This document provides information about incision and drainage of abscesses. It discusses what an abscess is, common symptoms and signs, indications for incision and drainage, preoperative preparation and anesthesia, instruments used, the procedure steps, postoperative care, contraindications, and potential complications. It also provides background on John Erichsen, a notable 19th century surgeon.

1. By:
Dr. Mohammad Masoom Parwez
Academic Resident,
Department of Surgery, AIIMS Bhopal

3.  What is an abscess??
 Symptoms
 Signs
 Indications of I & D
 Preoperative preparation and anaesthesia
 Instruments
 Procedure
 Post op care
 Contraindications
 Complications

4.  Born in Essex, 1805
 Professor of human anatomy and surgery
at RCS
 Surgeon-extraordinary to Queen Victoria
 President of Royal College of Surgeons
 Nicknamed “Anatomical John”
 First to reduce a case of obturator hernia
 Died 1878
 Hint: has one law and one line to his
name

6.  A collection of pus (neutrophils)---
accumulated within a tissue
because of an inflammatory
process
 defensive reaction of the tissue to
prevent the spread of infectious
materials to other parts of the
body
 Abscess has an abscess wall or
capsule formed by healthy
surrounding tissue to confine the
pus

7.  Pain
 Fever
 Swelling
 Redness
 Local rise of temperature
 Loss of function
 Diagnosis of abscess: observation of a tender, erythematous, warm, fluctuant mass
on physical examination
 Bedside ultrasonography: valuable adjunct to identify localized areas of fluid under
the skin and also provides accurate dimensions of the cavity

8.  Superficial abscesses larger than 5mm in diameter
 Abscesses in accessible areas
 No associated induration/cellulitis
 Dependent areas of the body

9.  Large or complex abscesses
 Those in sensitive areas (face, palms, genitalia)
 Abscess in close proximity to major blood vessels
 Those not resolving to multiple drainage attempts
 Very small abscesses (<5mm)
 Cold abscess

10.  Tetanus prophylaxis
 Xylocaine sensitivity test
 Informed consent
 Positioning of the patient
 Skin preparation with alcohol swabs/betadine solution
 Proper draping
 Clean gloves and sterile instruments
 Prophylactic antibiotics in selected cases ( IE, prosthetic valves, congenital heart
disease, transplants)

11.  Local anesthetic such as lidocaine or bupivacaine
 injected within the roof of the abscess
 a ring of anesthetic into the subcutaneous tissue approximately 1cm around the
circumference of the abscess
 You will note blanching of the tissue as the anesthetic spreads out
 However, the maximum safe dose of anesthetic should not be exceeded
 Depending on the abscess size and location, as well as the patient’s individual
characteristics and preferences, procedural sedation may be necessary

12.  Personal protective equipment (eye shield, mask, gloves)
 Injectable anesthetic such as lidocaine +/- epi, bupivacaine
 10cc syringe, 18g & 25g needles
 No 11 blade scalpel
 Curved hemostat
 4×4 gauze pads
 Saline and syringe with 18-gauge angiocatheter or splash shield
 Thin packing gauze such as iodoform
 Scissors
 Forceps
 Tape

13.  Percutaneous aspiration initially- content and depth of abscess
 Hold the scalpel between the thumb and forefinger
 Incision directly over the center
 Steady, firm pressure- controlled entry
 Extend the incision large enough to ensure adequate drainage and prevent
recurrence
 Use a swab or syringe to obtain a sample from the abscess cavity
 Use curved hemostats for further blunt dissection to break loculations and to allow
the abscess cavity to be opened completely

15.  Gently irrigate the wound with normal saline
 Continue irrigation until the effluent is clear
 Gently pack the abscess by starting in one quadrant and gradually working around
the entire cavity
 Use wound-packing material, such as 1/4- or 1/2-in. packing strips with or without
iodoform
 Healing is by secondary intention and prevent premature closure
 Avoid overpacking– causes ischemia and impedes drainage

18.  For a simple abscess – antibiotics are not required
 Extensive cellulitis beyond the abscess area or significant comorbidities are
indications for antibiotics
 Cover the abscess wound with a sterile, nonadherent dressing
 Remove packing material from all abscesses within a few days
 Oral analgesia for pain
 Regular dressings and follow-up

19. Recommendations by the Infectious Disease Society of America for use of antibiotics
in:
Severe or extensive disease (i.e.: abscesses in multiple sites, recurrences)
Rapid disease progression with cellulitis
Associated systemic illness (i.e.: fever)
Immunosuppression or complicating co-existing conditions
Extremes of age
Abscess in area that is difficult to drain (i.e.: genitalia, face)
Septic phlebitis
Lack of response to I&D alone

20.  Acidic environment of infected tissue- impairs the effect of local anaesthetic agent
 Progression to surrounding cellulitis or lymphangitis
 Fever
 Secondary infection
 Recurrence
 Non healing of the wound- immunosuppression, other infective foci

22.  Introduction
 Indications
 Preoperative preparation and anaesthesia
 Instruments
 Procedure
 Post op care
 Contraindications
 Complications

23.  Retention cyst
 Blockage of duct of sebaceous cyst
 Common in face, scalp and scrotum
 Not seen in palms and soles
 Contains yellowish white cheesy
material, putty like consistency
 Lined by only epidermal layer of
squamous epithelium

24.  Recurrent inflammation
 Annoyance
 Cosmetic concerns

25.  severe inflammation
 Infected cyst
 and recent incision and drainage

26.  Tetanus prophylaxis
 Xylocaine sensitivity test
 Informed consent
 Positioning of the patient
 Skin preparation with alcohol swabs/betadine solution
 Proper draping
 Clean gloves and sterile instruments

28.  Sterile surgical tray
 Chlorhexidine
 Sterile drapes
 Local anesthesia (usually lidocaine 1% with epinephrine)
 Suture material
 Sterile gloves
 4-cm by 4-cm gauze pads
 Essential are a scalpel, two curved hemostats, a needle driver, scissors, toothed
forceps, and suture material

30.  Choose the appropriate skin incision
 Initial incision should be light so as not to go completely through the dermis and into
the cyst
 Use the curved hemostat to “test” the depth of the incision by gently spreading
perpendicular to the incision
 When the incision is deep enough, the tissues will spread, and the cyst will be
evident
 Use blunt dissection, Place the hemostat around the cyst (with the tip away) and
spread
 Firm areas of connective tissue can be divided with a scalpel

31.  If the cyst ruptures, try to clamp the hole with hemostats
 Lift the intact cyst with a hemostat, and use the scalpel to dissect the pedicle
 Avoid two-layer closure for small and moderate-sized cysts (up to 2-cm diameter)
 Simple interrupted closure can be done
 Clean wounds thoroughly and apply sterile dressing

33.  Infection and abscess formation
 Cock’s peculiar tumour- chronic
granuloma on an ulcerated surface of a
sebaceous cyst
 Sebaceous horn
 Multiple sebaceous cysts associated with
Gardner’s syndrome
 Scrotal sebaceous cyst– might need
partial/total scrotectomy

35.  Introduction
 Indications
 Preoperative preparation and anaesthesia
 Instruments
 Procedure
 Post op care
 Complications

36.  Lymph nodes are part of the lymphatic
system
 Enlargement of lymph nodes indicates
local inflammation, infection, malignant
or other disease
 alternatively it may be a local
manifestation of generalized disease
 Enlarged nodes may be singular, multiple,
discrete, matted, mobile or fixed
 Lymph nodes are fragile and if they are
crushed the accuracy of the diagnosis is
prejudiced

37.  Check for cancer in the nodes
 Remove nodes that are cancerous
 Reduce risk of recurrence
 To plan further treatment in malignancy
 To rule out chronic infective pathology (tuberculosis)

38.  Tetanus prophylaxis
 Xylocaine sensitivity test
 Informed consent
 Positioning of the patient
 Skin preparation with alcohol swabs/betadine solution
 Proper draping
 Clean gloves and sterile instruments
 Field block with local anaesthetics is usually sufficient

39.  Sterile surgical tray
 Chlorhexidine
 Sterile drapes
 Local anesthesia (usually lidocaine 1% with epinephrine)
 Suture material
 Sterile gloves
 4-cm by 4-cm gauze pads
 Essential are a scalpel, two curved hemostats, a needle driver, scissors, toothed
forceps, and suture material

40.  Place the incision in a skin crease if possible and approach with caution
 Lymph nodes may be very fragile, especially if they are diseased
 Having reached the surface of the node, work around the sides but do not grasp it
with forceps
 If possible leave a little connective tissue attached to it so that you can grasp this
 Reach the deeper aspects, move the mobilized gland from side to side
 Examine its attachments from different aspects
 Vessels usually enter from the undersurface
 Carefully check the field and ensure total haemostasis
 Close the wound to give the best possible cosmetic result

42.  Signs of infection: pain, redness, discharge, fever
 Seroma
 Change in sensation- pain and numbness
 Lymphoedema (chances increases with number of nodes removed)