Case Files: The Best Incision and Drainage Technique. Ever!

This will be the first installment in a series of case files on the blog, where I review anecdotally novel techniques, procedures, and other tools used by myself or colleagues in the ED. As usual I welcome your stories and experiences as well!

Last night I encountered a patient who presented with a pilonidal cyst abcess with surrounding cellulitis over the left gluteus. There were no complicating factors (DM, HIV etc).

Recently I came across Dr. Rob Orman's cast and elegant summary on the LOOP abscess drainage technique, which comes from a recent publication in the Journal of Pediatric Surgery. In short, the traditional technique of making a large incision and inserting packing with scheduled changes is replaced by two smaller (more cosmetic friendly) incisions and tunneling a small rubber cathether or drain tied together to make a loop. This obviates the need for painful packing changes, possible premature wound closure, and need for repeat procedure. See schematic below:

credit: Michelle Lin, Academic Emergency Medicine

In the case above, I followed the same procedure described in Dr Orman's video and made some minor adjustments to accomodate the nature of the pilonidal abscess. A second small incision was then made superior to the point of drainage and, with the hemostat, a tunnel was burrowed between the two points. I work in an emergency department with limited resources and equipment, so surgical vascular tubing used in the video were not availbale. Instead I cut off the vacutainer and needle of the two ends of a butterfly and used it in its place. Aftercare instructions were provided as in the paper and video.

The patient afterward was extremely pleased, smiling, and I must confess--I was too :)