Fournier gangrene surgery

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Steven C. Campbell, M.D., Ph.D.; Associate Editor(s)-in-Chief:  Yamuna Kondapally, M.B.B.S[1]; Jesus Rosario Hernandez, M.D. [2]

## Overview

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Surgery is the mainstay of treatment for Fournier gangrene.[1]. As the patients are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.[2]

## Surgery

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Radical surgical debridement

Surgery is the mainstay of treatment for Fournier gangrene.[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 Fournier gangrene patients.[3][4]
* As the patients are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.[2]
* Effects of analgesia can be measured by documenting pain score regularly.
* Stop any NSAIDs on patient admission.

Procedure

* Radical debridement of areas of overt subcutaneous necrosis should be done in the operation theater in the lithotomy position to allow access to all perineal structures.
* Deep fascia and muscle are rarely involved, thus debridement is usually not required.
* Separation of the skin and subcutaneous tissue with a hemostat has been recommended to define the limits of excision. Debridement is stopped where these tissues do not separate easily.

Fecal and urinary diversion

* Urinary or fecal diversion is required to treat an underlying condition or prevent wound contamination.[5]
* When there is gross urinary extravasation or periurethral inflammation, suprapubic cystostomy is required. A urinary catheter is used in milder cases.
* Colostomy is required when there is gross sphincter infection or colonic or rectal perforation.
* Testes are temporarily implanted into subcutaneous tissue pouch (medial thigh or lower abdomen) until healing or reconstruction is complete.
* Orchidectomy is performed if there is any pre-existing epididymo-orchitis or scrotal abscess.

Plastic reconstruction

* The split thickness skin graft is a commonly used technique for reconstructive surgery. For large defects, rotational or free myocutaneous flaps and omental flaps are used to cover larger defects.[5]

Wound management

* The wound is monitored closely after surgery.
* Multiple surgical debridement are required with an average of 3.5 procedures per patient.[6]
* Sodium hypochlorite or hydrogen peroxide are used post-operatively for topical application.[7]
* Lyophilized collagenase (an enzyme that digests and debrides necrotic tissues) is used for enzymatic debridement twice daily until definite reconstruction can be performed.[8]

Vacuum-assisted closure device
The vacuum assisted closure device is used for faster and effective wound closure.[9][1] This devices helps wound healing by absorbing excess exudates, reducing localized edema, and finally drawing wound edges together.

## References

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1. ↑ 1.0 1.1 1.2 1.3 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.CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 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.
3. ↑ 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.CS1 maint: Multiple names: authors list (link)
4. ↑ 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.CS1 maint: Multiple names: authors list (link)
5. ↑ 5.0 5.1 Paty R, Smith AD (1992). "Gangrene and Fournier's gangrene". Urol Clin North Am. 19 (1): 149–62. PMID 1736475.
6. ↑ Chawla SN, Gallop C, Mydlo JH (2003). "Fournier's gangrene: an analysis of repeated surgical debridement". Eur Urol. 43 (5): 572–5. PMID 12706005.CS1 maint: Multiple names: authors list (link)
7. ↑ Hejase MJ, Simonin JE, Bihrle R, Coogan CL (1996). "Genital Fournier's gangrene: experience with 38 patients". Urology. 47 (5): 734–9. PMID 8650874.CS1 maint: Multiple names: authors list (link)
8. ↑ Aşci R, Sarikaya S, Büyükalpelli R, Yilmaz AF, Yildiz S (1998). "Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application". Eur Urol. 34 (5): 411–8. PMID 9803004.CS1 maint: Multiple names: authors list (link)
9. ↑ 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.CS1 maint: Multiple names: authors list (link)