View source for Fournier gangrene surgery

__NOTOC__
{{Fournier gangrene}}
{{SCC}}; {{AE}} {{YK}}; {{JH}}

==Overview==
Surgery is the mainstay of treatment for Fournier gangrene.<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>. As the patients are cardiovascularly unstable, immediate [[resuscitation]] with [[intravenous fluids]], [[colloids]] and [[inotropes|inotropic agents]] are usually necessary.<ref name="pmid11097546">{{cite journal| author=Baxter F, McChesney J| title=Severe group A streptococcal infection and streptococcal toxic shock syndrome. | journal=Can J Anaesth | year= 2000 | volume= 47 | issue= 11 | pages= 1129-40 | pmid=11097546 | doi=10.1007/BF03027968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11097546  }} </ref>


===Surgery===
'''Radical surgical debridement'''

Surgery is the mainstay of treatment for Fournier gangrene.<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
*Indications include:<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
:*Patients displaying intense pain and skin color change such as [[edema]] and/or [[ecchymoses]]
:*Signs of [[ischemia|skin ischemia]] with [[blister|blisters]] and bullae
:*[[Altered mental status]], [[hypotension]], elevated [[band cell|band forms]] in the differential [[WBC]] count and [[metabolic acidosis]].
* Immediate surgical referral remains the only method of reducing [[mortality]] and [[morbidity]] in Fournier gangrene patients.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774  }} </ref><ref name="pmid16830885">{{cite journal| author=Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS| title=Necrotizing fasciitis in rheumatic diseases. | journal=Lupus | year= 2006 | volume= 15 | issue= 6 | pages= 380-3 | pmid=16830885 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16830885  }} </ref>
*As the patients are cardiovascularly unstable, immediate [[resuscitation]] with [[intravenous fluids]], [[colloids]] and [[inotropes|inotropic agents]] are usually necessary.<ref name="pmid11097546">{{cite journal| author=Baxter F, McChesney J| title=Severe group A streptococcal infection and streptococcal toxic shock syndrome. | journal=Can J Anaesth | year= 2000 | volume= 47 | issue= 11 | pages= 1129-40 | pmid=11097546 | doi=10.1007/BF03027968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11097546  }} </ref>
*Effects of [[analgesia]] can be measured by documenting pain score regularly.
*Stop any [[NSAID|NSAIDs]] on patient admission.

'''Procedure'''
*Radical debridement of areas of overt [[necrosis|subcutaneous necrosis]] should be done in the operation theater in the [[lithotomy]] position to allow access to all perineal structures.
*Deep fascia and muscle are rarely involved, thus debridement is usually not required.
*Separation of the skin and subcutaneous tissue with a hemostat has been recommended to define the limits of excision. Debridement is stopped where these tissues do not separate easily.

'''Fecal and urinary diversion'''
*Urinary or fecal diversion is required to treat an underlying condition or prevent wound contamination.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475  }}</ref>
*When there is gross urinary extravasation or periurethral inflammation, [[suprapubic cystostomy]] is required. A urinary catheter is used in milder cases.
*[[Colostomy]] is required when there is gross sphincter infection or colonic or rectal perforation.
*Testes are temporarily implanted into subcutaneous tissue pouch (medial thigh or lower abdomen) until healing or reconstruction is complete. 
*[[Orchidectomy]] is performed if there is any pre-existing [[epididymo-orchitis]] or [[abscess|scrotal abscess]].

'''Plastic reconstruction'''
*The split thickness [[skin graft]] is a commonly used technique for reconstructive surgery. For large defects, rotational or free myocutaneous flaps and omental flaps are used to cover larger defects.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475  }} </ref>

'''Wound management'''
*The wound is monitored closely after surgery.
*Multiple surgical debridement are required with an average of 3.5 procedures per patient.<ref name="pmid12706005">{{cite journal| author=Chawla SN, Gallop C, Mydlo JH| title=Fournier's gangrene: an analysis of repeated surgical debridement. | journal=Eur Urol | year= 2003 | volume= 43 | issue= 5 | pages= 572-5 | pmid=12706005 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706005  }}</ref>
*[[Sodium hypochlorite]] or [[hydrogen peroxide]] are used post-operatively for topical application.<ref name="pmid8650874">{{cite journal| author=Hejase MJ, Simonin JE, Bihrle R, Coogan CL| title=Genital Fournier's gangrene: experience with 38 patients. | journal=Urology | year= 1996 | volume= 47 | issue= 5 | pages= 734-9 | pmid=8650874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8650874  }}</ref>
*[[Collagenase|Lyophilized collagenase]] (an enzyme that digests and debrides [[necrotic]] tissues) is used for enzymatic debridement twice daily until definite reconstruction can be performed.<ref name="pmid9803004">{{cite journal| author=Aşci R, Sarikaya S, Büyükalpelli R, Yilmaz AF, Yildiz S| title=Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application. | journal=Eur Urol | year= 1998 | volume= 34 | issue= 5 | pages= 411-8 | pmid=9803004 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9803004  }} </ref>

'''Vacuum-assisted closure device'''
<br>The vacuum assisted closure device is used for faster and  effective wound closure.<ref name="pmid18470279">{{cite journal| author=Silberstein J, Grabowski J, Parsons JK| title=Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm. | journal=Rev Urol | year= 2008 | volume= 10 | issue= 1 | pages= 76-80 | pmid=18470279 | doi= | pmc=2312348 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18470279  }}</ref><ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }}</ref>  This devices helps wound healing by absorbing excess [[exudate|exudates]], reducing localized [[edema]], and finally drawing wound edges together.

==References==
{{Reflist|2}}