Most fullfilling patients and cases you get involved with as a General Surgeon

[SLUser11]

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What about those of generous size (abscess cavities and patients)? I worry that without an elliptical incision or some packing they will recur (but that might just be from having to take all the failed microstab I+D's the ER doc has done). Sometimes if it is really huge I will make counterincisions and leave a penrose for a week instead of making a gaping hole and when I remove that I never have them pack and the cavity heals just fine. Perhaps I should rethink my strategy. Teach me your butt pus secrets.

I think a 3cm (0r more if necessary) radial incision is adequate for most run-of-the-mill perianal and perirectal abscesses.

For large ones, which are typically horseshoe abscesses, I do use drains and counter-incisions liberally, so I think you're approach doesn't require rethinking. I do a "modified Hanley" with a seton instead of fistulotomy.

Another approach, which I never use but is an option, is to sew a malecot drain into the abscess cavity. I typically only do this if there is a transsphincteric fistula with cephalad extension sinus tract.

What would you say is your threshold for "is Ok for the ER doc to try and see me in clinic" vs "must be approached by a surgeon on the first shot?"

I have the liberty of surgical residents, so I don't have to make this decision very often. If the ER doc can't get it drained, our residents will get it done.

I do think it's acceptable in certain cases to see in the office the following day, but I would be cautious, as anorectal sepsis can come on quickly, and I don't trust the ER doc to be able to discriminate. Still, in private practice you can certainly do this, especially if you have a robust clinic with coverage every day.

I forgot to mention earlier that I will give antibiotics after drainage if there is cellulitis, if the patient is immunocompromised, or if there were severe systemic sx (e.g. rigors). In general, most patients won't need abx after drainage, and it certainly will not impact whether or not they get a fistula.

 

[dpmd]

The easier that it goes in the better too.

One time I reduced a hernia before the ED nurse had even gotten her IV in. Ha.

I admitted her and fixed it the next morning though.

As much as I enjoy it, I do try to teach them my tricks, if only to reduce the chances I have to get up out of bed to come do it. I feel like every ER doc I have ever met never learned how to do it right. They all just mash at it and only a couple ever start by putting the patient in trendelenburg and giving some pain meds a while before trying (have come in at least once to discover the patient has self reduced since the ER doc saw them last and the nurse subsequently gave them some pain meds).

 

[universallove]

Draining a simple perianal abscess in a average sized American at 2am in the ER

HAHA funny