Opening phlegmon

Before you figure out how the phlegmon is opened, first you need to explain what this pathology is.

So, phlegmon is an acute limited purulent inflammatory reaction in the tissues, accompanied by their melting, with the further formation of a cavity. In fact, this is the same abscess, but without clearly marked contours, which is explained by the same tissue melting. Pus with phlegmon often spreads, affecting closely located organs and tissues.

To treat phlegmon, surgeons use the so-called autopsy procedure, which is performed under general or local anesthesia. The pathological cavity is opened, the purulent contents are pumped out, sanitized and the phlegmonous capsule is removed. [1]

Indications for the procedure

Phlegmon is a bacterial infectious focus that affects the subcutaneous tissue. Most often, the inflammatory process develops under the influence of streptococci or staphylococci. The main clinical signs of phlegmon are clearly defined soreness, hot flashes, rapidly diverging redness and swelling. Against the background of progression, fever often occurs, and in severe cases, you may notice an increase and hardening of nearby lymph nodes.

An autopsy of phlegmon is always prescribed with the progression of the inflammatory process occurring against the background of an elevated temperature and with softening of the infiltrate. Conservative treatment for phlegmons is prescribed only in isolated cases - for example, if the painful reaction is at the very initial stage of serous inflammation, and the local clinical picture is not yet pronounced: the patient's condition is satisfactory, the temperature is kept within subfebrile limits, and there are any contraindications to the autopsy operation...

In all other cases, phlegmon and other purulent processes in the skin, surgical intervention is indicated, and on an emergency basis.

Preparation

An autopsy of phlegmon is performed after examination and consultation with a medical specialist - as a rule, a surgeon who examines and diagnoses a pathological formation. Standard steps in preparation for opening an abscess include:

• thorough examination by the surgeon;
• ultrasound examination;
• if necessary - carrying out a diagnostic puncture to take the contents of the phlegmonous cavity with its further study (determination of the pathogen and its sensitivity to antibiotic therapy);
• laboratory tests (as a rule, they allow to assess the severity of the inflammatory reaction).

In addition, the doctor must clarify with the patient information about the presence of allergies to anesthetics and other medications.

Phlegmon opening tools

An autopsy of phlegmon is performed using a strictly defined set of instruments. This set includes:

• one scalpel each - pointed and abdominal;
• two pairs of scissors - pointed and Cooper's;
• four Kocher clamps and the same number of Billroth clamps;
• two clamps Mosquito;
• two anatomical and surgical forceps;
• four linen claws;
• a pair of forceps;
• two hooks - toothed and lamellar Farabef;
• one probe each - grooved and bulbous.

All sterile instruments are laid out on a large tray and served by the nurse to the surgeon during the operation of opening the phlegmon.

Technique opening the phlegmon

Opening of phlegmon, as well as other superficial purulent formations, can be carried out both under local and under intravenous anesthesia. The type of anesthesia is chosen by the doctor: anesthesia should be sufficient to conduct a thorough revision of the phlegmonous focus. Sometimes local anesthesia may be contraindicated due to the high likelihood of spreading the infection.

The nuances of the operative access depend on the anatomical and topographic features of the affected area. If possible, the surgeon performs an autopsy along the lower pole of the phlegmon to ensure optimal conditions for the release of purulent contents. Most often, layer-by-layer cutting of tissues, opening of phlegmon, removal of necrotic tissues and secretions using tampons or a special suction is performed. After that, a high-quality revision of the focus is performed, the layers present are highlighted, and tissue sequestrations are excised. The cavity is washed with an antiseptic solution, drainage is established using a base incision or counter-opening.

The surgeon performs the opening and drainage of the phlegmon. Drains are removed the next day, in the absence of pathological discharge. The stitches are removed for 5-6 days.

• The incision for opening the phlegmon of the hand is carried out using different methods, depending on the location of the problem:
  • with commissural phlegmon, the incision is performed over the focus of inflammation from the interdigital fold to the border of the base of the heads of the metacarpal bones; if purulent discharge is present between the metacarpal bones to the carpal rear, a symmetry incision is made with drainage;
  • with deep median-palmar phlegmon, a longitudinal-median incision is performed on the border of the inner edge of the thenar; with the help of a grooved probe, the palmar aponeurosis is dissected, purulent contents are removed; when pus spreads to the hypotenar, the next incision with drainage is performed;
  • with deep phlegmon of the carpal rear, a longitudinal-median incision is performed on the back side.
• Opening the phlegmon of the foot from the dorsum is performed by making two or three longitudinal incisions parallel to the extensor tendons. The skin and subcutaneous tissue, superficial and deep dorsal fascia are dissected. When the phlegmon is localized in the sole area, the opening is performed using two typical Delorma incisions. The external and internal incisions run along the sides of the densest area of the plantar aponeurosis. The lines are marked as follows: one of them passes at a distance of three fingers from the posterior heel edge. Its middle is connected to the third interdigital space (second line). The third line is the junction of the midpoint from the medial half of the transverse calcaneal line with the first interdigital space. Such an opening of subgaleal phlegmon of the sole is called according to Voino-Yasenetsky: Incisions in the soft tissues in this way do not lead to damage to the plantar aponeurosis and the short digital flexor. [2]
• Opening phlegmon of the neck depends on the localization of the process. With deep peri-esophageal phlegmon, an incision is made along the medial border of the sternocleidomastoid muscle. With an orientation to the lateral tracheal wall, a deeper revision is performed, with the outward displacement of the vascular accumulation. The opening of the vaginal phlegmon also takes place, with the separation of the fusion and fascia outward from the esophageal tube below the sternocleidomastoid muscle. When opening the phlegmon of the lateral cervical triangle, it is cut along a line two centimeters above the contour of the clavicle. Platysma is dissected, the buccal cellular space is exposed. If necessary, a deeper revision is performed, with the division of the third fascia of the neck. [3]
• The dissection of the submandibular phlegmon is carried out by incision of the skin and platysma along a line parallel to the horizontal mandibular branch. After exposure of the submandibular gland, if necessary, a deeper revision is carried out, up to the mandibular edge. [4]
• Opening of the phlegmon of the femur of the medial bed is carried out by means of longitudinal incisions in the area of the anteromedial femoral surface. The superficial tissues are cut in layers two or three centimeters medial to the location of the femoral artery. After opening the wide fascia, the median border of the long adductor muscle is highlighted, and through the intermuscular spaces, access to the phlegmon opens. The opening of the phlegmon of the posterior bed is performed by longitudinal cutting along the lateral border of the biceps muscle, or along the semitendinosus muscle. The wide fascia of the thigh is opened, access to the purulent focus is opened. [5]
• Opening the phlegmon of the perineum consists in performing an incision of the perineal skin to the deep fascial muscular sheaths. The surgeon determines the degree of adhesion of the fascial structures to each other. In the absence of a necrotizing process, with the help of digital revision, the fascial sheets are peeled off from adjacent tissues, and access to the phlegmon is exposed. Similarly, an opening of the phlegmon of the penis and pubic region is performed. [6]
• Opening of the phlegmon of the forearm in the flexor bed is carried out using a longitudinal incision, with an orientation to the projection of the radial and ulnar vessels. The skin, the PC, the intrinsic fascia of the forearm are dissected, and the superficial digital flexor is stratified. If the phlegmon is located deeper, then the deep leaf of the fascia of the forearm is also dissected, the elements of the deep digital flexor are moved apart, and the cellular space of Pirogov is exposed. According to Voino-Yasenetsky, radial and ulnar incisions are used to access Pirogov's space.  
• The dissection of the phlegmon of the axillary region according to Pirogov is performed with the arm retracted upward and in the lateral direction. The limb is placed on a separate surface. The apical phlegmon is opened by cutting parallel and below the clavicular line. The skin, the PC and its own fascia are dissected, the bundles of the pectoralis major muscle are separated, the deep fascia is opened. In the same way, the fiber is divided and the phlegmon is opened. Sometimes it is required to transect or undercut the pectoralis major and minor. If pus is found in the axillary fossa, additional incisions are made. [7]

Contraindications to the procedure

There are no contraindications for an emergency operation to open the phlegmon. The intervention is performed urgently, within an hour from the moment of diagnosis.

Consequences after the procedure

If the opening of the phlegmon occurs on time, then no negative consequences arise: complete healing is observed within a couple of weeks. In rare cases, after opening, lymphangitis, regional lymphadenitis, thrombophlebitis, sepsis, meningitis and encephalitis occur when the focus is located in the face. These problems are usually associated with the initial neglected state of phlegmon. However, in such cases, the patient is prescribed a course of antibiotics, antihistamines and vitamin preparations, as well as detoxification treatment.

• Why does the temperature rise after opening the phlegmon? During the first three days after the intervention, the patient may have a slight subfebrile temperature. This condition is considered normal and should not be a cause for concern. But the cases when the temperature is held for more than three days, or sharply "jumps" to high values (above 38 ° C), this indicates a re-development of inflammation and requires urgent help from a surgeon.
• If platelets are increased in the blood after opening the phlegmon, then there is no need to panic: this happens during inflammatory processes caused by infection, as well as during injuries and surgical interventions. Against the background of the disappearance of symptoms of inflammation, along with the improvement of other clinical and laboratory parameters, the level of platelets always decreases.

Complications after the procedure

To begin with, I would like to point out the possible complications, if the patient does not want to open the cellulitis, or does not seek medical help at all.

• Untimely treatment for opening the phlegmon can lead to further spread of the painful process, including to large vessels, which can cause damage and bleeding.
• If you delay the opening, the process can affect the nerve trunks (neuritis), the bone apparatus (osteomyelitis).
• Phlegmon can easily spread to neighboring tissues, and the purulent process can spread throughout the body. This is a very dangerous complication that requires urgent medical attention.

To avoid such troubles, it is important to consult a doctor at the first sign of phlegmon development. By the way, in the early stages of development - namely, at the stage of serous phlegmon - the inflammatory process can be cured without opening, with the help of conservative therapy.

The operation itself to open the phlegmon rarely ends with the development of complications, however, in about 3-4% of patients, they still occur:

• relapse of the inflammatory process;
• hemorrhage or hematoma;
• compaction in the area of opening the phlegmon, the formation of a rough scar.

Such complications are not critical and are solved with the help of additional therapeutic measures. So, with the repeated development of the inflammatory process, an autopsy is performed again, the tissues are additionally cleaned and treated, and antibiotic therapy is prescribed. Hematomas often resolve on their own, sometimes physiotherapy and external therapy methods can be connected. When the operated site is compacted, drugs are prescribed that improve microcirculation.

Care after the procedure

Depending on the size and location of the phlegmon, the recovery period can last from several days to two weeks. As a rule, after opening the phlegmon, the attending physician prescribes a course of drug treatment for the patient to speed up healing and prevent the development of complications. This treatment usually includes:

• analgesics, antipyretics;
• antibiotics;
• immunostimulants.

Caring for the phlegmon opening site consists of the following stages:

• observance of hygiene of the body and the operated area;
• regular dressings;
• fulfillment by the patient of all medical prescriptions and control of healing by the doctor.

How the phlegmon heals after opening depends on several factors at once:

• on the size of the pathological focus, its depth and degree of neglect;
• from the localization of phlegmon (the wound heals faster in areas with better blood supply and thinner skin);
• on the general health and age of the patient (young people who do not suffer from chronic diseases and diabetes mellitus, healing is faster).

On average, the complete tightening of the operated tissues after opening the phlegmon occurs within 2-3 weeks.