EP414 - Totally extraperitoneal combined with transsacral approach for the management of supralevator pelvic infectious diseases

Purpose/Background: Background:
Deep pelvic abscesses extending from supralevator abscesses are rare yet present significant challenges in clinical practice, particularly when the extraperitoneal compartment is involved. An effective surgical approach is essential for adequate drainage while minimizing the risk of concomitant injury. this study aimed to analyze the outcomes of patients receiving the total extraperitoneal-transsacral approach for the management of supralevator pelvic abscesses exhibiting extraperitoneal extension.

Methods/Interventions:

Methods:
Patients diagnosed with supralevator pelvic abscesses exhibiting extraperitoneal extension from August 2014 to July 2024 were identified. Demographic and clinical data, including surgical details, perioperative morbidity, and postoperative outcomes, were collected for analysis. Surgical procedure：Patients were positioned prone for the transsacral approach, involving a vertical incision in the natal cleft and severing the coccyx to access the deep posterior anal space. A posterior incision on the levator ani muscle allowed for drainage of abscesses and necrotic tissue. For the extraperitoneal approach, patients were placed in the lithotomy position, and a midline incision was made to expose the extraperitoneal space. Care was taken to avoid unnecessary peritoneal incision. Upon entering the cavity, copious pus was drained, and various stab incisions facilitated drainage of associated extraperitoneal cavities. A drainage tube was positioned to allow for effective contradrainage.

Results/Outcomes:

Results:
A total of 9 male patients with deep pelvic abscesses exhibiting extraperitoneal extension were analyzed. The median age was 52 (range 20-70) years. Notably, diabetes was present in only 33.3% of patients. Most had prior surgical interventions, including perianal drainage or Fournier gangrene debridement. Continuous pus discharge and symptoms like fever prompted further treatment. Preoperative tests revealed elevated white blood cell counts and procalcitonin levels, with cultures identifying Escherichia coli (33.3%) and other pathogens. CT scan confirmed the abscess location and supralevator and extraperitoneal extension. The procedure took a median of 127 minutes, blood loss was minimal (median 40 mL), and two patients required ileostomy. No early complications were noted; however, one patient developed an anal fistula later. All patients were discharged within 11 (range 6-36) days, healing primarily via the total extraperitoneal-transsacral approach.

Conclusion/Discussion:

Conclusion:
The total extraperitoneal-transsacral approach combined anterior and posterior surgical incisions with a linked drainage technique. This method demonstrated favorable outcomes in the cohort study, achieving a high healing rate and satisfactory results without any fatalities.

Representative images of the surgical procedure.
Representative images of the surgical procedure. (a)An incision was used by the master and elevator muscles to access the pre sacral space, where the bodhisattva was drained;(b)The extraperitoneal space was accessed by sequentially cutting through the superficial abdominal fascia and the linea alba; (c)The extraperitoneal abscess was drained through blunt dissection;(d)An extensive link-up loop consisting of an extraperitoneal tube and a trans-sacral tube was established to enable contrandirectional drainage of the extraperitoneal-pelvic-sacrococcygeal space.


Preoperative CT imaging.
Preoperative CT imaging. (a)Axial CT imaging showed abscess extension into the anterior abdominal wall; (b) Sagittal CT imaging showed the abscess of the anterior abdominal wall extending from the underlying supralevator abscess; (c-d) Coronal CT imaging showed the abscess extension to the right supralevator.