Necrotizing fasciitis surgery
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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.[1]
- 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.
- Finger probe test
- Finger probe test is useful in the diagnosis of necrotizing fasciitis.
- Procedure
- This test is carried out in the ward, emergency room and in the theatre 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"
- Procedure
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
- Extensive soft tissue necrosis with involvement of the underlying muscles
- ASA score III and above[8]
- 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.
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.[9]
- Care must be taken to avoid contractures.[10][11]
Vacuum-assisted closure device
- Vacuum assisted closure device is used for faster and effective wound closure.[12][1]
- Helps wound healing by absorbing excess exudates, reducing localized edema, and finally drawing wound edges together.
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] -
![Wound management. Vacuum assisted closure device.[1]](/images/e/e4/VACD.jpg)
Wound management. Vacuum assisted closure device.[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)
![Wound management. Vacuum assisted closure device.[1]](/index.php/File:VACD.jpg)
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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.
- ↑ Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC (2001). "Necrotising fasciitis of a limb". J Bone Joint Surg Br. 83 (5): 709–14. PMID 11476311.
- ↑ 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.
- ↑ Adachi K, Tsutsumi R, Yoshida Y, Watanabe T, Nakayama B, Yamamoto O (2012). "Necrotizing fasciitis of the breast and axillary regions". Eur J Dermatol. 22 (6): 817–8. doi:10.1684/ejd.2012.1838. PMID 23131384.
- ↑ Yamasaki O, Nagao Y, Sugiyama N, Otsuka M, Iwatsuki K (2012). "Surgical management of axillary necrotizing fasciitis: a case report". J Dermatol. 39 (3): 309–11. doi:10.1111/j.1346-8138.2011.01456.x. PMID 22211460.
- ↑ Netscher DT, Baumholtz MA, Bullocks J (2009). "Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk)". Plast Reconstr Surg. 124 (6): 427e–35e. doi:10.1097/PRS.0b013e3181bf8323. PMID 19952603.
- ↑ Silberstein J, Grabowski J, Parsons JK (2008). "Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm". Rev Urol. 10 (1): 76–80. PMC 2312348. PMID 18470279.