Incision and Loop Drainage of Abscess

Incision and Loop DrainagePerforming procedures is obviously an important aspect of what we do in the Emergency Department. Our procedural prowess is depended upon by our patients and their families. We have discussed several procedural strategies previously (ex, Suturing, Tongue lacerations, Spinal Tap, ETT placement, Pigtail Thorocostomies, Transillumination of Ptx, and many more). One common condition that often requires a procedure is the subcutaneous abscess. We have previously discussed whether antibiotics are needed for abscesses. Now let us look at whether there is another strategy to the classic incision and drainage: Incision and Loop Drainage.

Loop Drainage: The Technique

This technique is described by several paper – [Aprahamian, 2016; Ladde, 2014; Ladd, 2010; Tsoraides, 2010]

Aprahamian, 2016 recommends it as the “definitive treatment of choice for subcutaneous abscesses in children.”

  1. Incise lateral edge of abscess cavity.
    • Small, 4-5 mm incision.
  2. Break up the loculations.
    • Insert small curve hemostat or small needle driver through small incision.
    • Gently explore abscess cavity and break up loculations.
  3. Find edge of abscess cavity.
    • While probing the cavity, determine the dimensions of the cavit.
  4. 2nd incision in this region.
    • Ideally, make second small (4-5mm) incision within 4 cm of the first.
    • For very large abscess cavities, you can use additional small incisions.
      • 3 or 4 incisions with each being ~ 4cm apart from the other.
  5. Irrigate and get the pus out!
    • Now with an ingress and an egress, you can decompress the abscess.
    • Irrigation can help remove debris.
  6. Pass vessel loop, sterile rubber band, or Penrose Drain though two incisions.
    • Vessel loop work very well for this as it is a small calibre and is easy to tie.
    • Vessel Loop
    • Vessel Loop Drainage 1
    • Passing the Vessel Loop
  7. Tie ends together, ensuring no tension on skin.
    • Use a surgeon’s knot for the first tie.
    • Ensure that there is plenty of slack to avoid tension on the skin.
    • Surgeon's Knott for Loop Drainage
    • Tie multiple other knots tightly on top of the surgeon’s knot to ensure security.
    • Loop Drainage tied
    • (yes… I know this abscess looks like it has a lot of Vitamin C…)

Loop Drainage: Home Care

  • Keep area clean.
  • Can cover with gauze to absorb the residual drainage.
  • Can shower and/or bathe.

Loop Drainage: The Removal

  • The loop drain can removed once:
    • Drainage has stopped.
    • Cellulitis has improved.
  • Usually is within 7-10 days.

Loop Drainage: The Benefits

  • Minimizes scarring (two small incisions instead of one large one). [Aprahamian, 2016]
  • Eliminates the need for repeat visits for wound packing changes. [Aprahamian, 2016]
  • This saves the patient / family the time of returning multiple times.
  • Also saves the patient the pain and anxiety of having the packing changed.
  • Also saves ED visit cost.
  • In theory, the loop could be removed by any provider (PCP, Urgent Care, etc).

References

Aprahamian CJ1, Nashad HH2, DiSomma NM3, Elger BM4, Esparaz JR5, McMorrow TJ4, Shadid AM4, Kao AM3, Holterman MJ1, Kanard RC4, Pearl RH6. Treatment of subcutaneous abscesses in children with incision and loop drainage: A simplified method of care. J Pediatr Surg. 2016 Dec 30. PMID: 28069270. [PubMed] [Read by QxMD]

Ladde JG1, Baker S2, Rodgers CN3, Papa L4. The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. Am J Emerg Med. 2015 Feb;33(2):271-6. PMID: 25435407. [PubMed] [Read by QxMD]

Kessler DO1, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7. PMID: 22653459. [PubMed] [Read by QxMD]

Ladd AP1, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg. 2010 Jul;45(7):1562-6. PMID: 20638546. [PubMed] [Read by QxMD]

Tsoraides SS1, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010 Mar;45(3):606-9. PMID: 20223328. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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