Surgery

Early and aggressive surgical debridement is essential, because it significantly decreases morbidity and mortality (Bahlmann et al. 1983). The procedure should be done under general anesthesia, as the true extent of the infection is usually unknown preoperatively. The patient should be placed in a dorsal lithotomy position (Paty and Smith 1992; Smith et al. 1998). The aim of de-bridement is to remove the origin of the infection as well as the infected tissues (Quantan and Kirby 2004). The surgeon as well as the patient should be prepared for radical debridement.

A midline perineal and scrotal incision usually gives the best initial exposure (Jones et al. 1979). Debride-ment is extended radially from the skin incision, keeping the anatomy of the fascial planes in mind. Only skin that is clearly necrotic should be excised. Viable skin should be mobilized so that all the underlying necrotic subcutaneous tissue and fascia can be excised.

A good indication of the extent of the infection is where the affected fascia fails to separate from the deep fascia and muscle on blunt dissection (Jones et al. 1979; Smith et al. 1998; Santora and Rukstalis 2001). The wound edges should bleed like normal tissue, indicating patent nutrient vessels.

If no purulent discharge can be milked from the urethra, and an F16 catheter can be passed into the bladder, it is reasonable to assume that the urethra is not the origin of the infection. However, if it is not possible to pass a transurethral catheter easily, a suprapubic catheter should be inserted (Benizri et al. 1996). Catheteriza-tion of the bladder is essential for monitoring fluid management and for adequate wound care (Laucks 1994).

Colostomy is indicated if the anal sphincter is involved, if rectal or colon perforation is present, in im-munocompromised patients with fecal incontinence, and if there is extensive involvement of the posterior perineal triangle (Fig. 6.3). Colostomy allows for better wound care (Paty and Smith 1992; Laucks 1994, Benizri et al. 1996). Some authors feel that doing a diverting co-

Fig. 6.3.Extensive debridement for necrotizing fasciitis arising from ischio-rectal area (note transurethral as well as suprapubic catheters, and stoma bag for transverse co-lostomy)

Fig. 6.3.Extensive debridement for necrotizing fasciitis arising from ischio-rectal area (note transurethral as well as suprapubic catheters, and stoma bag for transverse co-lostomy)

lostomy can be delayed until the second-look debride-ment when the patient is better resuscitated and more stable, because most acutely ill patients have an ileus for at least 48 h after admission (Bronder et al. 2004).

The testes, because of their nonperineal blood supply, are rarely affected, and orchidectomy is required in only 10%-20% of cases, if there is extensive involvement or a testicular cause for the infection (Baskin et al. 1990; Okeke 2000).

During scrotectomy, all necrotic tissues except the testes and spermatic cords should be debrided. The tes-tis can be buried in a lateral thigh pouch or in a subcutaneous abdominal pouch, depending on the extent of the debridement. This should not be done during the initial debridement, but during one of the subsequent procedures, because this decreases the risk of a thigh abscess and extension of the infection. If the testes are buried in thigh pouches, they should be placed at different levels, eliminating the risk of the testes rubbing against each other with the patient walking (Laucks 1994). Removal of the testes from the pouches and scro-tal reconstruction can be considered later.

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