Classification of abscess localization
The choice of surgical tactics is entirely determined by the anatomical location of the purulent focus. There are four main types of acute paraproctitis:
- Subcutaneous (perineal) abscess — localized directly beneath the perineal skin.
- Submucosal paraproctitis — develops in the submucosal layer of the anal canal.
- Ischiorectal (ischiorectal) abscess — lies in the fossa of the same name.
- Pelvirectal (pelvirectal) abscess — the deepest process, located above the pelvic floor muscles.
Treatment of superficial forms
Superficial forms include subcutaneous and submucosal paraproctitis, which require relatively sparing surgical approaches.
- Subcutaneous paraproctitis: The surgeon makes a radial skin incision precisely over the focus of tissue softening.
- Submucosal paraproctitis: The abscess is opened from the lumen of the anal canal with a longitudinal incision. After evacuation, the cavity is treated with a hydrogen peroxide solution and a 2–4% potassium permanganate solution. As a drain, a tampon with Vishnevsky ointment is inserted into the rectum.
Surgery for deep paraproctitis
Deep forms of inflammation require more complex surgical techniques and adequate drainage:
- Ischiorectal paraproctitis: The approach is performed using an arcuate skin incision at the height of the infiltrate, 4 cm away from the lateral circumference of the anus. If extensions are identified, the incision is expanded, the cavity is washed with antiseptics, and drained with an ointment gauze tampon.
- Pelvirectal paraproctitis: The surgery is performed through the intestinal lumen. After expanding the anus with retractors, the abscess is punctured with a thick needle, and upon obtaining pus, the rectal wall is incised. A drainage tube is inserted into the cavity. In women, this deep abscess may be opened through the posterior vaginal fornix.
The depth of the incision is dictated by anatomy: subcutaneously — radially right over the abscess, ischiorectally — in an arc 4 cm from the anus, pelvirectally — internally through the intestinal lumen.
Class and exam questions
What incision is used for subcutaneous paraproctitis?
A radial incision is used, performed directly over the focus of tissue softening.
What are the features of the approach in ischiorectal paraproctitis?
The surgeon makes an arcuate skin incision at the height of the infiltrate, exactly 4 cm away from the lateral circumference of the anus.
How is pelvirectal paraproctitis opened?
Rectal specula are inserted into the intestinal lumen, the abscess is punctured with a thick needle, and the rectal wall is incised along it. In women, an approach through the posterior vaginal fornix is permitted.
What else to study on this topic
- Anatomical structure of the ischiorectal fossa
- Boundaries of the pelvirectal fascial space
- Methods of draining pelvic purulent wounds
- Prevention and treatment of purulent extensions
- Instruments for examining the rectal lumen
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