Chronic groin sinus: an unusual complication of sterilisation clips

Abstract

We report the case of a patient presenting with a chronic groin sinus secondary to a tubal ligation clip migration (Filshie clip) 21 years after the laparoscopic sterilisation took place. Our case report adds to the small number of cases describing tubal clip migration with resultant local sepsis. Although this is a rare complication, it should be borne in mind for women who have undergone tubal clip ligation and present with recurrent or chronic groin, perineal or peri-anal sepsis.

Laparoscopic tubal ligation with Filshie clips is a relatively safe method of surgical sterilisation performed routinely in NHS hospitals. The migration of tubal ligation clips across tissue planes is rare; migration with resultant local sepsis is even rarer. Migration is usually a late, rather than an early, complication. We report the case of a patient presenting with a chronic groin sinus secondary to a tubal ligation clip migration (Filshie clip) 21 years after the laparoscopic sterilisation took place.

Case history

A 56-year-old post-menopausal woman (gravida 4, para 3, abortus 1) was referred to the general surgical clinic with a 4-week history of a lump in the left groin which had not responded to treatment with oral, broad-spectrum antibiotics. Past medical history of note included a laparoscopic sterilisation with Filshie clips performed in 1985. The procedure was uneventful and no complications were noted.

Clinical examination revealed a non-tender 10 × 5 cm fluctuant lump in the left groin with some surrounding erythema. A single ‘shotty’ right inguinal lymph-node was noted. There was no evidence of other lymphadenopathy or organomegaly. White cell count, C-reactive protein and erythrocyte sedimentation rate were not elevated. Incision and drainage (I+D) of the left groin abscess was performed in September 2006. The subcutaneous fat was noted to be indurated and oedematous. The abscess cavity was opened and purulent fluid was retrieved; no foreign bodies were noted. Microscopy of the fluid showed polymorphs but culture did not grow any organisms. Acid-fast bacilli stain was negative. Histology of the cavity wall showed evidence of chronic inflammation with fibrous septa but no evidence of lymphatic tissue or malignancy. Two weeks post-operatively, there was evidence of slow wound healing; the patient was advised to continue with regular alginate dressing changes. Two weeks later, there was evidence of incomplete healing with intermittent seropurulent discharge. A course of oral Co-amoxiclav was prescribed, while swabs taken at the time grew Staphylococcus aureus. Almost 6 months postoperatively, satisfactory would healing was noted with no further discharge.

A year after the initial I+D, the patient was referred again by her general practitioner as there was evidence of abscess recurrence with intermittent discharge for the past few weeks . The lump was prominent and tender. A pinhole opening which was intermittently discharging a seropurulent fluid was noted. The patient was, therefore, offered a repeat exploration and excision of the sinus. The procedure was carried out in a minor operations theatre one month later; a Filshie clip was found just showing in the left groin sinus. It was easily removed, while the swab taken grew mixed anaerobic bacteria. A month later, the skin had healed completely, while a plain radiograph of the pelvis showed a Filshie clip normally placed in the right side of the pelvis.

Discussion

Occlusion of the fallopian tubes is the single most popular method of fertility regulation world-wide. The incidence rate for tubal occlusion in 1999 was 3.91 per 1000 English women aged 20–54 years. In the same year, 41,300 tubal occlusions were performed in NHS hospitals in England.¹ Laparoscopic tubal occlusion using Filshie clips is a safe and technically straightforward procedure. This method has been used for more than 20 years; the incidence of failure is estimated at 0.2–0.5%.²

Filshie clips are 12.7 mm long and 4 mm wide. They are lined with silicone rubber and have titanium jaws which are locked across each fallopian tube. Eventually avascular necrosis occurs leaving two occluded stumps. The clips usually become covered with a thin layer of peritoneum at the site of the tubal separation. Occasionally, one or both clips migrate before their peritonealisation occurs. This occurs in over 10% of cases and the clips usually settle in the pouch of Douglas or the paracolic gutters.³ The incidence of clip migration with expulsion via natural orifices (urethra, vagina, rectum) has been estimated as 0.6 per 1000 cases.²

Cases of peri-anal,^3–5 bladder,⁶ pelvic⁷ and groin abscess⁸ formation secondary to tubal clip expulsion have been sporadically reported in the literature. The present case is the first one of such a late abscess formation (21 years after the laparoscopic sterilisation).

The presumed pathogenesis involves a low-grade inflammatory process which leads to clip migration and erosion into the abdominal wall or a hollow viscus with or without resultant local sepsis.² Although Filshie clips are made of relatively inert materials, they do cause a certain degree of host reaction. This is evident in cases of ectopic pregnancy following tubal occlusion, which are thought to be secondary to the formation of a tubo–peritoneal or tubo–tubal fistula.²

The present case report adds to the literature describing a late and rare complication of tubal occlusion. Doctors performing tubal occlusions should be aware of this rare risk of the procedure they perform and consider discussing it with a patient when taking consent. Doctors facing a female patient with recurrent or chronic groin, perineal or peri-anal sepsis, should consider tubal clips or other foreign bodies in the differential diagnosis. Following the removal or expulsion of a tubal clip, if fertility is of concern, hysterosalpingography could be used to assess tubal occlusion.²