Correspondence 1.
2.
Majeed AW, Reed MWR, Watkin DFL, Smart JG, Johnson AG. Sheffield Cholecystoscope: new instrument for minimally invasive gallbladder surgery. Br J Surg 1991; 78: 557-8. Cheslyn-Curtis S, Donald J, Ainley C, Lees WR, Russell RCG. Gallstone recurrence following cholecystolithotomy. Br J Surg 1990; 77: 1423 (Abstract).
Easy delivery of the gallbladder in laparoscopic cholecystectomy: a grooved director Sir Further to the recent Surgical Workshop (Br J Surg 1992; 79: 344) about the best method of retrieving the detached gallbladder from the peritoneal cavity at the end of laparoscopic cholecystectomy, we have found the most effective technique is to employ an otology speculum. This instrument is inserted into the subumbilical wound after withdrawal of the laparoscopic cannula, and a grasping forceps is passed through it to secure the gallbladder. The speculum can be opened to the required size to permit withdrawal of the gallbladder. This technique has proved to be straightforward in practice and does not require the manufacture of a specialized instrument, as the speculum is readily available in any hospital that has an ear, nose and throat department.
D. R. Andrew M. J. Kelly Department of General Surgery Leicester General Hospital teicester LE5 4P W UK
Necrotizing fasciitis: 10 years‘ experience in a district general hospital Sir The 10-yearaudit by Ward and Walsh of necrotizing fasciitis presenting to a district hospital in the UK (Br J Surg 1991; 78: 488-9) produced 14 patients for analysis. The authors commented that this is an uncommon condition. At the University Teaching Hospital, Lusaka, Zambia, on just one of five general surgical and trauma units in the first 4 months of 1991 we cared for six patients with necrotizing fasciitis. Two followed ischiorectal abscesses, one was of apparently spontaneous onset in the lower limb of a human immunodeficiency virus (HIV)-seropositive patient, one followed a colonic gunshot wound, one spontaneous extravasation of urine proximal to a urethral stricture, and the sixth followed a vaccination abscess in a 10-month-old infant. No patient was diabetic; two were HIV antibody seropositive. The authors of the article excluded Fournier’s gangrene. In Zambia, where scrota1 necrotizing fasciitis usually presents late with fasciitis extending widely on to the abdominal wall and sometimes on to the thighs, it is clear that the distinction is arbitrary, and that Fournier’s gangrene is just one of the eponyms by which necrotizing fasciitis has become known’. In the authors’ recommended management they omit one important modality, namely correction of anaemia. Patients are frequently anaemic on admission and lose blood heavily during the major debridements that are necessary. As the authors observe, necrotizing fasciitis can be easily recognized clinically by the grey necrotic fascia but, as similar fascia can be seen in pressure sores and gangrenous pyoderma, the important clinical feature is that in necrotizing fasciitis the grey necrotic unhealthy fascia extends beneath apparently healthy skin well beyond the margin of the wound. Diagnosis and determination of how far debridement will have to extend can be helped by stab incisions away from the woundmargin.
C. Bern Department of Surgery PO Box 50110 Lusaka Zambia 1.
Roberts JO, Fenton OM, Peters JL. Necrotising fasciitis. Hospital Update 1985; 11: 289.
Br. J. Surg., Vol. 79, No. 11, November 1992
Retroperitoneal necrotizing fasciitis Letter 1 Sir Woodburn et al. (Br J Surg 1992; 79: 3 4 2 4 ) linked the high mortality rate associated with retroperitoneal necrotizing fasciitis to delayed diagnosis caused by the late manifestation of the latter in the overlying cutaneous tissues as well as a lack of means for earlier diagnosis. I have dealt with several cases of Fournier’s gangrene with retroperitoneal involvement and have found that an infarcted gangrenous testis is a good and early sign of retroperitoneal necrotizing fasciitis. The testicular blood supply is thrombosed early in the course of retroperitoneal involvement and a gangrenous testis is an indication for laparotomy with a view to retroperitoneal debridement.
F. Seow-Choen Department of Colorectal Surgery Singapore General Hospital Singapore 0316
Letter 2 Sir We read with much interest the article by Woodburn et al. on retroperitoneal necrotizing fasciitis (Br J Surg 1992; 79: 342-4) and feel that they have presented the problem well. In view of the terrible mortality rate they report for retroperitoneal fasciitis, we would like to describe a case that demonstrates that survival is possible in younger patients who are treated aggressively. A 28-year-old nurse presented with a 6-day history of increasing abdominal pain with signs of peritonitis. After resuscitation and under appropriate antibiotic cover a perforated appendix was removed and the peritoneal cavity was thoroughly lavaged with saline. Culture of the intra-abdominal pus yielded Streptococcus rnilleri and Bacteroides sp. She was making a slow recovery when, 1 week later, the wound began to discharge copious amounts of pus. This grew Pseudomonas aeruginosa, and intravenous ciprofloxacin and benzylpenicillin were added to the regimen. Pus continued to drain and 4 days later the abdominal wound was explored under general anaesthesia. This revealed extensive necrotizing fasciitis of the subcutaneous tissues of the abdominal wall from the right to left flank. Over 2 litres of pus were drained and the dead abdominal wall skin and muscle were debrided. The abscess continued deep into the extraperitoneal tissues in the right iliac fossa. Cultures of the pus once again yielded S. milleri and Bacteroides sp., in addition to Escherichiu coli. Following this extensive debridement the patient showed an initial improvement. However, 10 days later large quantities of small bowel contents were discharged from the original wound site. Abdominal computed tomography (CT) revealed multiple intraabdominal abscesses. Her condition declined despite intensive antibiotic therapy and repeat CT showed obvious necrotizing fasciitis of the retroperitoneal tissues with extension of the intra-abdominal collections. At laparotomy the fistula was found to come from a necrotic area of caecum. An ileocaecal resection was performed and a defunctioning ileostomy was raised. The intra-abdominal abscesses were drained and the abdomen again thoroughly lavaged with saline. The patient’s condition improved gradually and repeat CT 10 days later showed no residual necrosis or collections. She was discharged 9 weeks after initial admission. A subsequent admission for reversal of the stoma was uneventful and she has now returned to full health. This case illustrates the value of CT in determining the presence and extent of retroperitoneal fasciitis and the timing of subsequent surgical procedures. It also demonstrates that survival in this deadly condition is dependent on the successful eradication of the source of sepsis.
M. J. Osborne J. R. Novel1 A. A. M. Lewis University Department of Surgery The Royal Free Hospital London N W3 2QG UK
1247
2.
Majeed AW, Reed MWR, Watkin DFL, Smart JG, Johnson AG. Sheffield Cholecystoscope: new instrument for minimally invasive gallbladder surgery. Br J Surg 1991; 78: 557-8. Cheslyn-Curtis S, Donald J, Ainley C, Lees WR, Russell RCG. Gallstone recurrence following cholecystolithotomy. Br J Surg 1990; 77: 1423 (Abstract).
Easy delivery of the gallbladder in laparoscopic cholecystectomy: a grooved director Sir Further to the recent Surgical Workshop (Br J Surg 1992; 79: 344) about the best method of retrieving the detached gallbladder from the peritoneal cavity at the end of laparoscopic cholecystectomy, we have found the most effective technique is to employ an otology speculum. This instrument is inserted into the subumbilical wound after withdrawal of the laparoscopic cannula, and a grasping forceps is passed through it to secure the gallbladder. The speculum can be opened to the required size to permit withdrawal of the gallbladder. This technique has proved to be straightforward in practice and does not require the manufacture of a specialized instrument, as the speculum is readily available in any hospital that has an ear, nose and throat department.
D. R. Andrew M. J. Kelly Department of General Surgery Leicester General Hospital teicester LE5 4P W UK
Necrotizing fasciitis: 10 years‘ experience in a district general hospital Sir The 10-yearaudit by Ward and Walsh of necrotizing fasciitis presenting to a district hospital in the UK (Br J Surg 1991; 78: 488-9) produced 14 patients for analysis. The authors commented that this is an uncommon condition. At the University Teaching Hospital, Lusaka, Zambia, on just one of five general surgical and trauma units in the first 4 months of 1991 we cared for six patients with necrotizing fasciitis. Two followed ischiorectal abscesses, one was of apparently spontaneous onset in the lower limb of a human immunodeficiency virus (HIV)-seropositive patient, one followed a colonic gunshot wound, one spontaneous extravasation of urine proximal to a urethral stricture, and the sixth followed a vaccination abscess in a 10-month-old infant. No patient was diabetic; two were HIV antibody seropositive. The authors of the article excluded Fournier’s gangrene. In Zambia, where scrota1 necrotizing fasciitis usually presents late with fasciitis extending widely on to the abdominal wall and sometimes on to the thighs, it is clear that the distinction is arbitrary, and that Fournier’s gangrene is just one of the eponyms by which necrotizing fasciitis has become known’. In the authors’ recommended management they omit one important modality, namely correction of anaemia. Patients are frequently anaemic on admission and lose blood heavily during the major debridements that are necessary. As the authors observe, necrotizing fasciitis can be easily recognized clinically by the grey necrotic fascia but, as similar fascia can be seen in pressure sores and gangrenous pyoderma, the important clinical feature is that in necrotizing fasciitis the grey necrotic unhealthy fascia extends beneath apparently healthy skin well beyond the margin of the wound. Diagnosis and determination of how far debridement will have to extend can be helped by stab incisions away from the woundmargin.
C. Bern Department of Surgery PO Box 50110 Lusaka Zambia 1.
Roberts JO, Fenton OM, Peters JL. Necrotising fasciitis. Hospital Update 1985; 11: 289.
Br. J. Surg., Vol. 79, No. 11, November 1992
Retroperitoneal necrotizing fasciitis Letter 1 Sir Woodburn et al. (Br J Surg 1992; 79: 3 4 2 4 ) linked the high mortality rate associated with retroperitoneal necrotizing fasciitis to delayed diagnosis caused by the late manifestation of the latter in the overlying cutaneous tissues as well as a lack of means for earlier diagnosis. I have dealt with several cases of Fournier’s gangrene with retroperitoneal involvement and have found that an infarcted gangrenous testis is a good and early sign of retroperitoneal necrotizing fasciitis. The testicular blood supply is thrombosed early in the course of retroperitoneal involvement and a gangrenous testis is an indication for laparotomy with a view to retroperitoneal debridement.
F. Seow-Choen Department of Colorectal Surgery Singapore General Hospital Singapore 0316
Letter 2 Sir We read with much interest the article by Woodburn et al. on retroperitoneal necrotizing fasciitis (Br J Surg 1992; 79: 342-4) and feel that they have presented the problem well. In view of the terrible mortality rate they report for retroperitoneal fasciitis, we would like to describe a case that demonstrates that survival is possible in younger patients who are treated aggressively. A 28-year-old nurse presented with a 6-day history of increasing abdominal pain with signs of peritonitis. After resuscitation and under appropriate antibiotic cover a perforated appendix was removed and the peritoneal cavity was thoroughly lavaged with saline. Culture of the intra-abdominal pus yielded Streptococcus rnilleri and Bacteroides sp. She was making a slow recovery when, 1 week later, the wound began to discharge copious amounts of pus. This grew Pseudomonas aeruginosa, and intravenous ciprofloxacin and benzylpenicillin were added to the regimen. Pus continued to drain and 4 days later the abdominal wound was explored under general anaesthesia. This revealed extensive necrotizing fasciitis of the subcutaneous tissues of the abdominal wall from the right to left flank. Over 2 litres of pus were drained and the dead abdominal wall skin and muscle were debrided. The abscess continued deep into the extraperitoneal tissues in the right iliac fossa. Cultures of the pus once again yielded S. milleri and Bacteroides sp., in addition to Escherichiu coli. Following this extensive debridement the patient showed an initial improvement. However, 10 days later large quantities of small bowel contents were discharged from the original wound site. Abdominal computed tomography (CT) revealed multiple intraabdominal abscesses. Her condition declined despite intensive antibiotic therapy and repeat CT showed obvious necrotizing fasciitis of the retroperitoneal tissues with extension of the intra-abdominal collections. At laparotomy the fistula was found to come from a necrotic area of caecum. An ileocaecal resection was performed and a defunctioning ileostomy was raised. The intra-abdominal abscesses were drained and the abdomen again thoroughly lavaged with saline. The patient’s condition improved gradually and repeat CT 10 days later showed no residual necrosis or collections. She was discharged 9 weeks after initial admission. A subsequent admission for reversal of the stoma was uneventful and she has now returned to full health. This case illustrates the value of CT in determining the presence and extent of retroperitoneal fasciitis and the timing of subsequent surgical procedures. It also demonstrates that survival in this deadly condition is dependent on the successful eradication of the source of sepsis.
M. J. Osborne J. R. Novel1 A. A. M. Lewis University Department of Surgery The Royal Free Hospital London N W3 2QG UK
1247
