Performing 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.”
- Incise lateral edge of abscess cavity.
- Small, 4-5 mm incision.
- Break up the loculations.
- Insert small curve hemostat or small needle driver through small incision.
- Gently explore abscess cavity and break up loculations.
- Find edge of abscess cavity.
- While probing the cavity, determine the dimensions of the cavit.
- 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.
- Irrigate and get the pus out!
- Now with an ingress and an egress, you can decompress the abscess.
- Irrigation can help remove debris.
- 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.
- 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.
- Tie multiple other knots tightly on top of the surgeon’s knot to ensure security.
- (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).