Pilot study to assess the role of minimal access surgery in the management of superficial surgical infections

Introduction The standard treatment for an abscess since time immemorial has been Incision and Drainage [I&D] without primary closure at most sites. Post-I&D, pain and ugly scar are the most common complaints in these patients. In this study, we have evaluated the role of minimal access surgery [MAS] in the management of superficial surgical infections. Materials and methods This was a prospective study, comparing the clinical and cosmetic outcomes of patients undergoing conventional I&D of superficial abscesses and those undergoing MAS [ 5mm incision for a port of 5mm diameter] drainage. Results A total of 50 patients were recruited, out of which 2 patients had a spontaneous rupture. 25 patients underwent I&D and 23 underwent MAS drainage. The mean age was 35.8 ±13.5 years, mean size of the abscess was 6 ± 1.9 cm. Baseline characteristics like age, sex distribution, duration of symptoms, size of the abscess and volume of the pus drained were comparable between the two groups. Resolution of pain and redness was achieved earlier in MAS drainage compared to conventional I&D. Resolution of induration was statistically insignificant. Duration of the need for dressing and duration of return to daily activity was less with MAS drainage. Scar size was significantly less in the MAS drainage group. Staphylococcus aureus was the most common organism isolated, and both groups had comparable rates of complications and recurrences. Conclusion Our study has shown that MAS drainage offers earlier recovery along with better cosmetic outcomes. Correspondence: Yashwant Singh Rathore E-mail: dryashvant.r@gmail.com https://orcid.org/0000-0002-0229-452X Received: 31-07-2021 Accepted: 07-11-2021 DOI: http://doi.org/10.4038/sljs.v39i3.8871 The Sri Lanka Journal of Surgery 2021; 39(3): 28-32 28 Introduction Wounds and abscesses have been recognized even in ancient history; the earliest recorded evidence being found in historic Greco-Roman texts [1]. Incision and drainage [I&D] with or without antibiotics have generally been considered an adequate treatment modality for abscesses. This is however associated with postoperative morbidity like requiring repeated dressings and scar related problems. Ultrasoundguided aspiration is another frequently used modality that offers several advantages like cosmesis, and a less morbid postoperative course. However, patients may require multiple sessions for complete resolution of the abscess. Minimally access surgery [MAS] drainage marks a paradigm shift in the treatment of superficial surgical infections. In this study, we have evaluated the role of minimal access drainage in breast, perianal and gluteal and other superficial abscesses and found that MAS drainage offers added advantage of direct visualization of the abscess cavity, the walls of the cavity [diagnostic], thereby aiding in the scraping of the walls [therapeutic] of the abscess cavity. There is little documented literature available for MAS drainage of superficial infections. This is the first pilot study to assess the role of MAS drainage in the management of superficial infections. Materials and methods This study was a single centre, in hospital, prospective, clinical interventional, comparative, cohort study. A formal ethical clearance was taken before the conduct of the study. All the pat ients vis i t ing the surgery outpat ient department/casualty at our tertiary care academic institute were recruited under the study protocol. A total of 50 patients were recruited in the study, out of which 2 patients had spontaneous rupture of the abscess and were thus excluded. Patients aged 18 – 65 years, with superficial abscesses of >3 cm size, were included. Pregnant, hemodynamically unstable patients were excluded from the study. All the patients underwent routine blood investigations, pre-anaesthetic check-ups, ultrasonography of the abscess. All procedures were performed under general anaesthesia. The patients were divided into two groups: group A: conventional I&D and group B: MAS drainage. Their distribution was done based on chits kept inside sequentially numbered opaque envelopes bearing either of the names [following the allocation concealment procedure] [2]. Patients were divided into two groups: Group A: conventional I&D – 25 cases Group A1: breast abscess – 10 cases Group A2: anorectal abscess – 12 cases Group A3: others – 3 cases – one case each of inguinal, back, and anterior abdominal wall abscess. Group B: MAS drainage – 23 cases Group B1: breast abscess – 14 cases Group B2: anorectal abscess – 9 cases Group B3: others – no cases were present in this group. Perioperatively all the patients were empirically given amoxicillin + clavulanic acid, 1.2 G IV or 625 mg oral TDS and metronidazole 400 mg IV or 500 mg oral TDS, and antibiotics were changed according to the culture report, once available.[3] Patients in group A: Under General anaesthesia, with aseptic precautions, the abscess was examined, and the most fluctuant point was marked with a sterile marker. The adequately sized incision was made over the point of maximum fluctuation. All the pus contained in the abscess cavity was drained out and sent for microbiological study [gram stain and culture]. Septations were broken down using blunt dissection using finger or sinus forceps. Thorough wash was given using warm Normal saline. The cavity was packed with betadine-soaked gauze with no drains. The wound was left open for continuous drainage and healing by secondary intention. Patients in group B: Under general anaesthesia, with aseptic precautions, the abscess was examined, and the most fluctuant point was marked with a sterile marker. A 5mm small stab incision was made at the point of maximum fluctuation. Now, a single 5 mm port was inserted [figure 1] and egress of the pus was aspirated [figure 2] and collected for pus culture and sensitivity. The abscess cavity was visualized using a 5 mm 0°-degree telescope [figure 3]. A suction cannula was inserted through the 5-mm port and any remaining pus was aspirated. The abscess cavity was washed with normal saline repeatedly until there was a clear return. CO2 insufflation was performed at low pressure of 5mm of Hg, to expand the cavity for better visualization. When all the pus had been drained, septations were broken down Maryland forceps blindly. The abscess cavity was visualized again for any remaining septations for confirmation of completion of the procedure. A repeat normal saline wash was given in the end. A 14 fr closed suction drain was inserted through the 29 same incision site and CO2 gas was allowed to escape. The incision site was closed over the drain using 2-0 silk sutures. Post-procedure the wound was examined for resolution of redness and induration. Drain output [if present] was monitored. It was decided that in case of failure of resolution of the abscess after primary operation, the second operation if needed would be I&D. Patient satisfaction was analyzed concerning the size of the scar, and duration of time to resume normal activity. These patients were followed up for 90 days postoperatively. Scars after both the procedures are shown in figures 4 and 5. Results The mean age in group A was 36.2 ± 13.6 years group B was 34.4 ± 11.4 years. Group A had 56% female patients and Group B had 74% female patients. 1. Resolution of pain: The duration to the resolution of pain in both the groups remained around 6 days with no statistically significant difference, as shown in table 1. 2. Resolution of redness: Redness resolved earlier in the MAS group as compared to the I&D group. Sub-group analysis revealed significant differences amongst patients with breast abscesses. However, no such difference was observed in patients with another abscess group as shown in table 2. 3. Resolution of induration: There was no statistical difference concerning the resolution of induration in both groups as depicted in table 3. 4. Duration of dressing: Patients in the MAS drainage group required dressing for a shorter duration of time [7.7 days v/s 8.7 days, p = 0.007] as compared to the I& D group. A significant difference was noticed in the breast abscess group but not in the anorectal abscess group. [Table 4.] 5. Duration of hospital stay: Both groups of patients required hospital care for about 2 days which was statistically insignificant, as shown in table 5. 6. Return to daily activities: There was no significant difference in the time taken to return to daily activities, about 7 days in each group as shown in table 6. 7. Size of scar: The size of the scar was significantly smaller in the MAS group against the conventional I&D group, as shown in table 7. The Sri Lanka Journal of Surgery 2021; 39(3): 28-32 Discussion An abscess is a localised collection of pus or fluid that is walled off due to local tissue reaction. It is a part of the defence mechanism of the body against infective organisms wherein, the body walls off a local inflammatory reaction. This does not allow infection to spread elsewhere. However, it hinders the action of antibiotics. Breast abscess The incidence of lactational breast abscess is approximately 0.4 to 11 % [4]. They develop following mastitis in 5%–11% of the patients [8]. Non-lactational abscesses are more common in obese and smokers because of periductal mastitis [5]. The usual signs of a breast abscess include redness, warmth, tenderness and swelling. [6] Ultrasonography has been described as a primary investigation of choice in patients having an abscess or signs of acute inflammation. The presence of interstitial fluid and hypoechoic wall of abscess cavity is diagnostic of breast abscess. Patients without such signs can be managed with antibiotics alone. The presence of abscess mandates the need for surgical intervention [9]. The commonest organisms found in mastitis and breast abscess are coagulase-positive Staphylococcus i.e, Staphylococcus aureus and Staph. Albus [7] A study by Chandika et al