Soft Tissue Infection and Loss of Abdominal Wall Substance
Incisional hernias that follow the common abdominal wound infections result from loss of abdominal wall substance (LAWS). But far more substantial LAWS is caused by the major necrotizing infections of the abdominal wall discussed in this chapter. These in
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Soft Tissue Infection and Loss of Abdominal Wall Substance Ronald T. Lewis
Incisional hernias that follow the common abdominal wound infections result from loss of abdominal wall substance (LAWS). But far more substantial LAWS is caused by the major necrotizing infections of the abdominal wall discussed in this chapter. These infections are quite uncommon, but they are devastating and dramatic. Indeed, when they occur, the immediate risk is to life. Early diagnosis, prompt treatment by radical surgical debridement, and broad systemic support are essential for survival. The resulting loss of abdominal wall substance is then a major issue of further management, but is in part the price of survival.
Classification Most necrotizing infections of the abdominal wall are diffuse. Many causative organisms and conditions occur that are not readily differentiated clinically when they present. The main distinguishing characteristic is the presence or absence of inflammatory cells on Gram's stain of the wound discharge. 1 Inflammatory cells are absent in clostridial myonecrosis, commonly known as gas gangrene. The remaining nonclostridial conditions marked by an intense inflammatory response in the wound discharge are now grouped conveniently under the generic title necrotizing fasciitis because they require a common approach to diagnosis and initial treatment. 1,2 The early descriptions of necrotizing fasciitis were of superficial monomicrobial infections such as Meleney's "acute hemolytic streptococcus gangrene" caused by group-A J3-hemolytic streptococci. 3 We now know that these organisms are also responsible for 20% of the more deeply seated necrotizing fasciitis,4 and that they may even penetrate the fascia and involve muscle. 5 In addition, the past 15 years have seen an increasing incidence of necrotizing fasciitis caused by group-A J3-hemolytic streptococci associated with toxic shock syndrome. 6 Other monomicrobial infections caused by zygomycoses 7 and halophic marine vibrios 8 have been described that may destroy the abdominal wall. Today, most necrotizing fasciitis is polymicrobial. The term coined by Wilson refers to necrotizing infection involving Scarpa's fascia, but sparing the deep fascia and muscle. 9 These infections are caused by synergy between gram positive cocci such as nongroup-A J3-hemolytic streptococci, and gram negative bacilli. But deeper infections result from synergy between aerobic and anaerobic gram negative bacilli.lo They are common in the perineum under the name of Fournier's ganR. Bendavid et al. (eds.), Abdominal Wall Hernias © Springer Science+Business Media New York 2001
grenell and extend freely to involve and destroy abdominal wall muscle, subcutaneous tissue, and skin. Loss of abdominal wall substance may also result from focal necrotizing infection. Meleney's progressive synergistic gangrene is the best example.I 2 Another focal infection, idiopathic scrotal gangrene, described by Fournier, 13,14 is usually confined to the perineum, but may break through to the abdominal wall and
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