Surgery is the mainstay of treatment for Fournier gangrene.^[1]. As the patients are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.^[2]

Radical surgical debridement

Surgery is the mainstay of treatment for Fournier gangrene.^[1]

• Indications include:^[1]

• Patients displaying intense pain and skin color change such as edema and/or ecchymoses
• Signs of skin ischemia with blisters and bullae
• Altered mental status, hypotension, elevated band forms in the differential WBC count and metabolic acidosis.

• Immediate surgical referral remains the only method of reducing mortality and morbidity in Fournier gangrene patients.^[3][4]
• As the patients are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.^[2]
• Effects of analgesia can be measured by documenting pain score regularly.
• Stop any NSAIDs on patient admission.

Procedure

• Radical debridement of areas of overt subcutaneous necrosis should be done in the operation theater in the lithotomy position to allow access to all perineal structures.
• Deep fascia and muscle are rarely involved, thus debridement is usually not required.
• Separation of the skin and subcutaneous tissue with a hemostat has been recommended to define the limits of excision. Debridement is stopped where these tissues do not separate easily.

Fecal and urinary diversion

• Urinary or fecal diversion is required to treat an underlying condition or prevent wound contamination.^[5]
• When there is gross urinary extravasation or periurethral inflammation, suprapubic cystostomy is required. A urinary catheter is used in milder cases.
• Colostomy is required when there is gross sphincter infection or colonic or rectal perforation.
• Testes are temporarily implanted into subcutaneous tissue pouch (medial thigh or lower abdomen) until healing or reconstruction is complete.
• Orchidectomy is performed if there is any pre-existing epididymo-orchitis or scrotal abscess.

Plastic reconstruction

• The split thickness skin graft is a commonly used technique for reconstructive surgery. For large defects, rotational or free myocutaneous flaps and omental flaps are used to cover larger defects.^[5]

Wound management

• The wound is monitored closely after surgery.
• Multiple surgical debridement are required with an average of 3.5 procedures per patient.^[6]
• Sodium hypochlorite or hydrogen peroxide are used post-operatively for topical application.^[7]
• Lyophilized collagenase (an enzyme that digests and debrides necrotic tissues) is used for enzymatic debridement twice daily until definite reconstruction can be performed.^[8]

Vacuum-assisted closure device
The vacuum assisted closure device is used for faster and effective wound closure.^[9][1] This devices helps wound healing by absorbing excess exudates, reducing localized edema, and finally drawing wound edges together.