Perianal Abscess: Incision and Drainage

To drain infection of the soft tissue surrounding the rectum, which is caused by obstruction of the anal crypts and ducts

CONTRAINDICATIONS

Perianal abscesses with fistula-in-ano should be drained in the operating room (OR)

LANDMARKS

Most perianal abscesses form in the soft tissue adjacent to the anal sphincter

Ischiorectal, intersphincteric, external sphincter, and supralevator abscesses form internally underneath the subcutaneous tissue adjacent to the rectum (FIGURE 70.1)

General Basic Steps

Analgesia

Incision

Blunt dissection

Packing and dressing

TECHNIQUE

Supplies

Adhesive tape

1% Lidocaine with epinephrine (1:100,000)

25- and 22-guage needles, 10-mL syringes

FIGURE 70.1 Anorectal abscesses. (From Coates WC. Perianal, rectal, and anal diseases. In: Wolfson AB, ed. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:609, with permission.)

No. 11 scalpel blade

Hemostat

Saline

Sterile packing

4 × 4 gauze pads

Preparation

Consider mild oral sedative or anxiolytic for the patient before procedure

Place patient in the prone position

Separate buttocks with adhesive tape to the lateral aspect of the hip (FIGURE 70.2)

Analgesia

Infiltrate area around the abscess with 1% lidocaine with epinephrine (1:100,000)

Incision

Using a no.11 blade, a linear or elliptical incision is made over the most fluctuant part of the abscess

Express as much as possible from the abscess with gentle squeezing pressure (FIGURE 70.3)

Blunt Dissection

Explore abscess with a hemostat to break loculations

Irrigate the abscess with normal saline (FIGURE 70.4)

FIGURE 70.2 When excising a thrombosed external hemorrhoid or performing incision and drainage of an anal abscess, separate the buttocks by using 3-inch adhesive tape, as shown, to provide optimal exposure. (From Simon RR, Brenner BE. Emergency Procedures and Techniques. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:33, with permission.)

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