Surgery and Healing in the Developing World - Dartmouth-Hitchcock
Surgery and Healing in the Developing World - Dartmouth-Hitchcock Surgery and Healing in the Developing World - Dartmouth-Hitchcock
Abscesses and Other Infections Treated by Surgery Figure 17. Two-bottle waterseal drainage for the pleural space. 371 Bartholin’s Abscess Bartholin’s abscess usually occurs in a pre-existing cyst of one of the greater vestibular glands (Bartholin’s glands) at the introitus of the vagina. A tender mass is present deep to the labium majus on one side of the vaginal outlet. Treatment is incision and drainage. If possible, marsupialize the infected cyst by opening the cavity and suturing the lining to the skin. This may not be possible due to inflammation, in which case marsupialization may be done at a later stage. Deep Abscesses In this section, we briefly discuss the abscesses which occur in or around the thoracic and abdominal cavities. Diagnosis of deep abscesses has been a major challenge and, even with modern imaging technology, diagnosis is sometimes difficult and tentative. Where advanced technology is not available, we are forced to resort to old and time-tested methods to achieve a diagnosis and embark on effective treatment. Exploratory laparotomy for intra-abdominal infections is an effective diagnostic and therapeutic technique, albeit an invasive one. We could still more often use this “technology” in “hi-tech” centers when persistence with one imaging test after another fails to reveal the problem and causes undue delays and adverse outcomes. There is a useful role for ordinary X-rays. Pulmonary Empyema, is an abscess in the pleural space. It is much commoner in poor regions than privileged populations due to the tardy or absent diagnosis and treatment of pneumonias. Tuberculous empyema is also relatively more common in poor populations. Therefore the surgeon in developing regions needs to know how to manage these problems safely and effectively. Untreated empyema will produce a collapsed lung trapped in fibrous tissue with eventual severe respiratory disability. An early empyema which has not developed a thick fibrous peel can be treated by tube thoracostomy. Diagnosis of an early empyema is based on the observation that the fluid pus will shift when the patient is placed in lateral decubitus position for X-ray. Drainage is necessary, using a tube and a water-seal bottle arrangement (Fig. 17). Before inserting the intercostal tube, confirm the site and diagnosis with a 35
35 372 Surgery and Healing in the Developing World Figure 18. open chest drainage with large tubes 21 gauge needle on a syringe to aspirate for pus. If the empyema is more chronic and has developed a thick pleural peel, resection of a segment of rib is required in order to produce an open thoracostomy. The opening should be made in the most dependent part of the abscess and maintained by inserting into the opening three large rubber tubes tied together (Fig. 18). This must be maintained until the cavity has disappeared which may take several weeks or months. A more permanent procedure is the creation of a skin flap to keep the cavity open, the Eloesser technique. This requires experience. Treatment of lung abscesses is more difficult and requires training and experience in lung surgery. Intra-Abdominal Infections Intra-abdominal infections may present as generalized peritonitis or as localized abscesses. Abscesses are often more difficult to diagnose than peritonitis. In this section, we discuss the more common intra-abdominal infections requiring surgical treatment. Bacterial Peritonitis Bacterial peritonitis is a lethal infection involving the linings of the peritoneal cavity. In Western countries a common cause is diverticulitis but this condition is rare in developing regions. On the other hand, peritonitis due to tuberculosis or typhoid is more common in the developing world. Perforation of the stomach or gut and pelvic inflammatory disease (PID) are the other common causes of peritonitis. Usually the patient is severely ill and has a persistently high fever. The abdomen is acutely tender and there is involuntary guarding, usually with “rebound tenderness”. Often the abdomen is silent, on auscultation for two minutes, due to paralytic ileus. There may be absence of liver dullness on percussion due to free intraperitoneal gas from a perforation. In tuberculous peritonitis the abdomen may feel “doughy” (flabby and slow to rebound after indentation) and the patient is usually wasted and feeble, complaining of a long-standing abdominal pain. Where possible, abdominal X-rays in the supine and upright positions should be made. Free intraperitoneal gas indicates perforation of stomach or intestine. Exploratory laparotomy is indicated, without further diagnostic procedures, once fluid
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35<br />
372 <strong>Surgery</strong> <strong>and</strong> <strong>Heal<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> Develop<strong>in</strong>g <strong>World</strong><br />
Figure 18. open chest dra<strong>in</strong>age<br />
with large tubes<br />
21 gauge needle on a syr<strong>in</strong>ge to aspirate for pus. If <strong>the</strong> empyema is more chronic<br />
<strong>and</strong> has developed a thick pleural peel, resection of a segment of rib is required <strong>in</strong><br />
order to produce an open thoracostomy. The open<strong>in</strong>g should be made <strong>in</strong> <strong>the</strong> most<br />
dependent part of <strong>the</strong> abscess <strong>and</strong> ma<strong>in</strong>ta<strong>in</strong>ed by <strong>in</strong>sert<strong>in</strong>g <strong>in</strong>to <strong>the</strong> open<strong>in</strong>g three<br />
large rubber tubes tied toge<strong>the</strong>r (Fig. 18). This must be ma<strong>in</strong>ta<strong>in</strong>ed until <strong>the</strong> cavity<br />
has disappeared which may take several weeks or months. A more permanent procedure<br />
is <strong>the</strong> creation of a sk<strong>in</strong> flap to keep <strong>the</strong> cavity open, <strong>the</strong> Eloesser technique.<br />
This requires experience.<br />
Treatment of lung abscesses is more difficult <strong>and</strong> requires tra<strong>in</strong><strong>in</strong>g <strong>and</strong> experience<br />
<strong>in</strong> lung surgery.<br />
Intra-Abdom<strong>in</strong>al Infections<br />
Intra-abdom<strong>in</strong>al <strong>in</strong>fections may present as generalized peritonitis or as localized<br />
abscesses. Abscesses are often more difficult to diagnose than peritonitis. In this<br />
section, we discuss <strong>the</strong> more common <strong>in</strong>tra-abdom<strong>in</strong>al <strong>in</strong>fections requir<strong>in</strong>g surgical<br />
treatment.<br />
Bacterial Peritonitis<br />
Bacterial peritonitis is a lethal <strong>in</strong>fection <strong>in</strong>volv<strong>in</strong>g <strong>the</strong> l<strong>in</strong><strong>in</strong>gs of <strong>the</strong> peritoneal<br />
cavity. In Western countries a common cause is diverticulitis but this condition is<br />
rare <strong>in</strong> develop<strong>in</strong>g regions. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, peritonitis due to tuberculosis or<br />
typhoid is more common <strong>in</strong> <strong>the</strong> develop<strong>in</strong>g world. Perforation of <strong>the</strong> stomach or<br />
gut <strong>and</strong> pelvic <strong>in</strong>flammatory disease (PID) are <strong>the</strong> o<strong>the</strong>r common causes of peritonitis.<br />
Usually <strong>the</strong> patient is severely ill <strong>and</strong> has a persistently high fever. The abdomen<br />
is acutely tender <strong>and</strong> <strong>the</strong>re is <strong>in</strong>voluntary guard<strong>in</strong>g, usually with “rebound<br />
tenderness”. Often <strong>the</strong> abdomen is silent, on auscultation for two m<strong>in</strong>utes, due to<br />
paralytic ileus. There may be absence of liver dullness on percussion due to free<br />
<strong>in</strong>traperitoneal gas from a perforation. In tuberculous peritonitis <strong>the</strong> abdomen may<br />
feel “doughy” (flabby <strong>and</strong> slow to rebound after <strong>in</strong>dentation) <strong>and</strong> <strong>the</strong> patient is<br />
usually wasted <strong>and</strong> feeble, compla<strong>in</strong><strong>in</strong>g of a long-st<strong>and</strong><strong>in</strong>g abdom<strong>in</strong>al pa<strong>in</strong>.<br />
Where possible, abdom<strong>in</strong>al X-rays <strong>in</strong> <strong>the</strong> sup<strong>in</strong>e <strong>and</strong> upright positions should be<br />
made. Free <strong>in</strong>traperitoneal gas <strong>in</strong>dicates perforation of stomach or <strong>in</strong>test<strong>in</strong>e. Exploratory<br />
laparotomy is <strong>in</strong>dicated, without fur<strong>the</strong>r diagnostic procedures, once fluid