Incision
Depending upon the site of abscess, incisions are made along the line of blood vessels and nerves and not across it. Where possible natural skin crease is selected in a dependent area. Most often the point where it fluctuates the most may be utilised. The length of the incision will depend upon the width and depth of the abscess. Generally, incision is made through most of the width of the abscess.
Once skin incision is made, drainage is done as follows:
An opening is made into the abscess using a sinus forceps or a closed blunt hemostat and when the abscess is entered open the jaws of the sinus forceps or hemostat allowing the purulent material to escape (Hilton's method). For an abscess of larger size, the index finger is inserted through the opening into the abscess cavity and pus is evacuated carefully palpating for deep pockets if any. Make sure that the finger does not open normal tissue space. Once all the purulent material is evacuated the cavity may be irrigated with normal saline using a bulb syringe. At this point the cavity could be packed with saline gauze part of which hangs out of the wound and also a corrugated rubber drain may be utilised for deeper pockets. Initial dressings are best managed by packing with saline gauze, Gamji pads and bandages or adhesive tapes as necessary. Abscesses are preferably dressed at least once a day and as often as necessary when it gets soaked with purulent drainages with each dressing further saline irrigation may be carried out particularly if the pockets are deep. Local application of antibiotics or use of betadine or chlorhexidine in the cavity does not seem to help particularly where abscesses have been adequately drained and dressed with saline gauze. Dressings can be facilitated particularly in the extremities utilising warm saline soaks in clean bowls. Elevation of the extremities involved, above the level of the heart adds to the comfort of the patient and helps in early healing.
It is always desirable to get a culture and sensitivity of the purulent material drained and while awaiting the final report, antibiotic is started. At times a gram stain may indicate the nature of the organisms and help in the selection of antibiotics.
Caution:
In abscesses along the spinal olumn, neck, chest and in typical areas where tuberculous cold abscess can present itself, it is better to evaluate the patient more thoroughly before incision and drainage is undertaken. Long history of symptoms, past history, local signs and symptoms, x-ray evidence and skin testing etc will help evaluate the possibility of tuberculous cold abscess.
Caution:
Special type of abscess (a) infection of the hand, (b) infection of the feet and carbuncles in the back and neck have to be dealt with according to specific management strategies.
Caution:
Like in all infections possibility of diabetes, immune compromised status etc must be kept in mind, evaluated and treated as necessary.
Caution:
Abscesses in the axilla and groin may be from lymphnodes; swelling in popliteal area raise the possibility of papliteal aneurysm. Large abscess particularly in the lower quadrants of the abdomen may indicate lesions inside the peritoneal cavity. Abscesses of the breast require incision and counter incision to promote adequate drainage.
Caution:
Peri-rectal abscesses require fair sized, crucial (cross shaped) incision to prevent the development of fistula in ano.
Caution:
Signs of abscess near the ends of bones, particularly in children may signify acute osteomyelitis and require more aggressive care in a hospital.
Caution:
Abscess in the region of labia majora may be Bartholin's abscess and must be managed appropriatey.
Caution:
A tender swelling below the inguinal ligament near or about its middle, particularly in a female, the possibility of an obstructed femoral hernia must be ruled out before carrying out incision and drainage.
Caution:
Drainage of Quincy (peritonsillar abscess and abscess of oropharynx and retropharynx) must be done with adequate precautions and ensuring availability of endotracheal tubation, suction and other facilities to prevent aspiration of purulent material.
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