Subphrenic and Lesser Sac Abscess

Subphrenic and lesser sac abscesses are often post surgical or post traumatic. Lesser sac is also a common site for abscesses following complicated duodenal ulcer and pancreatitis. The preferred approach for a subphrenic abscess is to go subcostally or intercostally without injuring the liver/spleen and without pleural transgression. As the pleural recess is most shallow along the anterior aspect, it is often best to enter from here. The skin entry is much caudal to the location of the abscess and then the catheter has to be carefully navigated towards the abscess, at variable angles in all the three dimensions (Fig. 16.10). Hence, these are among the most technically difficult abscesses to drain percutaneously. Sometimes, hydrodissection to create a plane between the abdominal wall and liver/spleen may be required to place such drains. In select circumstances, a transhepatic or transdiaphragmatic drain insertion into a subphrenic abscess may be done. This should be avoided as far as possible; it should be performed only after the patient and the primary treating physician have been informed about the potential risk of hepatic abscess or emphyema.

The lesser sac is a fairly closed space and it can be impossible to get safe percutaneous access to an abscess in this region. If there is no response to medical management, the abscess often tracks out from the lesser sac, thereby giving a window to drain if percutaneously. If the patient is too sick for such an expectant management, transhepatic approach may be required for draining the lesser sac. The risk of secondary liver abscess exists with this approach.

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  • Category: Surgical treatment