Open Drainage of Liver Abscessin Hazaribagh: Preparation, Procedure & More

A liver abscess is an abnormal collection of pus (a thick yellow fluid consisting of white blood cells, germs, and dead tissue) in your liver that most often occurs as an inflammatory response to an infection in your body. Symptoms of a liver abscess include high-grade fever (>103°F), upper right abdominal pain, sudden and unexplained weight loss, dark-colored urine, and white or clay-colored stool with/without diarrhea. The abscess can be easily diagnosed through an abdominal ultrasound or a CT (Computed Tomography) scan to know the exact size and extent of the abscess. Open drainage is the most effective method to treat complex and severely infected liver abscesses.

Treatment for a liver abscess usually depends on the size and severity of the abscess. These include either non-surgical or surgical methods.

Non-surgical treatment

These are usually used as a first-line treatment for liver abscess less than 3 cm in diameter.

Medication

• A liver abscess smaller than 4 cm can be easily treated through antibiotics.
• Once the organism causing the infection is identified with the help of a blood culture, your doctor may prescribe the appropriate antibiotics to help treat the infection, which can eventually reduce the size of a liver abscess. 

High-intensity focused ultrasound (HIFU)

• It is a non-invasive method that uses sound energy to help reduce the size of the abscess with the help of an ultrasound device. This is gaining momentum since it aids in faster healing with minimal postoperative complications, no incisions or scars, and no drainage catheter is required. 

Surgical treatment

Surgical methods for liver abscess treatment are often recommended when non-surgical methods fail.

Open Drainage

• A single large incision (cut) is made using a surgical knife (scalpel) over the liver abscess for direct access (de-roofing the abscess), where the abscess is scraped, and the pus is completely drained.
• An additional drainage tube (catheter) drains the residual pus.

Percutaneous Drainage

• This procedure is performed via a needle puncture of the skin over the abscess and placing a draining catheter left in place to drain the pus.
• It is an ultrasound-guided procedure to reach the liver abscess. 

Laparoscopic Drainage 

• This minimally invasive procedure involves multiple small incisions on the skin overlying the liver abscess.
• A special tube-like device (laparoscope) with a light source and camera is used to view the abscess through images captured by the camera.
• The catheter drain is inserted via other incisions to drain the abscess. 

Open drainage of liver abscess is a conventional surgical approach that involves cutting through the skin overlying the abscess. This procedure uses a surgical knife known as a scalpel to make a single large incision to cut across the layers of the skin and underlying tissues, thereby exposing the liver abscess. 
Blunt surgical instruments are used to completely scrape out the abscess lining while placing a thin catheter tube for additional drainage of the residual pus. The surgical wound is stitched up using sutures, and the catheter drain is left in place and secured with surgical tapes. This drain is usually removed 1 to 2 weeks after completely reduced infection. 

Open drainage is a surgical method of draining a liver abscess that is usually recommended for the following reasons:

• If the non-surgical methods fail to treat the liver abscess.
• For large liver abscess measuring over 5 cm in diameter. 
• Multiple liver abscesses with or without multiloculated (having several cavities within the abscess)
• In case of an abscess rupture which increases the risk of spread of the infection to the surrounding organs and structures.
• If the liver abscess is associated with biliary problems, such as bile duct obstruction (as seen due to gallstones), intra-abdominal conditions such as appendicitis (inflammation of the appendix), and peritonitis (inflammation of the membrane lining the abdominal wall). 

You must consult your healthcare provider if you notice symptoms associated with a liver abscess. Your doctor will evaluate your symptoms and record your medical history to gain information about:

• Any pre-existing condition like diabetes (increased blood sugar levels), hypertension (high blood pressure), or any blood disorders that may negatively impact your healing and recovery process.
• Any drug allergies, previous surgeries, or injuries. 
• Medications being taken such as blood thinners, anti-inflammatory and anti-hypertensive drugs, antidepressants, or other herbal and vitamin supplements.
• Social habits like smoking and alcoholism may negatively alter your recovery process. This helps the doctor take necessary precautions during and after the surgery to avoid complications.

Your doctor will then conduct a physical examination to check for abdominal pain, tenderness, or skin discoloration. Your surgeon may advise the following diagnostic tests to confirm the presence of a liver abscess and evaluate the size, severity, and exact location of the abscess. It also helps to determine the type of treatment that best suits you according to your condition.

• Complete blood count
  • This test helps to check the levels of blood components like RBCs (red blood cells), WBCs (white blood cells), etc.
  • Your doctor will also get a clear picture of any blood infection present that may have led to liver abscess development.
  • This test also evaluates the liver function test to check for other liver-related pathologies.
• Blood culture test
  • This test helps to identify the organism causing the infection in your body.
  • Blood culture reports are important to determine the type of antibiotics needed after the drainage.
• Abdominal ultrasound scan
  • This imaging test uses sound waves that help identify the size and the extent of a liver abscess.
• CT (Computed Tomography) scan
  • Utilizes special X-ray images to determine the exact location of a liver abscess.
  • This imaging test also helps to rule out the possibility of malignancy (cancer-forming ability).

Preparation before open drainage is important to help reduce stress and anxiety for a smoother procedure and optimal healing.

• You must discontinue medications like blood thinners, etc., and other herbal supplements 2 weeks before the procedure to prevent the risk of bleeding during and after the procedure.
• You must avoid smoking and alcohol at least a week before the surgery since this may delay the wound healing.
• You may be started on a course of antibiotics to help treat the infection and prevent any further infection post-surgery.
• You must fast 8 to 12 hours before the abscess drainage since it will be performed under general anesthesia. Fasting helps to prevent the aspiration of food particles into the windpipe.

Open drainage for a liver abscess is a surgical procedure that is performed as an inpatient procedure requiring hospitalization. 

• Once your doctor confirms the size, severity, and extent of the liver abscess, you will be scheduled for open drainage.
• It is usually performed by a general surgeon specializing in the surgical procedures of diseased organs and structures.
• On the day of the procedure, you will be made to sign a consent form to provide legal permission to your surgeon to perform the procedure.
• Your nurse will prep you for the procedure by shaving the surgical site to remove excess hair (if present).
• The surgical area will be further disinfected using an antiseptic solution to remove surface contaminants.
• Your anesthesiologist will administer general anesthesia (a numbing agent that completely sedates you) through an IV (intravenous) line while continuously monitoring your vitals (blood pressure, pulse, heart rate, and oxygen levels).
• Your surgeon will use a scalpel (a surgical knife) to make a single large incision near your upper right abdominal area to gain access to the liver abscess. The incision usually measures around 3 to 4 cm.
•  Once the abscess is located, your surgeon will cut it open to drain it. 
• Blunt surgical instruments will completely scrape out the abscess content to remove the lining.
• A catheter will be placed near the surgical site to drain any residual pus. 
• Your surgeon will close the surgical wound using stitches, and the catheter will be secured using surgical tapes. 
• A surgical dressing will be placed over the stitches to prevent infection and provide protection.
• The entire drainage procedure will take around 60 to 90 minutes.

You will be in the recovery room after the surgical drainage of your abscess, where your vitals will be monitored, and once stabilized, you will be shifted to your room for further recovery. 

• Once the effect of anesthesia wears off, it is normal to experience mild pain, soreness, and discomfort near your surgical area. 
• Your surgeon will begin IV antibiotics as an initial antibiotic treatment to prevent post-op infection and minimize any residual pus discharge.
• You will be given sips of water initially as you regain consciousness, and once you can take in fluids, your surgeon will recommend semi-solid foods from the second day following the procedure.
• You will be made to walk the following day to prevent the formation of blood clots.
• You will be discharged after 3 to 7 days once your pain is under control and you can walk around easily. 
• Be sure to rest once you are back home for optimal healing and quick recovery. 
• You can take a shower after 3 days post-drainage.
• You must change your surgical dressing every alternate day and keep it clean and dry.
• Your stitches will be removed after 7 to 10 days post-procedure. 
• Your surgeon will prescribe oral antibiotics for 1 to 2 weeks to reduce your risk of post-op infections. 
• Avoid the following for at least 2 weeks:
  • Lifting heavy objects
  • Strenuous exercises and activities
  • Soaking your surgical wound 
  • Swimming and tub baths
  • Spicy foods (chilies, peppers), carbonated drinks, smoking, and alcohol.
• Your drainage catheter will be removed once there is no pus discharge (approximately after 1 to 2 weeks).
• Complete recovery after open liver abscess drainage may take 2 to 3 weeks. 

Though a conventional method, open drainage of liver abscesses is still widely used due to the following benefits.

Benefits

• Open drainage provides good accessibility and visibility to the surgeon, unlike other alternative treatment methods (like laparoscopic drainage)
• It helps you eliminate the chronic (long-lasting) pain caused by the infected liver abscess, improving your quality of life.
• It provides a permanent solution since the abscess is completely drained to remove pus, and reduces the risk of abscess recurrence.

Risks 

Like any other surgical procedure, an open liver abscess drainage can pose the following risks:

• Hematoma formation (abnormal swelling beneath the skin near the surgical site due to blot clot formation).
• Mild scarring at the incision site.
• Numbness near the surgical site due to damage to the nearby nerves.
• Allergic reactions due to the anesthesia cause skin rash, redness, itching, hives, dizziness, confusion, nausea, vomiting, and shortness of breath.
• Formation of blood clots that may get dislodged into the bloodstream and travel to internal organs like the lungs (pulmonary embolism), causing life-threatening complications.
• Wound infection causing pain with/without pus discharge due to poor post-operative care.

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