Necrotizing fasciitis surgery: Difference between revisions
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*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. | *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. | *The extent and depth of debridement is so extensive that it may involve group of muscles which requires removal of all the muscles. | ||
====Amputation==== | |||
*Indications:<ref name="pmid15723996">{{cite journal| author=Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E| title=Predictors of mortality and limb loss in necrotizing soft tissue infections. | journal=Arch Surg | year= 2005 | volume= 140 | issue= 2 | pages= 151-7; discussion 158 | pmid=15723996 | doi=10.1001/archsurg.140.2.151 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723996 }} </ref> | |||
:*Extensive soft tissue necrosis with involvement of the underlying muscles | |||
:*ASA score III and above<ref name="pmid21712864">{{cite journal| author=Daabiss M| title=American Society of Anaesthesiologists physical status classification. | journal=Indian J Anaesth | year= 2011 | volume= 55 | issue= 2 | pages= 111-5 | pmid=21712864 | doi=10.4103/0019-5049.79879 | pmc=3106380 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21712864 }} </ref> | |||
:*Shock | |||
===Perineal, perianal or scrotal infection=== | ===Perineal, perianal or scrotal infection=== | ||
Revision as of 01:38, 12 September 2016
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Necrotizing fasciitis Microchapters |
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Necrotizing fasciitis surgery On the Web |
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American Roentgen Ray Society Images of Necrotizing fasciitis surgery |
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Risk calculators and risk factors for Necrotizing fasciitis surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]
Overview
Surgery
Surgery is the mainstay of treatment for necrotizing fasciitis.
- Indications include:[1]
- Patients displaying intense pain and skin color change such as edema and/or ecchymoses
- Signs of skin ischemia with blisters and bullae
- Altered mental status, hypotension, elevated band forms in the differential WBC count and metabolic acidosis.
- Immediate surgical referral remains the only method of reducing mortality and morbidity in necrotizing fasciitis patients.[2][3]
- As the patient's are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.[4]
- Effects of analgesia can be measured by documenting pain score regularly.
- Stop the NSAID's on admission of patients.
Extremities
- Debridement of the tissue is the main surgical procedure.[2][5]
- To achieve better surgical wound healing and less scarring, incisions are performed parallel to Langer's lines.[1]
- 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.
Amputation
- Indications:[6]
- Extensive soft tissue necrosis with involvement of the underlying muscles
- ASA score III and above[7]
- Shock
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
- Incision:[1]
- Skin incision is made in the longitudinal direction along the muscle-fascial layers of inner abdominal wall until healthy tissue is found.
- Post-operative management:
- Serial dressing changes until the wound is free of ongoing or recurrent infection.
- In 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 retroperitonial site is performed followed by partial bowel excision depending on the part of the bowel involved.
- A diverting colostomy with multiple drainage'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.
Images
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![Surgery of necrotizing fasciitis.The excision of the necrotic tissues should extend until healthy tissue is found, but should be limited to the edges of the infection.[1]](/images/e/e0/Surgery_NF.jpg)
Surgery of necrotizing fasciitis.The excision of the necrotic tissues should extend until healthy tissue is found, but should be limited to the edges of the infection.[1]
![Surgery of necrotizing fasciitis.The excision of the necrotic tissues should extend until healthy tissue is found, but should be limited to the edges of the infection.[1]](/index.php/File:Surgery_NF.jpg)
References
- ↑ 1.0 1.1 1.2 1.3 Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A (2014). "Current concepts in the management of necrotizing fasciitis". Front Surg. 1: 36. doi:10.3389/fsurg.2014.00036. PMC 4286984. PMID 25593960.
- ↑ 2.0 2.1 Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J (2011). "Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs". World J Emerg Surg. 6 (1): 46. doi:10.1186/1749-7922-6-46. PMC 3310784. PMID 22196774.
- ↑ Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS (2006). "Necrotizing fasciitis in rheumatic diseases". Lupus. 15 (6): 380–3. PMID 16830885.
- ↑ Baxter F, McChesney J (2000). "Severe group A streptococcal infection and streptococcal toxic shock syndrome". Can J Anaesth. 47 (11): 1129–40. doi:10.1007/BF03027968. PMID 11097546.
- ↑ Elliott DC, Kufera JA, Myers RA (1996). "Necrotizing soft tissue infections. Risk factors for mortality and strategies for management". Ann Surg. 224 (5): 672–83. PMC 1235444. PMID 8916882.
- ↑ Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E (2005). "Predictors of mortality and limb loss in necrotizing soft tissue infections". Arch Surg. 140 (2): 151–7, discussion 158. doi:10.1001/archsurg.140.2.151. PMID 15723996.
- ↑ Daabiss M (2011). "American Society of Anaesthesiologists physical status classification". Indian J Anaesth. 55 (2): 111–5. doi:10.4103/0019-5049.79879. PMC 3106380. PMID 21712864.