INCISION AND DRAINAGE OF SUPERFICIAL LESIONS. PREVENTIVE AND CURATIVE DRAINAGE Bogdan Stancu Learning objectives What you should know What is a scalpel What are the types of scalpel blades used How to use a scalpel Classification of incisions What is surgical drainage What are the indications of surgical drainage Drainage modalities What type of drains to use When to remove drains What you should do Choose the materials required for incision and drainage Check the identity of the patient undergoing incision/drainage Open the package of a scalpel blade Mount a scalpel blade on the handle Perform a skin incision Perform an abscess incision Place a drain Maintain the sterility of materials throughout the procedure Dismount a blade from the scalpel handle Throw the blade to the container for sharp objects Definition Incision represents a cut into superficial or deep tissues using a sharp instrument (scalpel) in order to create direct surgical access for exposure of anatomical elements (arteries, veins, nerves, tendons, muscles), approach of an internal organ, drainage of an abscess, removal of a foreign body or a tumor, performance of biopsy, or excision of scar or necrotic tissues. Drainage is a surgical procedure that is usually complementary to a more or less extensive surgery, whose aim is to remove pathological or potentially pathological collections that exist or are at risk to develop in natural cavities or surgical wounds. Drainage is classified as preventive (prophylactic) and therapeutic (curative). Indications of incision: Hot abscess Perianal abscess Ischiorectal abscess Breast abscess Pilonidal disease Hidradenitis Carbuncle (anthracoid furuncle) Panaritia Phlegmon Hematoma Contraindications of incision: Furuncle Coagulation disorders Chronic treatment with oral anticoagulants Instability of vital functions Drainage of superficial lesions Preventive drainage – a safety procedure that prevents the development of hematic, serous collections or extravasated secretions from the natural pathways (gastric, biliary, intestinal secretion, etc.), which are susceptible to infection and transformation into purulent collections. Indications: Complicated wounds, with intense microbial contamination After laborious surgical procedures with imperfect hemostasis (thyroidectomy, surgical treatment of eventrations, etc.), with a risk of postoperative hemorrhage/lymphorrhagia Surgical procedures in organs with acute inflammation (appendicectomy, cholecystectomy, etc.) Acute pancreatitis Following anastomoses Curative drainage – aimed to remove a purulent septic collection from a tissue, organ or serous cavity. Healing in the case of an already established cavity will be slow, “ ” as granulation tissue develops from depth to the surface. Indications: Superinfected wounds Abscesses Phlegmons Hematomas Septic collections of serous cavities, parenchymal organs or adipose spaces of the body Peritoneal effusion in the case of cavity organ perforations Elements of anatomy The important blood supply of the skin is in the hypodermis, from which capillaries branch, reaching up to the dermis. Normal skin varies depending on topographic regions regarding thickness, consistency, elasticity, mobility in the underlying planes and linear folds, which should be taken into account when performing an incision. The subcutaneous cellular layer is poorly vascularized, being susceptible to infections. The investing fasciae of the muscle groups as well as the muscles should be cut longitudinally to connective fibers, to avoid affecting tonicity and the development of incisional hernias. Materials required for incision Scalpel Straight or curved scissors Hollow probe Surgical hemostats Pƒan’forceps Retractors Drains Antiseptic solutions Sterile compresses Materials required for drainage Drains (preferably silicone drains) Kehr’tube Rubber sheets Gauze pads Mikulicz bag Pƒan’forceps Needle holder Surgical hemostat Needles and sutures Scissors Antiseptic solutions Sterile compresses Incision technique The identity of the patient undergoing incision is checked and the patient is positioned (in dorsal, lateral, ventral decubitus, gynecological position) to provide optimal exposure and ligthing of the region concerned. Asepsis of the surgical field: Hair shaving in the region concerned Application of antiseptic solutions to the skin Isolation of the region with sterile drapes Anesthesia: Local or locoregional with lidocaine 1%; For more extensive or deeper lesions, spinal or general anesthesia is preferred. The surgeon is positioned on the side of the lesion, facing one or two assistants. Placement of the incision: The incision should be perpendicular to the surface of the dermis, the cut being continuous, with one movement, plane by plane, along the same line. Incisions are superficial when involving the cutaneous fat layers, and deep when involving underlying muscular aponeurotic, tendinous, vascular, nervous and visceral layers of parenchymatous or cavity organs. The incision pattern can be simple (straight, curved) or more complex (U, Z, D, T-shaped, circular or cross-shaped); care should be taken not to devascularize the dermis, in order to prevent its necrosis. An incision can be extended when intraoperatively it is found to no longer serve the aim pursued. The incision, which must be sufficiently large, will be placed at the most declivous site of the maximum fluctuation area for an effective drainage of purulent collections. The length of the incision should be proportional to the approached lesion and to the affected anatomical segment, in order to obtain good visibility and safety of the wound. Handling of the scalpel: The scalpel is held in the right hand, in different positions to ensure ease of use and maximum safety. With the other hand, the skin of the area concerned is held in place and stretched out. An incision always starts with the scalpel perpendicular to the skin, then it continues at a 30… angle, with the index pressing the superior ridge of the blade, cutting the skin up to the subcutaneous tissue, exerting uniform pressure, and at the end of the incision, the blade is held again in vertical position. For large incisions, the scalpel will be held like a knife, with the scalpel handle in the palm and the index finger on the superior ridge of the blade. For small incisions, the scalpel is held like a pencil, the cubital edge of the hand resting on the ’skin. The other hand stretches out the skin to be incised between the thumb and the index finger. For the incision of collections, the scalpel can be held like a dagger for puncturing and cutting, with the cutting edge of the blade upwards or so as to avoid injury to underlying anatomical parts. Deep incisions in the proximity of viscera or vessels are performed plane by plane using a hollow probe. In the case of abscesses, instrumental or blunt debridement is performed to empty the entire cavity. In the case of large subcutaneously tunneled cavities, a counterincision and drainage at the most declivous site are also carried out. In the case of perianal abscesses, incision is oriented radially towards the anal orifice. In the case of carbuncle, incision is cross-shaped, with the removal of necrotic tissues. Incision for panaritia is made on the lateral side of the digit, at the limit between palmar and dorsal skin, the incision line being discontinued at joint level. Hemostasis is performed by electrocautery or by ligation. Incision by electrocautery is indicated to obtain aesthetic scars (face, neck) as well as to open highly septic collections (anthrax, gas gangrene, diffuse phlegmon). Wound dressing is finally applied. Superficial lesion drainage technique The identity of the patient undergoing drainage is checked. Asepsis of the surgical field: Hair shaving in the area concerned Application of antiseptic solutions to the skin Isolation of the area with sterile drapes Anesthesia: Local or locoregional with lidocaine 1%; For more extensive or deeper lesions, spinal or general anesthesia is preferred. The surgeon is positioned on the side of the lesion, facing one or two assistants. An incision of superficial lesions is performed. Drainage involves placing a drain through the wound or the counterincision in the residual cavity at the most declivous site, following gravity. Drains are provided with multiple orifices, which must be Figure 1. Placement of a drain for situated inside the residual cavity. preventive purposes The drain should be adapted to a given situation regarding thickness and length, so as not to get clogged, and it should be sufficiently rigid not to collapse. The drain is secured by ligation following skin Figure 2. Placement of a drain by suturing. counterincision for curative purposes Drainage should be monitored daily for permeability, amount and quality of secretions. For the drainage of small cavities or panaritia, rubber sheets are used, which are brought out through the wound (Penrose drainage). When in addition to drainage, hemostasis is intended, gauze pads or a Mikulicz bag can be used, which will line the cavity until its filling, and these will be gradually removed. The drain tube is removed when secretions are no longer discharged through it, or it can be withdrawn successively – by mobilizing and resecuring it to avoid its displacement. Closed drainage involves the connection of the drain tube to a sterile plastic bag, an aspiration bellows system, or a vacuum container