Laparoscopic Excision of Infected Urachal Remnant in a Patient Presented with Recurrent Abdominal Wall Abscesses

Saad A Shebrain, MD, Mohamed H Elgamal, MD, Elizabeth Steensma, MD, Valerie M Gironda, MD MPH, Brandon Minnick, MD. Kalamazoo Center for Medical Studies/Michigan State University

Introduction: Surgical excision is the curative treatment for urachal remnant complicated by recurrent infections. We report a video case of performing a laparoscopic excision of urachal cyst/sinus tract in an obese male with recurrent abdominal wall abscesses.

Methods and Procedures: Initially, the patient was taken for an incision , debridement and drainage of the abdominal wall abscess with wound packing twice a day and two weeks of antibiotics. One week after initiating antibiotics a repeat CT scan was obtained with a Cystogram. The Cystogram showed no evidence of connection between the urinary bladder and the cyst /sinus tract. However, it showed bladder diverticula.

A 5 mm access port was placed in the left upper quadrant in the mid-clavicular line and two working ports, one 5 mm and another 10 mm, were placed in the left side of abdomen in the anterior and middle axillary lines respectively. An extra 5 mm port was placed in the right side lateral to the rectus muscle and above the level of the umbilicus to help retract the intraabdominal fat. The lateral, medial and median umbilical folds were readily identified. The urachal remnant infection has grossly resolved with antibiotics with only a band-like structure remaining in the midline. Using a three-way Foley catheter, the bladder was infused with methylene blue to delineate its border. This also confirmed the absence of a connection with the urachal remnant. Using the hook tip electrocautery, a window was created around the middle portion of the urachal remnant which was then circumferentially isolated. A Penrose drain was passed around this structure to help with retraction while dissecting it. The urachal remnant was traced toward the umbilicus where no evidence of any inflammatory process was noted. The remnant was then clipped and transected. On the side of urinary bladder, two Endo-loops were used and another clip was placed. The remnant was transected and removed through the 10 mm port. The fascia of the LLQ trocar site was closed using endo closure technique with 0-Vicryl. Skin incisions were closed with 4-0 Vicryl.

Results: Operative Time was 40 minutes and the patient was discharged on POD # 1. The recurrent episodes of UTIs were attributed to neurogenic bladder with diverticula.

Conclusion: Laparoscopic excision of urachal remnant can be performed safely once the infection cleared with antibiotics without significant comorbidities that are usually associated with open surgery.