When is wound packing recommended after Incision and Drainage (I&D)?

Wound Packing After Incision and Drainage (I&D)

Routine wound packing after incision and drainage of uncomplicated abscesses is not recommended as it increases pain without providing clear benefits for healing or recurrence rates. 1, 2, 3

Evidence on Wound Packing

The World Journal of Emergency Surgery guidelines (2021) explicitly state that no recommendation can be made regarding the use of packing after drainage of an anorectal abscess based on the available literature 1. A Cochrane review cited in these guidelines included only two small studies with high risk of bias, making it unclear whether packing influences healing time, wound pain, fistula development, or abscess recurrence.

For perianal abscesses specifically in Crohn's disease, the guidelines recommend adequate surgical drainage without routine requirement for wound packing, noting that packing may have a limited role only for short-term hemostatic requirements 1.

Key findings from research:

• Multiple studies show that packing is associated with increased pain compared to non-packing approaches:
  • Patients with packed wounds reported significantly higher pain scores immediately post-procedure and at 48-hour follow-up 3
  • Packed patients used more pain medications, particularly opioids 3
• No significant differences were found in:
  • Treatment failure rates
  • Recurrence rates
  • Need for secondary interventions 2, 4, 3

When Packing May Be Considered

While routine packing is not recommended, there are specific situations where it may be appropriate:

1. Short-term hemostasis: When active bleeding needs to be controlled 1
2. Large abscess cavities: Some clinicians suggest packing for larger abscesses, though evidence is limited
3. Alternative packing materials: If packing is deemed necessary, consider silver-containing hydrofiber dressings which have shown faster wound healing and less pain compared to traditional iodoform packing 5

Alternative Approaches

1. High-vacuum wound drainage systems: These have been shown to reduce pain and treatment time compared to traditional I&D with packing, particularly in pediatric patients 6

2. Catheter or drain placement: Some surgeons place a catheter or drain into the abscess cavity with a small stab incision under local anesthetic, leaving it in place until drainage stops 1

Important Considerations for I&D Management

• Ensure adequate drainage of all loculations even if the abscess is spontaneously draining 7
• Avoid aggressive probing for fistulas to prevent iatrogenic complications 7
• For anorectal abscesses with obvious fistulas:
  • Perform fistulotomy only for low fistulas not involving sphincter muscle
  • Place a loose draining seton for fistulas involving sphincter muscle 1
• Consider antibiotics only in specific situations:
  • Sepsis or systemic infection
  • Surrounding soft tissue infection
  • Immunocompromised patients
  • Incomplete drainage 7

Follow-up Care

• Monitor for signs of infection
• Follow up within 48-72 hours to assess for reaccumulation
• Be vigilant for potential complications including recurrent abscess and fistula formation 7

In conclusion, the evidence suggests that routine packing of abscess cavities after I&D is painful for patients and likely unnecessary in most cases. The decision to pack should be based on specific clinical needs rather than routine practice.