureteric fat stranding. In the absence of an obvious source, a duodenal perforation was thought to be the most likely cause of the retroperitoneal air. Based on these findings, the patient was taken to the operation room for an exploratory laparotomy. There was significant small bowel distension, and the sigmoid colon had multiple noninflamed diverticula. The retroperitoneum was accessed, and the duodenum and right colon were mobilized. The retroperitoneum contained a thin seropurulent fluid that seemed to be tracking toward the right lower quadrant. The descending colon was mobilized, and a pinpoint perforation of a diverticulum on the retroperitoneal aspect of the distal descending colon was identified and seemed to be the source of the retroperitoneal contamination. All purulent material was evacuated and a thorough washout of the peritoneal cavity and retroperitoneum completed. The area of perforation was exteriorized to create a double-barrel colostomy. JacksonPratt drains were placed in both paracolic gutters. The bowel was massively distended and edematous. A tensionfree fascial closure was not deemed possible. The abdominal cavity was closed using an insert of absorbable mesh, with as much approximation of the fascial edges as was possible. The patient was managed in the ICU postoperatively, with gradual improvement of sepsis and abdominal distension. It was anticipated that the patient would develop a large ventral hernia if definitive closure of the wound was not undertaken. He returned to the operating room on the 6th postoperative day. A large amount of thin, purulent fluid was encountered in the peritoneal cavity and retroperitoneum. This was evacuated and a thorough washout was performed. A tension-free fascial closure was completed. The skin and subcutaneous tissue were left to heal by secondary intention. The patient’s subsequent recovery was gradual and uneventful. He was discharged on the 12th postoperative day. On the 16th postoperative day, the patient presented to the emergency department with complaints of abdominal pain, low-grade fever, and right-sided scrotal swelling and tenderness. He had mild tachycardia with a heart rate of 95 to 100 per minute, respiratory rate of 16/minute, and blood pressure 124/76 mm of Hg. There was no abdominal tenderness. The colostomy was functioning well. However, the scrotum was edematous, erythematous, and tender. A CT scan was repeated (Fig. 2). Inflammatory changes were seen tracking down the right paracolic gutter and extending to the right hemiscrotum with scrotal edema and intense inflammation. A diagnosis of scrotal abscess secondary to extension of inflammatory fluid along the right paracolic gutter was made. He returned to the operating room. A scrotal incision was used to evacuate the pus from the right hemiscrotum. A right inguinal incision was used to access the retroperitoneum. This was drained and debrided. Irrigation catheters were placed. Postoperatively continuous irrigation with sterile normal saline was performed to evacuate any residual infected inflammatory fluid. Daily dressing of the scrotal wound and midline laparotomy Address correspondence and reprint requests to Sadaf Khan, M.D., Department of Surgery, Aga Khan University, Stadium Road, Karachi, Pakistan 74800. E-mail: [email protected].