Primary closure of gluteal injection abscess (a study of 100 cases).
The theory of primary closure of acute pyogenic abscess is a challenge to the conventional surgical teaching which mentions that every abscess must have a free drainage. Although this technique is providing good results, it has not yet gained generalised acceptance.
Most of the previous studies were conducted upon small superficial abscesses, specially at the sites where tissue adequacy was sufficient. This tissue sufficiency facilitates the obliteration of abscess cavity which is an essential step of this technique. We selected deep gluteal injection abscesses for this study as these abscesses constitute a typical problematical group for primary closure technique. This paper presents a study of 100 cases of injection abscesses managed by primary closure technique. Elaboration and management of problems related to this abscess group are also attempted.
An antibiotic was started 48 hours prior to surgery. Operative part of the patient was prepared, painted and draped. Short acting general anaesthesia (pentothal sodium + pentazocine + diazepam) was used. An adequate linear incision along the long axis of the abscess was applied. All the necrotic material and slough was drained out. Culture of pus was examined as a routine. Thorough inspection of the abscess cavity was done to exclude any side pocket or necrotic material. Deep vertical mattress sutures were applied around the abscess cavity [Fig. 1]. A corrugated rubber drain was put in the wound. Sutures were tied with adequate tension to occlude the abscess cavity completely. Soft cotton dressing was applied over the wound, being supported by adhesive straps. Daily spirit cleaning of the wound and change of dressing were done. A careful recording of wound condition was done. Drain was removed on the 2nd to 4th post-operative day according to the amount and nature of discharge. Stitches were removed on the 7th-10th postoperative day. The antibiotic and supplementory medication (anti-inflamatory drug and vitamin-C) were continued till the removal of stitches. Follow-up was done after one, six and twelve months.
One hundred cases of injection abscess at the gluteal region were managed by primary closure technique under antibiotic cover. Eleven patients had bilateral abscesses and were managed at the same sitting. No topical antibiotic was used in the wound. The results are summarised as follows:
Time of healing
The complete skin to skin healing time? of the wound ranged between 7 and 10. days with an average time of 8.5 days. This is much less than the healing time; of the open drainage method which is usually 30-50 days.
Cost of treatment
It was estimated to be Rs. 50 to Rs. 200 per case in this study. In the open drainage method, this varies from Rs. 200 to Rs. 500 per case.
Recurrence of abscess formation
No patient in our series had second time anaesthesia for a recurrent abscess in the same wound.
Three patients had a sinus formation at the end of one month. This constitutes the failure group of this series.
Pus culture examination revealed Staphylococcus aureus (60%), followed by Streptococcus viridans (20%). Other bacteria isolated were B. proteus, Pseudomonas, and E. coli. In 10% cases, no micro-organism was isolated.
In this study, we used cephalexin, cloxacillin and erythromycin 500 mg 6 hourly for 7-10 days. These antibiotics were instituted 48 hours prior to surgery in every patient. No toxic or side effects of these antibiotics were seen except with erythromycin where some patients experienced pain in the abdomen, nausea and vomiting.
These were: less blood oozing, avoid.-lance of painful bulky filling dressings, early ambulation of the patient and a neat linear scar.
Prior to classic original idea of primary closure of acute abscesses by Ellis (1953, 1960, 1970), the infected abscesses were managed by open drainage. Till date, the conventional surgical teaching in the management of pyogenic abscess is a wide open drainage of the abscess cavity and allowing the wound to heal by secondary intention from its floor. This teaching carries even greater weight in case of a big gluteal injection abscess where there is an increased risk of sinus and recurrent abscess formation.
Ellis (1953, 1960, 1970) pioneered the idea that the healing of acute pyogenic abscess can be achieved by primary intention. This idea was well supported by Benson and Goodman, (1970), Page (1974), Jones and Wilson (1976), Mehta and Achrekar (1980), Rangabashyam (1981) and Howie et al (1982). All these studies were conducted with excellent results and proved that the primary closure of acute pyogenic abscess is a safe, reliable and convenient procedure.
The primary closure technique depends mainly upon following steps (i) localization of the abscess (ii) elimination of infection (iii) currettage of the abscess cavity wall and (iv) complete obliteration of the abscess cavity space. In our series, localization of the abscess cavity was ensured by institution of an antibiotic 48 hours prior to surgery. This preoperative antibiotic sterilises the peripheral area of the abscess and stops further abscess formation. Even if this antibiotic does not penetrate into the abscess cavity due to unhealthy granulation tissue barrier, it definitely localises the abscess. In some cases it may convert the infected abscess into a sterile pus collection. An adequate incision along the long axis of the abscess cavity will help to drain all the abscess and permit a thorough inspection of the interior of the abscess cavity. No side abscess pocket or slough in the cavity should however remain, otherwise failure is inevitable. Currettage of the wall of the abscess cavity is done to break the so called barrier of penetration of the antibiotic. Complete obliteration of the abscess cavity is very important. Any residual space will invite the collection of serum or blood which is bound to get infected, and will lead to failure of the procedure. The complete obliteration of abscess cavity will also help to approximate the epithelial surfaces and granulation tissues thus inviting tissue healing by primary intention. The antibiotic is continued till the removal of stitches. This helps in eradication of any residual infection. All these factors are very essential for the success of primary closure technique and fortunately are under, the control of the dealing surgeon.
Macfie and Harvey (1977) doubted the role of primary closure technique in the management of acute pyogenic abscess. They thought that the antibiotic cannot penetrate the abscess cavity wall barrier and that the primary closure may impede the free drainage of pus and complete obliteration of abscess cavity may not be possible. These authors experienced 11.7% failure rate in their series of primary closure. Mehta and Achrekar (1980) also agreed with Macfie and Harvey (1977) that once the abscess is formed, antibiotic has very little role to play and acts only as an adjunct to surgical procedures. However, we consider the role of antibiotic very crucial in the primary closure technique.
All studies till date were conducted upon the abscesses situated mainly at sites other than the gluteal region [Table - 1]. Gluteal injection abscess poses some basic problems different from abscesses at other sites. These abscesses are usually deep seated, irregularly placed and have many side pockets. Tissue laxity at the gluteal region as compared to the breast or axilla is also compromised. Hence, the complete obliteration of abscess cavity is a difficult job at the gluteal region. We were able to achieve complete obliteration only by applying sutures under tension with thick suture materials assisted by tension tubes.
Gluteal injection abscess takes much more time for healing, when managed by conventional open drainage method. Big raw wound, which is allowed to heal by secondary intention from its floor with the help of pack dressings, usually heals within 30-50 days. This healing duration was cut short very effectively to an average of 8.5 days in this series. This reduction in healing time clearly indicates the usefulness of this procedure.
A large wound after an open drainage oozes blood in big quantities which is quite evident on the removal of the first post-operative dressing. There is again a certain amount of blood loss from the newly developing friable granulation tissues at every change of pack dressing. This blood loss is minimum, when gluteal injection abscess is managed by primary closure. None of the patients of our series required any change or super-dressing during the first post-operative day.
The total cost of treatment ranged between Rs. 50 and 200 per case in this series. The money was mainly spent upon the antibiotic and supplementary medication. In open drainage method, when the patient is having wound for a longer period, the cost of treatment will be naturally more.
The use of large bulky pack dressings in the big wound can be completely omitted by suturing the wound. We required only mild spirit cleansing and light cotton dressing to cover the stitched wound. The removal of large bulky dressings from an open wound may cause a variable amount of pain due to irritation of naked nerve endings. This was experienced at the least by the patients of this series.
As the wound was completely stitched and there was less pain, an early ambulation of patients was achieved within 12 hours after operation. Early ambulation facilitates the drainage of any residual collection and better approximation of wound edge due to gluteal muscular contractions. A closed stitched wound and early ambulation provide a psychological support to the patient.
The big raw wound of an open drainage method heals irregularly. The result may be an irregular ugly scar on the buttock. We achieved a neat linear, scar which was hardly visible in fair coloured persons.
Antibiotics play a central role in the primary clousure technique of injection abscess. Antibiotic must belong to the bactericidal group and must be highly effective against causative micro-organisms. It should be given in full doses and for an adequate period. The antibiotic must maintain an effective bactericidal blood concentration. Idealy the antibiotic should be effective in the presence of pus. We used cephalexin, cloxacillin and erythromycin. The problem of penicillin resistant strains of micro-organisms led us to select the latest set of antibiotics.
A meticulous surgical technique is a requisite for the success of primary closure. Complete evacuation of pus and elimination of any side pocket must be done. Thorough breakage of abscess cavity wall should be done to permit the entry of antibiotic loaded blood into the abscess cavity. This penetration of antibiotic is highly desirable so as to eradicate any residual infection.
The results of our series were excellent. None of the patients had a recurrent abscess formation. Three patients had a sinus formation which was managed by excision of the sinus tract. Rest of the patients had eventless post-operative period. No early or late complication was recorded.
We observed certain typical problems related to the primary closure of gluteal injection abscess (i) A few patients kept on discharging serous fluid from any one of the suture holes. Usually the wound became dry on the 4th-6th post-operative day. We attribute this discharge either to a residual infection or due to the tissue reaction to the suture material. In this study thick braided silk or mono-filament nylon was used. Such cases were managed effectively by the change of antibiotic. (ii) sinus formation occurred in three cases of this series. Exploration revealed a tortuous sinus track almost connected with every suture passage. Excision of sinus tracks led to a great loss of gluteal tissues. (iii) Irregular abscess cavity with side pockets may cause difficulty in obliteration of dead space. (iv) Skin necrosis was noticed in three cases. Eliptical excision of dead skin and subcutaneous tissues was done along with the incision. This permitted suturing, and approximation of healthy tissues. Two patients had eventless recovery but one case developed central disruption of wound, on the fourth day. Luckily, this patient did not develop a sinus but took a longer period to heal.
In case, of bilateral abscesses, we could manage both sides at the same sitting. We encountered 11 such cases. Complete eventless recovery was achieved in every case.
The high success rate (97%) of this series proves that this procedure is very convenient, effective and economical in the management of gluteal injection abscess.