What is the management approach for minor swellings in general surgery?

Management Approach for Minor Swellings in General Surgery

For minor swellings in general surgery, tranexamic acid (TXA) is the preferred prophylactic option, with surgical excision being the definitive treatment for most cases after appropriate diagnostic evaluation. 1

Diagnostic Approach

• Initial evaluation should include assessment for potential causes including infection, trauma, vascular abnormalities, and neoplastic processes 2, 3
• Radiographs are the first-line imaging modality for swellings with suspected underlying bone involvement 1
• MRI with and without contrast is the preferred advanced imaging for soft tissue swellings when radiographs are inconclusive or further characterization is needed 1
• CT with contrast is an alternative when MRI is contraindicated 1
• Fine needle aspiration cytology (FNAC) or incisional biopsy may be necessary for suspicious swellings to rule out malignancy 2, 4

Management Based on Etiology

Surgical Management

• Surgical excision with clear margins is the treatment of choice for most minor swellings, especially when:
  • Diagnosis is uncertain 2
  • Swelling is enlarging or symptomatic 4
  • Malignancy is suspected 4
• Minor surgery in general practice settings is cost-effective compared to hospital settings for appropriate cases 5
• Specimens should be sent for histopathological examination to avoid missing malignancies 5

Bleeding Disorders and Surgical Prophylaxis

For patients with known or suspected bleeding disorders undergoing minor surgical procedures:

• Tranexamic acid (TXA) is the preferred prophylactic option (used in 79% of cases) 1
• For bleeding during minor surgery in patients with bleeding disorders:
  • Desmopressin (DDAVP) is the most frequently used first-line treatment (56% of cases) 1
  • If first-line treatment fails, recombinant Factor VIIa (30%) or fresh frozen plasma (25%) may be considered 1

Management of Specific Types of Swellings

Inflammatory/Infectious Swellings

• For cellulitis with skin lesions:
  • Appropriate antibiotic therapy based on suspected pathogens 1
  • Surgical drainage if abscess formation is present 6
  • For odontogenic infections in particular, options include immediate surgical management with or without antibiotics, or antibiotics followed by delayed surgical management 6

Post-traumatic Swellings

• Evaluate for vascular injuries, especially if swelling worsens after initial trauma 3
• Consider compartment syndrome in cases of increasing pain and swelling 3
• Imaging with ultrasound or MRI/MRA may be necessary to rule out arteriovenous fistulas or other vascular abnormalities 3

Vascular Access-Related Swellings

• Persistent swelling of extremities should be expeditiously evaluated and underlying pathology corrected 1
• For arteriovenous fistula complications, evaluate for:
  • Inadequate flow 1
  • Aneurysm formation 1
  • Stenosis (>50%) in venous outflow or arterial inflow 1

Special Considerations

• In immunocompromised patients, consider fungal infections as potential causes of subcutaneous swellings 2
• For palatal swellings, incisional biopsy is mandatory as the risk of malignancy is significant 4
• Rectal prolapse with swelling may be managed conservatively with manual reduction under sedation if no signs of ischemia or perforation are present 1

Common Pitfalls to Avoid

• Failure to send specimens for histopathological examination (general practitioners send only 61% versus 90% in hospital settings) 5
• Misdiagnosing malignant conditions as benign (occurs in 10% of general practice cases versus 1% in hospital) 5
• Inadequate excision of lesions (5% in general practice) 5
• Delaying surgical management in cases of strangulated or ischemic swellings 1
• Overlooking potential underlying causes such as bleeding disorders or vascular abnormalities 1, 3