Anaerobic abscess

OPERATIONS FOR ANAEROBIC ANORECTAL ABSCESSES

1.1 The steps in the operation for suppiirativc abscesses: 1. Wide incision of the perineum. (Occasionally it is made through nccrotic tissues)

2.2 The steps in the operation for suppiirativc abscesses:The abscess cavity is washed with hydrogen peroxide

Anaerobic anorectal abscesses are uncommon, and may develop from an acute anorcclal abscess which has not been operated on it time. Three forms of anaerobic abscess arc distinguished: (1) suppurative; (2) progressive gangrenous; and (3) abscess with anaerobic lymphangitis.
In suppurative anaerobic abscess no tissue crepitation is elicited on palpation and the pathologic process does not tend to spread. Operations consist in laying the abscess wide open (Fig. 1,1) and making a wide dissection of the necrotic tissues (Fig. 1,2 and 3) including a margin of healthy skin. The issuing pus has an offensive sweetish smell. The cavity of a deep abscess is washed
with a 4 per cent hydrogen peroxide (Fig. 1,2), rubber tubes are inserted as far as the bottom of the wounds (suppurative abscesses are usually bilateral), and the abscess cavity is packed with gauze impregnated with 4 per cent hydrogen peroxide.

3.3 The steps in the operation for suppiirativc abscesses: Necrotic tissues are excised at the scrotal root

3.4 The steps in the operation for suppiirativc abscesses: Cotton-gauze dressing, with the drainage tubes brought out to the outside

A large cotton-gauze dressing is then applied, with the ends of the rubber tubes protruding from it (Fig. 1,4). Every 4—5 hours 8 to 10 ml of 4 per cent hydrogen peroxide is injected into these tubes by means of a syringe. Antibiotics (Auromy-cin and Rondomycin) and cardiac preparations are administered if required.
No sphincterotomy is per for/tied in  anaerobic anorectal abscesses.

2. Operation in gangrenous abscess. Radial incisions of perineal and gluteal integuments

In progressive gangrenous anorectol abscess, the operative procedure is begun in the same way as in suppu-rative abscess. After the nccrolic tissues of the ischiorec-tal and pelvirectal fossae have been widely opened, that portion of dead fatty tissues which contains air bubbles is excised taking special care to spare the rectal wall, and 4 or 5 radial incisions are made outwards and forward the ischiorectal fossa and carried through the crepitating tissue 2-3 cm deep as far as the boundaries of normal tissues, excercising care to avoid injury to the internal pudendal artery (Fig. 2).

The wound is treated in the same manner as in the case of suppurative abscess, that is, with removal of some of the necrotic septa, irrigation with hydrogen peroxide, and leaving a tube in the wound cavity. The postoperative care of the patient is also the same as that in
suppurative abscess, except that subcutaneous or intravenous injections of an antigangrenous serum in physiological salt solution are given (10 to 12 prophylactic doses of the serurn, primarily for B. perfingens, to 500 ml of physiological solution). It is advisable to make these injections under general anesthesia. Should signs of further tissue crepitation appear after first dressings, additional incisions must be made.
Operation for anorectol abscess with anaerobic lymphangitis. This condition is characterized by the development of an anaerobic lymphangitis which originates from ischiorectal tissues and which spreads towards the scrotum, femoral lymph nodes, and on to the anterior abdominal wall. The lesion spreads in foci where passive hyperemia and distinct crackling (tissue crepitation) may be elicited on palpation.

3.1 The steps in the operation in anorectal abscess with anaerobic lymphangitis: Wide dissection of crepitating tissues in the gluteal and scrotal root areas

This is an emergency operation performed under general anesthesia. With the patient in the same position as that used for hemorrhoidectomy, the ischiorectal ncc-rotic tissues are widely dissected. If there is crepitation in the groin or scrotal root area the overlying tissues are also widely dissected (Fig. 3,1).

The patient is then transferred to the supine position his legs arc stretched, the entire abdominal wall is painted with a 2 per cent iodine tincture, and wide trans-verst or oblique — transverst incisions are made over those areas of the abdominal wall where passive hypere-mia and crepitation are elicited by palpation (Fig 3,2). These incisions must be^ deep, with the abdominal muscles incised up to the transverse abdominal fascia. After hemostasis is instituted by means of catgut, a 4 per cent hydrogen  peroxide solution  is  applied  2  or 3 times tothe wounds and a thin rubber tube with side openings is laid deep inside each of the wounds (two tubes are laid into the largest wound). The wounds are then packed with gauz.c well soaked in hydrogen peroxide, and covered with a double-layer gauze impregnated with Vishnevsky ointment. A thick layer of cotton wool is now laid on the wounds, and the anterior abdominal wall is bandaged with a wide bandage.

The outer ends of the rubber tubes should protrude from the dressing 3 to 5 cm (Fig. 3,3). Six or 70 ml of 4 per cent hydrogen peroxide are introduced into the wounds through these every 4 hours. Otherwise, the postoperative care is similar to that in suppurative abscess. Dressings should be applied each day to see that hyperemia and crepitation do not spread any further. If they do, a new wide incision is necessary.