Surgical zyxwvutsr workshop Laparoscopic drainage of pyogenic liver abscess K. YANAGA, zyxwvutsrq S. KITANO, M. HASHIZUME, M. OHTA. zyxwvutsrqp T. MATSUMATA and K. SUGlMACHI zyxwvutsrqp Departtnenr zyxwvutsrq of Surgety zyxwvutsrqp 11, Kyushu University Faciil~y of Medicine, H@shi-Iiic firkirokrr 812. 3upan C'orrc.~~otid~iil.r to: I)/ K. Yunugu Laparoscopic cholecystcctomy is now the standard procedure for uncomplicated cholelithiasisl and other laparoscopic procedures have recently bcen Successful laparoscopic drainage of a pyogcnic liver abscess with local peritonitis is described. Surgical technique A 71-year-old man was admitted with a history of right upper quadrant ahdominal pain of 3 months' duration and weight loss of zyxwvuts I3 kg. On admission he had remittent fever of up to 38.7"C and a raiscd leucocyte count of 20400 per mm' without jaundice. Compulcd tomography (CT) demonstrated an abscess of 8 x 8.5 cm in livcr segments VII and Vlll (Fig. I ). No gallstones were seen. Aftcr a I-month course of intravenous antibiotic therapy the patient underwent percutaneous aspiration of the abscess under ultrawnogdphic guidance. Although 20 ml pus was aspirated, ihinagc was impossihlc owing to limiied access. Despite vigorous Paper accepted I I December 19Y3 Fig. 1 Preoperative computed tomogram demonstrating a large liver abscess in the posterosuperior aspect of the right hepatic lobe intravenous antibiotic therapy the man developed localized peritonitis the next day. The aspirate contained Streptococcus mitis. The patient's general condition failed to improve and the abscess could not be visualized by ultrasonography because abdominal guarding prevented deep inspiration. As the man was elderly and malnourished, it was decided to perform a laparoscopically assisted drainage procedure rather than conventional laparotomy. The patient was placed supine and a 10-mm laparoscopic cannula inserted 3 cm to the right of the umbilicus. Three additional cannulas were inserted in the right suhcostal area. Turbid ascites was aspirated from the subhepatic space and the area irrigated with 2 litres normal saline. After releasing soft adhesions to the greater omentum, the previous puncture site was identified. A 12-Fr double-lumen Argile catheter (Sherwood Japan. Tokyo, Japan) was introduced into the peritonea1 cavity through a separate stab wound, angled extremely cephalad and inserted into the liver. Approximately 40 ml pus was evacuated immediately. Three Rmrose drains were placed in the right subhepatic and suhphrenic spaccs. Postoperative recovery was rapid and uneventful. Follow-up CT demonstrated progressive decompression of the hepatic abscess. All Penrose drains were removed by day 7. The patient was discharged on day 19 and the drainage tube removed on day 42. Discussion Current indications for open laparotomy for pyogenic liver abscess include an intra-abdominal source of infection and failure of percutaneous drainage as a result of anatomical or technical difficulv'. In the present patient laparoscopic drainage rather than conventional laparotomy was indicatcd because of failed percutaneous drainage. the absence of an obvious cause of the hepatic abscess and poor general condition. With the recent acccptance of minimally invasive surgical procedures'-' laparoscopically a..sisted percutaneous drainagc appears to be a safe and useful treatment for pyogenic liver abscess and might replace conventional laparotomy in some cases. References 1 Dubois F. Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 1990; 2 Semm K. Endoscopic appendicectomy. Errdoscopy 1983; 15: 3 Hashizume M, Sugimachi K, Ueno K. Laparoscopic splenectomy with an ultrasonic dissector. N Engl J Med 1992; 327 438 (Letter). 4 Mompean JAL, Paricio PP, Campos RR, Ayll6n JG. Laparo- scopic treatment of a liver hydatid cyst. Rr 3 Surg 1993; 80 5 Gyow U, Frey CF, Sliva J Jr, McGahan J. Pyogenic liver abscess. Diagnostic and therapeutic strategies. Anri Sirrg 1987: 211: 60-2. 59-64. 907-8. 206: 699-705. 1022