Clinical case

We present the case of a 65-year-old woman of Venezuelan nationality, who went to the emergency department of Gynecology with progressive worsening pelvic pain for about two weeks and suspicion of pelvic organ prolapse. As relevant personal history, the patient had a large incisional hernia after gastric bypass surgery, with about 30 years of evolution, morbid obesity (body mass index of 50 Kg/m²), arterial hypertension medicated with losartan and diabetes mellitus controlled and medicated with metformin. About her obstetric and gynaecological history, she was in menopause since 50 years old, had two full-term pregnancies with cesarean delivery and two spontaneous abortions. She wasn’t currently sexually active. According to the her, the last gynaecological evaluation was several years ago.

The patient was hemodynamically stable and apyretic. Genital observation revealed a voluminous right inguino-labial neoformation, approximately 15 centimetres, painful on palpation with inflammatory signs, which obliterated the vagina, which is why the gynecological examination was postponed for a second evaluation (Figure 1). There was also a large incisional abdominal hernia with loss of home with no signs of acute pathology. Blood and urine tests were requested, and analgesic medication was prescribed. Taking into account the findings and considering an inguinal hernia with signs of incarceration as a differential diagnosis, the patient was sent to the general surgery emergency department for evaluation.

Figure 1 Right inguino-labial neoformation. (20 millilitres syringe for scale). 

Due to urinary retention, a Foley catheter was placed. Analytical evaluation showed leukocytosis (12000 leukocytes/uL) and a C-reactive protein of 227 mg/L. After the objective examination, an abdominal and pelvic radiography was requested, with no relevant changes and, later, an abdominal and pelvic computed axial tomography (CT scan). CT scan described a cystic formation in the area of the right labia majora measuring about 135x165x213 millimetres, corresponding to a volume of about 2500 cc, compatible with a Bartholin’s gland abcess (Figure 2). After these findings, the patient returned to the emergency department of Gynecology.

Figure 2 CT scan images showing the incisional hernia (+) and the Bartholin’s gland abcess (*). 

After discussing the case in a multidisciplinary team, the excision of the Bartholin’s gland under general anesthesia was proposed, which the patient accepted. An elliptical incision was then made over the mass, with blunt debridement of the cyst capsule, during which accidental rupture was observed, with drainage of about 1500 cc of purulent content, which was sent to microbiological study. After this, removal of the entire cyst capsule, excision of redundant tissue, review of haemostasis and closure of the surgical wound by layers was made, with a multifilament synthetic absorbable interrupted suture (Vycril ^® ), size 0 for the deep layer, a size 2-0 for the skin (Figure 3). The patient remained with a Foley catheter and a Blake 19 catheter in the surgical site (Figure 4). The gynaecological examination showed no other relevant changes.

Figure 3 Redundant labia majora tissue after gland excision. 

Figure 4 Immediate postoperative result. 

Intravenous broad-spectrum antibiotic therapy, piperacillin and tazobactam, was prescribed for ten days, and low molecular weight heparin during the entire hospital stay, for thromboembolism prophylaxis. During hospitalization hygiene care of the surgical wound was made with povidone-iodine foam. As intercurrences during hospitalization, she had a poor glycemic control, requiring medication adjustment, and an iron deficiency anemia (haemoglobin 8.7 g/dL), medicated with intravenous iron carboxymaltose. On the fourth postoperative day, she presented spontaneous externalization of the Blake 19 catheter, at which time draining was less than 50 cc of serohematic fluid in 24 hours. The microbiological study of the collected material was positive for anaerobic gram positive cocci and negative for aerobic bacteria.

On the tenth postoperative day, a small pearly area was observed in the middle third of the wound, measuring approximately 10x5 millimetres. Superficial surgical debridement was performed, less than five mm in depth. Due to the good evolution of the surgical wound, and clinical and hemodynamic stability, discharge was decided on the 14th day of hospitalization. Was recommended to keep the surgical wound washed with povidone-iodine and hygiene precautions to be taken were explained. The patient was reassessed two weeks and one month after surgery, with good evolution (Figure 5). She was referred for a general surgery appointment to follow up the incisional hernia, to the family doctor for follow-up of the remaining comorbidities and to the nutritionist.

Figure 5 One month postoperative result. 

The anatomopathological study identified a ruptured cavity formation with about 19.5x14.5 centimetres in greatest dimension. The microscopic study identified an epithelial cyst of non-keratinizing squamous epithelium with inflammatory infiltrate and ulceration of the lining, fibrohyaline wall with signs of activity, without signs of malignancy, compatible with the clinical diagnosis of Bartholin’s gland cyst with inflammatory signs.

Two months after the operation, the scar presented with the edges well coapted, with good healing, without inflammatory signs. Although she has limitations, taking into account her incisional hernia and obesity, the patient reports a significant improvement in her quality of life after the resolution of this acute episode.