Fournier's Gangrene Involving the Whole Abdominal Wall. Rescue by Vacuum-Assisted Closure (VAC): Therapy and Hyperbaric Oxygenation (HBO)

Case report

A 45-year-old tetraplegic male patient presented with a small necrotic patch at the scrotum, septic shock, and an inflammatory rash spreading to the bigger part of the abdomen. The origin of the process was a necrotizing left epididymitis that had spread to the left testicle. Left semicastration was necessary. The scrotal skin, skin, and soft tissue at the left groin and skin, subcutis, and fascia of practically the whole abdominal wall and the left obliquus externus abdominis muscle had to be resected. The wound comprised about 15% of the body surface (Fig. 1). High-dose antibiotic therapy and daily hyperbaric oxygenation at 2.5 bar were applied, fecal diversion was done by a temporary containment device (Zassi; Hollister Inc., Libertyville, IL, US), and a routine urinary catheter was used. When there was no longer formation of fresh necroses, a VAC system (Vacuum-assisted closure; VAC; Kinetic Concepts, Inc; San Antonio, TX) for preconditioning the surface to split-skin grafting was applied. In order to achieve a complete covering of the complex wound, the foam dressing was tailored liberally, preliminarily securing the pieces with staples. An air-tight fitting of the transparent adhesive dressing was achieved by fastening its borders to the glans penis. A low degree of continuous suction (125 mmHg) was applied (Fig. 2). The dressing was changed every 72 hours or in case of fever >38.5°C or of a rise in white blood cell (WBC) count or C-reactive protein (CRP) level. Clean granulation tissue formed within 10 days, and a one-stage split-skin grafting from both thighs resulted in an almost 100% take. The right testicle was covered with pedicled skin from the thigh (Fig. 3). The patient made an uneventful recovery.

Abstract

Keywords

Fournier's gangrene, hyperbaric oxygen, VAC treatment, granulation tissue