Necrotizing fasciitis surgery
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Surgery is the mainstay of treatment for necrotizing fasciitis.
- Indications include:
- Immediate surgical referral remains the only method of reducing mortality and morbidity in necrotizing fasciitis patients.
- As the patient's are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.
- Effects of analgesia can be measured by documenting pain score regularly.
- Stop the NSAID's on admission of patients.
Finger Probe Test
Finger probe test is useful in the diagnosis of necrotizing fasciitis.
- This test is carried out in the ward, emergency room, or in the theater under local or general anesthesia.
- After infiltrating the area, a 2cm incision is made down to the deep fascia.
- Fascia will be swollen and grey on gross inspection.
- Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive.
- Signs suggesting necrotizing fasciitis include:
- Lack of bleeding
- Lack of normal tissue resistance on finger probe
- Oozing of malodorous "dish water fluid"
- Debridement of the tissue is the main surgical procedure.
- To achieve better surgical wound healing and less scarring, incisions are performed parallel to Langer's lines.
- Wide resection is performed with boundaries at least as wide as the rim of cellulitis until surrounding healthy bleeding tissue found.
- After drainage of pus and/or hemorrhagic fluid, ventricle incisions are made, keeping the wound open which allows drainage and removal of additional necrotic tissue.
- Patients should be closely monitored after surgery and re-exploration with serial debridements, spaced 12 to 36 hours, may be needed to control the infection.
- The extent and depth of debridement is so extensive that it may involve group of muscles which requires removal of all the muscles.
- Extensive soft tissue necrosis with involvement of the underlying muscles
- ASA (American Society of Anaesthesiologists) score III and above
Perineal, perianal or scrotal infection
- A temporary diverting colostomy should be considered to facilitate the decrease need for frequent change of dressings, protect the skin graft for reconstruction and wound hygiene.
- After scrotal resection, the testes are treated by placing them in pockets in the medial aspects of the thighs.
Abdominal wall infection
- Skin incision is made in the longitudinal direction along the muscle-fascial layers of the inner abdominal wall until healthy tissue is found.
- Serial dressing changes until the wound is free of ongoing or recurrent infection.
- In the case of progression of infection, aggressive surgical debridement should be repeated.
Extension of infection into the bowel:
- In cases of extension of infection into the bowel, an exploratory laparotomy is required.
- Radical surgical debridement at the site of infection and retroperitoneal site is performed followed by partial bowel excision depending on the part of the bowel involved.
- A diverting colostomy with multiple drainages's of infected abdominal fluid collections is required.
- Hartmann’s resection is the procedure of choice in patients with perforated colon with peritonitis and in elderly patients with multiple co-morbidities.
Breast and axilla
- As the axillary region is rich in blood and lymphatic supply, this enables the infection to spread rapidly to distant sites. Hence the delay in surgical debridement proves to be lethal.
- Care must be taken to avoid contractures.
Vacuum-assisted closure device
- Vacuum assisted closure device is used for faster and effective wound closure.
- Helps wound healing by absorbing excess exudates, reducing localized edema, and finally drawing wound edges together.
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