A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access



Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach.


A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection.


The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient’s recovery after the procedure was successful, without the need for further intervention.


Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann’s procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Men S, Akhan O, Koroglu M (2002) Percutaneous drainage of abdominal abcess. Eur J Radiol 43:204–218

    PubMed  Article  Google Scholar 

  2. 2.

    Montgomery RS, Wilson SE (1996) Intraabdominal abscesses: image-guided diagnosis and therapy. Clin Infect Dis 23:28–36

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Sudakoff GS, Lundeen SJ, Otterson MF (2005) Transrectal and transvaginal sonographic intervention of infected pelvic fluid collections: a complete approach. Ultrasound Q 21:175–185

    PubMed  Article  Google Scholar 

  4. 4.

    Harisinghani MG, Gervais DA, Maher MM, Cho CH, Hahn PF, Varghese J, Mueller PR (2003) Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases. Radiology 228:701–705

    PubMed  Article  Google Scholar 

  5. 5.

    Giovannini M, Bories E, Moutardier V, Pesenti C, Guillemin A, Lelong B, Delpero JR (2003) Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 35:511–514

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Varadarajulu S, Drelichman ER (2009) Effectiveness of EUS in drainage of pelvic abscesses in 25 consecutive patients (with video). Gastrointest Endosc 70:1121–1127

    PubMed  Article  Google Scholar 

  7. 7.

    Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN (2006) Transgastric endoscopic splenectomy: is it possible? Surg Endosc 20:522–525

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Ko CW, Kalloo AN (2006) Per-oral transgastric abdominal surgery. Chin J Dig Dis 7:67–70

    PubMed  Article  Google Scholar 

  9. 9.

    Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P (2007) Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures. Endoscopy 39:870–875

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Hondo FY, Giordano-Nappi JH, Maluf-Filho F, Matuguma SE, Sakai P, Poggetti R, Mori ND, Fontes B, Birolini D, Ishioka S (2007) Transgastric access by balloon overtube for intraperitoneal surgery. Surg Endosc 21:1867–1869

    PubMed  Article  Google Scholar 

  11. 11.

    Perretta S, Dallemagne B, Coumaros D, Marescaux J (2008) Natural orifice transluminal endoscopic surgery: transgastric cholecystectomy in a survival porcine model. Surg Endosc 22:1126–1130

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007) Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 142:823–826 discussion 826–827

    PubMed  Article  Google Scholar 

  13. 13.

    Bernhardt J, Gerber B, Schober HC, Kahler G, Ludwig K (2008) NOTES–case report of a unidirectional flexible appendectomy. Int J Colorectal Dis 23:547–550

    PubMed  Article  Google Scholar 

  14. 14.

    Branco AW, Branco Filho AJ, Kondo W, Noda RW, Kawahara N, Camargo AA, Stunitz LC, Valente J, Rangel M (2008) Hybrid transvaginal nephrectomy. Eur Urol 53:1290–1294

    PubMed  Article  Google Scholar 

  15. 15.

    Zornig C, Mofid H, Emmermann A, Alm M, von Waldenfels HA, Felixmuller C (2008) Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients. Surg Endosc 22:1427–1429

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Varadarajulu S, Drelichman ER (2009) Natural orifice transluminal endoscopic surgery: breaching the boundaries safely. Gastrointest Endosc 69:115–116

    PubMed  Article  Google Scholar 

  17. 17.

    Coelho D, Ardengh JC, Eulalio JM, Manso JE, Monkemuller K, Coelho JF (2008) Management of infected and sterile pancreatic necrosis by programmed endoscopic necrosectomy. Dig Dis 26:364–369

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Hocke M, Will U, Gottschalk P, Settmacher U, Stallmach A (2008) Transgastral retroperitoneal endoscopy in septic patients with pancreatic necrosis or infected pancreatic pseudocysts. Z Gastroenterol 46:1363–1368

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Marks JM, Ponsky JL, Pearl JP, McGee MF (2007) PEG “Rescue”: a practical NOTES technique. Surg Endosc 21:816–819

    PubMed  Article  Google Scholar 

  20. 20.

    da Costa Martins B, Takada J, Kawaguti FS, Aguiar Ribeiro JP, Hondo FY, Lima MS, Neves CZ, Nahas CS, Marques CF, Sakai P, Maluf-Filho F (2011) PEG rescue with gastropexy after early tube withdrawal: an application of natural orifice transluminal endoscopic surgery. Gastrointest Endosc 74:709–711

    Article  Google Scholar 

  21. 21.

    Elmunzer BJ, Schomisch SJ, Trunzo JA, Poulose BK, Delaney CP, McGee MF, Faulx AL, Marks JM, Ponsky JL, Chak A (2009) EUS in localizing safe alternate access sites for natural orifice transluminal endoscopic surgery: initial experience in a porcine model. Gastrointest Endosc 69:108–114

    PubMed  Article  Google Scholar 

  22. 22.

    Denk PM, Swanstrom LL, Whiteford MH (2008) Transanal endoscopic microsurgical platform for natural orifice surgery. Gastrointest Endosc 68:954–959

    PubMed  Article  Google Scholar 

  23. 23.

    Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24:2200–2205

    PubMed  Article  Google Scholar 

  24. 24.

    Lorenz C, Nimmesgern T, Back M et al (2010) Transanal single port microsurgery (TSPM) as a modified technique of transanal endoscopic microsurgery (TEM). Surg Innov 17:160–163

    PubMed  Article  Google Scholar 

  25. 25.

    Ragupathi M, Haas EM (2011) Transanal endoscopic video-assisted excision: application of single-port access. JSLS 15:53–58

    PubMed  Article  Google Scholar 

  26. 26.

    Maclaren A (1908) Pelvic abscess, with special reference to rectal drainage. Ann Surg 47:1034–1036

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Pollard B (1908) On rectal drainage in cases of pelvic abscess due to appendicitis. Br Med J 2:196

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Eliot E, Pickhardt OC (1921) The management of pelvic abscess in acute appendicitis. Ann Surg 74:480–489

    PubMed  Article  CAS  Google Scholar 

  29. 29.

    Seewald S, Ang TL, Teng KY, Groth S, Zhong Y, Richter H, Imazu H, Omar S, Polese L, Seitz U, Bertschinger P, Altorfer J, Soehendra N (2009) Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis. Endoscopy 41:166–174

    PubMed  Article  CAS  Google Scholar 

Download references


B. C. Martins, Carlos Frederico Sparapan Marques, Caio Sérgio Rizkallah Nahas, Fábio Yuji Hondo, Wilson Pollara, Sérgio Carlos Nahas, U. Ribeiro Junior, Ivan Cecconello, and Fauze Maluf-Filho have no conflicts of interest or financial ties to disclose.

Author information



Corresponding author

Correspondence to B. C. Martins.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MOV 18125 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Martins, B.C., Marques, C.F.S., Nahas, C.S.R. et al. A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access. Surg Endosc 26, 2667–2670 (2012). https://doi.org/10.1007/s00464-012-2215-6

Download citation


  • Abdominal abscess
  • Drainage
  • Endoscopy
  • Therapeutic endoscopy