PRIMARY CLOSURE OF SOFT TISSUE ABSCESSES: CHALLENGING SURGICAL DOGMA

Objectives:

Objective:
Drain it and pack it. A surgical axiom as old and trusted as the profession of surgery itself. However, wound packing for a patient and their caregivers is often a logistically challenging and painful endeavor. The surgical field has done little to challenge or advance the management of soft tissue infections over the past 200 years. It was observed at our institution that in addition to abscess drainage, aggressive wound cavity debridement followed by primary wound closure with drain placement was both efficacious in preventing repeat infections as well as simplifying wound care for patients and families, many of which otherwise require home health nursing care for wound packing at home.

Methods:
This case series included 19 patients with soft tissue infections ranging from peri-anal abscesses to chest wall abscesses. Patient characteristics included a mean BMI of 34.8, age of 46.3, and comorbidities including diabetes mellitus (57.9%). All underwent operative abscess drainage, wound debridement and irrigation with saline or sterile water, primary closure of the wound with interrupted permanent suture, and drain placement with 15 or 19 Fr round drain. Exclusion criteria included inability to tolerate anesthesia, poor quality overlying skin for closure, excessive tension on wound closure site after debridement, and concern for peri-anal fistula.

Results:
One patient required re-operation for recurrent soft tissue infection which presented in a delayed fashion (4 months after index operation). This patient had the highest BMI in the cohort (57.7). The percentage of overall wound dehiscence (in respect to percentage of wound length) was 0.8% (10% wound dehiscence in one patient and 5% in another). The remaining 16 patients had no wound dehiscence. The average duration of post-operative antibiotics was 9.1 days, the average time until surgical drain removal was 8.4 days.

Conclusion:
Primary closure of abscess cavities following debridement and drain placement is a safe and effective management strategy for the overwhelming majority of patients. Although this technique often requires general anesthesia where most standard incision and drainage procedures could be done at bedside, this technique offers multiple advantages to standard wound packing and should be discussed with patients as a viable treatment strategy. Moving forward, a higher-powered study looking at similar abscesses managed with packing versus primary closure to compare length of time until wound care is no longer required would be worthwhile to compare these two cohorts, especially in respect to patient satisfaction and quality of life metrics.

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Conclusion: