Incision and drainage of abscess

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• pus collecting again (residual or recurrent abscess), needing a second drainage
• bleeding from the cavity
• open wound needing daily dressings until it heals
• scar
• spread of infection and sepsis
• sinus or fistula formation (for perianal abscess, a fistula may need later surgery)
• injury to nearby nerves or vessels
• an underlying tumour or other cause found later

Pre-operative details for this operation

1. Site and size of abscessside, region, size in cm, pointing, fluctuation, induration, cellulitis margin
2. Duration and systemic featuresdays of swelling, fever, pulse, signs of sepsis
3. Predisposing conditionsdiabetes (RBS / HbA1c), HIV, steroids or immunosuppression, injection site, trauma
4. Imaging or aspiration before incisionNot needed (superficial, pointing)USG doneCT / MRI done (deep or near vessels)a deep swelling near a major vessel may be an aneurysm or sarcoma
5. Antibiotic started before drainagedrug, dose, time
6. Perianal abscess only: proctoscopy / known fistulaNot applicableProctoscopy doneKnown fistula

Anaesthesia and position

1. AnaesthesiaGeneralSpinalLocal infiltration (small superficial abscess)
2. PositionSupineProneLateralLithotomyProne jackknife

Operative findings

1. Pusvolume in ml, colour, consistency, smell
2. Cavitysize and depth in cm, loculi, extensions
3. Deepest layer reachedSubcutaneousSubfascialIntramuscularIschiorectal fossaOther
4. Necrotic tissue or sloughNonePresent, debrided
5. Perianal only: internal opening seenNot applicableNone seenPresent (clock position)
6. Anything unusualsolid tissue, foreign body, bone, pulsatile cavity

Procedure (steps)

1. Skin preparation and drapingantiseptic used
2. Diagnostic aspirationPus aspirated with needle and syringeNot done (obvious pus)
3. IncisionLinearCruciateEllipticalsite (most fluctuant point, near anal verge for perianal), length, direction (along skin lines, parallel to nerves and vessels)
4. Cavity openedpyogenic membrane opened with sinus forceps (Hilton's method)
5. Pus sampleSent for culture and sensitivitySent for Gram stain, culture and sensitivity, AFB
6. LoculiBroken down with finger / sinus forcepsNot disturbed (perianal: digital breakdown avoided)
7. DeroofingSkin edges / cruciate flaps excisedNot neededso that the skin does not close before the cavity
8. Debridement of sloughDoneNot needed
9. Cavity washedNormal salinePovidone-iodine and salineHydrogen peroxide and saline
10. HaemostasisPressureCauteryPack

Closure, drains and dressing

1. WoundLeft open to heal by secondary intentionLoosely approximated over drain
2. Pack or drainPovidone-iodine gauze packCorrugated drainGauze wickNonenumber of pieces placed, so all are removed later
3. Dressingtype

Specimens and implants

1. Pus for culture and sensitivitySentNot sent (reason)
2. Tissue from cavity wall for HPENot neededSent (cavity looked unusual / recurrent abscess)

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals and temperaturefrequency; watch for sepsis
2. Antibioticsdrug, dose, route; change once culture report is back
3. Blood sugarmonitoring schedule and control plan if diabetic
4. Pack removal and first dressingwhen; count pieces removed against pieces placed
5. Daily dressingtype; look for fresh pus, spreading redness, slough
6. Analgesiadrug, dose, frequency
7. Perianal abscesssitz bath, stool softener, review with proctoscopy for a fistula
8. Follow-upculture and HPE report, wound check dates

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery