Successful management of necrotizing fasciitis involves early recognition, immediate initiation of resuscitative measures (including correction of ﬂuid, acid-base, electrolyte, and hematologic abnormalities), aggressive surgical debridement and redebridement as necessary, and broad-spectrum intravenous antibiotic therapy (104). During surgery, the incision should be made through the infected tissue down to the fascia. An ability to undermine the skin and subcutaneous tissues with digital palpation often will confirm the diagnosis. Multiple incisions can be made sequentially toward the periphery of the affected tissue until well-vascularized, healthy, resistant tissue is reached at all margins. The remaining affected tissue must be excised. The wound can be packed and sequentially debrided on a daily basis as necessary until healthy tissue is displayed at all margins. Hyperbaric oxygen therapy may be of some benefit, particularly in patients for whom culture results are positive for anaerobic organisms (110). Retrospective nonrandomized studies demonstrated that the addition of hyperbaric oxygen therapy to surgical debridement and antimicrobial therapy appears to significantly decrease both wound morbidity and overall mortality in patients with necrotizing fasciitis (110). The benefit of hyperbaric therapy demonstrated in one study was remarkable, given that patients receiving hyperbaric oxygen were sicker and had a higher incidence of diabetes mellitus, leukocytosis, and shock (106).
After the initial resuscitative efforts and surgical debridement, the primary concern is the management of the open wound. Allograft and xenograft skin can be used to cover open wounds, thus decreasing heat and evaporative water loss. Temporary biologic closure of open wounds seems to decrease bacterial growth (111). Amniotic membranes were effective wound covering in patients with necrotizing fasciitis (112).
A new technology demonstrated to significantly improve wound healing in laboratory and clinical studies is a vacuum-assisted closure (VAC) method that uses a subatmospheric pressure technique (113–115). In situations in which spontaneous closure is not likely, the VAC device may allow for the development of a suitable granulation bed and prepare the tissue for graft placement, thereby increasing the probability of graft survival. Skin ﬂaps can be mobilized to help cover open wounds when the infections resolve and granulation begins.
Traditionally, mechanical bowel preparation was advised before abdominal surgery, especially if colonic surgery was anticipated. Despite the infrequent need for colonic surgery (or injury) when performing gynecologic surgery, bowel preparation is part of the standard practice for many gynecologists. Advantages of mechanical bowel preparation include reduction of gastrointestinal contents, which facilitates the surgical procedure by allowing more room in the abdomen and pelvis. If a rectosigmoid colon enterotomy occurs, the mechanical bowel preparation eliminates formed stool and reduces the risk of bacterial contamination, thus reducing infectious complications.
Randomized clinical trials questioned the need for mechanical bowel preparation in colonic surgery (116). Although somewhat controversial, a meta-analyses including almost 5,000 patients showed no statistical difference between the groups for anastomotic leakage (p = 0.46), pelvic or abdominal abscess (p = 0.75), and wound sepsis (p = 0.11). The use of different mechanical regimes did not inﬂuence primary and secondary outcomes. The authors concluded that this analysis demonstrates that any kind of mechanical bowel preparation should be omitted before colonic surgery. The main limitation concerned rectal surgery for which the limited data preclude any interpretation.