Laparoscopic Drainage of a Gas-Forming Liver Abscess in a Hostile Abdomen: Surgical Feasibility Does Not Guarantee Survival

A pyogenic liver abscess (PLA) is a potentially fatal intra-abdominal infection. Prognosis worsens when gas formation, multiloculated cavities, or multidrug-resistant organisms, such as extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli), are involved. Management becomes more complex in patients with a "hostile abdomen," characterized by extensive adhesions from prior surgeries or chronic inflammation. We report the case of a 54-year-old man with type 2 diabetes mellitus, a previous open appendectomy, and a history of viral hepatitis who presented with jaundice, right upper quadrant (RUQ) pain, and systemic inflammatory response. Imaging with computed tomography (CT) revealed a 13 cm gas-forming, multiloculated hepatic abscess. Despite anatomical complexity and clinical deterioration, laparoscopic drainage was achieved using an open Hasson technique with extensive adhesiolysis. Initial improvement was followed by respiratory failure and multiorgan dysfunction, culminating in death in the intensive care unit (ICU). This case highlights the feasibility of laparoscopic drainage in hostile surgical fields but demonstrates that technical success does not ensure survival in systemically decompensated patients. It emphasizes individualized management guided by resistance patterns, comorbidities, and early recognition of sepsis using tools such as the Sequential Organ Failure Assessment (SOFA) score.