Terminology and essence of the pathology
In surgical practice, necrotizing fasciitis is a life-threatening condition characterized by purulent-infectious melting and necrosis of tissues at the level of the superficial fascia.
In older medical literature, this disease can be found under other names. Obsolete synonyms for this pathology include:
- Epifascial gangrene;
- Phagedenic ulcer.
The main clinical characteristic of the disease is its rapid progression, extreme severity of the patient's condition, and exceptionally high risk of a fatal outcome.
Surgical treatment: intraoperative assessment
The cornerstone of treatment for necrotizing fasciitis is surgical intervention. The primary and life-saving operation in this case is necrectomy. Without radical removal of dead tissues, drug therapy is powerless.
During the operation, the surgeon must perform a thorough intraoperative revision and assessment of the wound. This includes several critical steps:
- Identification of necrosis: The physician visually and instrumentally determines the borders of the necrotic superficial fascia.
- Assessment of detachment: The degree and area of detachment of the affected fascia from the underlying tissues, as well as from the subcutaneous adipose tissue (SAT), are assessed.
- Analysis of discharge: The surgeon pays close attention to the nature of the wound exudate, its odor, and the presence of specific markers of severe infection—gas bubbles and fat droplets in the wound.
Surgical technique
The technique of performing necrectomy in necrotizing fasciitis has strict rules, upon which the outcome of treatment depends:
- Access: The skin incision is made strictly within the boundaries of the already necrotic fascia.
- Tactic for dry necrosis: If distinct dry necrosis has formed in the wound, the surgeon performs excision of the tissues in full, reaching the borders of healthy skin.
- Tactic for complex courses: In situations where the lesion is extensive, the boundaries of necrosis are difficult to determine, or the infectious process continues to progress, the technique of staged necrectomies is used (repeat operations as new foci form).
- Crucial rule: Healthy, visually unchanged skin must under no circumstances be excised.
Additional treatment and drug therapy
Surgical scalpel excision (mechanical necrectomy) must be supplemented with other methods of wound cleansing. These include ultrasonic cavitation and chemical necrectomy (using sodium hypochlorite or various proteolytic enzymes).
Simultaneously with the surgery, intensive conservative support is immediately initiated:
- Antibacterial therapy (ABT): Prescribed as early as possible. If the streptococcal nature of the infection is precisely established, the drug of choice is high-dose benzylpenicillin (4–5 million IU every 4 hours). If the flora is mixed, a combination of broad-spectrum antibiotics with agents targeting anaerobic flora is used (e.g., hydroxymethylquinoxalinedioxide).
- Detoxification therapy: Performed according to the classic general principles of treating any severe purulent-inflammatory diseases.
Local treatment in the postoperative period
Following the successful performance of necrectomy, a prolonged period of local wound treatment begins, which is divided into several stages.
First and foremost, active wound care continues during dressings. For this purpose, proteolytic enzymes and sessions of ultrasonic cavitation are used. Antiseptic ointments strictly on a water-soluble base are used as local medications.
If new areas of necrosis are identified during monitoring, additional surgical excision of the necrotic tissue is performed as necessary.
When the wound is completely cleansed and enters the regeneration phase, the tactics change: medications and local agents are prescribed to stimulate tissue healing. The final stage of treatment, aimed at closing the extensive wound defect, is autodermoplasty (transplantation of the patient's own skin).
The rule of necrectomy in fasciitis: "Remove dry tissue down to healthy tissue, but spare clean skin. In doubt — stage it!"
Class and exam questions
Which anatomical structure is primarily affected in necrotizing fasciitis?
Infectious necrosis in this disease affects the superficial fascia of the body.
Is it permissible to excise healthy skin when performing a necrectomy?
No, this is a strict contraindication. According to surgical technique, unchanged skin is not excised.
What should be done if it is difficult to determine the boundaries of necrosis during surgery or if the process is progressing?
In such complex clinical situations, performing staged necrectomies is indicated.
What drugs are used to treat an established streptococcal infection in this pathology?
The primary drug is benzylpenicillin, administered at a dosage of 4–5 million IU every 4 hours.
What else to study on this topic
- Criteria for intraoperative assessment of discharge: causes of gas and fat droplet appearance
- Indications and algorithm for performing staged necrectomies
- Mechanism of action of ultrasonic cavitation and proteolytic enzymes in a purulent wound
- Selection of water-soluble antiseptic ointments: advantages over lipid bases
- Preparation of the cleansed wound surface for autodermoplasty
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Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"
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