TRAUMATIC AVULSION OF SCROTUM AND PENILE SKIN ~

Transcription

1 TRAUMATC AVULSON OF SCROTUM AND PENLE SKN ~ By R. L. MANCHANDA, M.S., F.R.A.C.S., RAJNDER SNGtt, M.S., R. K. KESWAN, M.S., F.R.C.S.(C), and C. G. SHARMA, M.B., B.S. From the Department of Plastic and Reconstructive Surgery, Government Medical College, Patiala (ndia) AVULSON of the skin from the external genitalia is a rare surgical emergency. n most of the cases this is caused by,industrial and farm accidents of" power take-off" variety although it has also been reported in a bull-fighter (Gonzales-Ulloa, 963). n the power take-off the folds of trousers, dhoti or any loose garment tied around the waist are caught in a turning power-shaft, twisted up to the genital region and torn off. f this accidental twisting of clothes engages the scrotum or the penile skin it results in its avulsion from behind forwards, the skin being stripped off the testes, spermatic cords and penis either partially or completely. The plane of cleavage in the scrotum is usually superficial to the cremaster muscle, i.e. through areolar tissues deep to the dartos muscle and in the penis it is just deep to the skin which is usually torn loose at the corona. This line of cleavage in the scrotum is due to the cremasteric reflex. When the scrotal skin is gripped, the cremaster muscles contract reflexly and retract the testes. The skin tear mayrarely extend backwards into the perineum and even rectum. Anteriorly there may be loss of the pubic skin. The testes, erectile tissue and urethra in the perineum usually escape major damage. Occasionally the skin specimen is brought with the patient but is rarely suitable for use. When the scrotal skin loss is partial, primary closure may be possible because of its lax nature. The regenerative capacity of the small fragments of the scrotal skin is well recognised (Roth and Warren, 944 ; Ferris, 949 ; Brtmer, x95o). When the scrotal skin loss has been complete implantation of the testes subcutaneously either in the upper thigh (Owens, 942 ; Whelan, 944 ; Brtmer 95O ; May, i95o; Pfeiffer and Miller, 95O) or in the inguinal region (Ferris, 949) has been practised. Douglas (i95 ) described primary reconstruction of the scrotum by local thigh flaps. Gibson (954) used avulsed scrotal skin as a full thickness free graft over the testes and achieved a 60 per cent. take. Balakrishnan (956) reported a case where a split skin graft was used for scrotal reconstruction by a two-stage procedure. McGregor Alton (963) presented three cases of penoscrotal skin avulsion repaired by split skin graft. MATERALS AND METHODS This paper deals with fourteen cases, seven of penoscrotal, six of penile and one of scrotal skin loss, treated since 959 in the emergency service of the Plastic Surgery Unit of the Government Medical College, Patiala (ndia). These patients Varied in age from 13 to 45 years. The trauma was indirect (Figs. and 2), i.e. dhoti, trousers or loose underwear caught in some running machinery in all cases except one, where the injury was direct as a result of a car accident and the paitent had other multiple injuries in addition (Table ). 1 Read at the Summer Session of the Plastic Surgery Section, Association of Surgeons of ndia at Pariah, August x965. G 07

2 98 BRTSH JOURNAL OF PLASTC SURGERY FG. ~ A FG., B FG., A.--Drawing showing electric saw (centre), electric toka (left) and cotton ginning machine (right). Note the accidental contact of rotating shaft with the loose underwear in each figure. FG., B.--Drawing depicting mode of accident. Leftfigure--underwear getting twisted around rotating shaft. Rightfigure--clothes torn off along with avulsion of penoscrotal skin. FG. 2.--Mode of external genitalia skin avulsion in cycle rikshaw accident. n upper figure the child is hanging behind the running rikshaw. Lower figure shows child with avulsed penoscrotal skin. TABLE Cause of njury Cause of njury. Electric chaff cutting machine 2. Cotton ginning machine 3. Electric saw.. 4. Cycle rikshaw accident 5. Motor car accident Total. No. of Cases The extent of damage to the penoscrotal skin and various methods of its repair carried out are shown in Tables and respectively.

3 TRAUMATC AVULSON OF SCROTUM AND PENLE SKN 99 TABLE Extent of Skin Loss Amount of Skin Loss No. of Cases t. PenoscrotaB 7 2. Penile 6 3. Scrotal Total n one case left testis was also avulsed in motor car accident. TABLE Methods of Repair Method of Repair No. of Cases (a) Penile (i) Split skin graft. o (ii) Penile skin pedicle 2 (iii) Abdominal tube pedicle (b) Scrotal (i) Split skin graft and small scrotal remnants. 5 (ii) Thigh flaps and scrotal remnant (c) Testes mplanted (Subcutaneously) (i) Upper thigh. (ii) nguinal re#on All the cases were referred to the Plastic Surgery Unit late, ten hours to eight days after the injury, and were infected. Shock was absent except in the one patient whose testis was damaged. The repair consisted of: (i) Thorough debridement with preservation of viable skin. (ii) Mooring of the testes to the tissues over Colles' fascia. (iii) Providing stable skin cover for the testes and spermatic cords. (iv) Skin grafting of the penis. (v) Repair of the perineal and other skin losses. DSCUSSON On admission of such a patient to the hospital early operation is indicated to avoid infection or thrombosis of the spermatic cord vessels. At operation thorough debridement is the first step. The testicular coverings, scrotal remnants, and prepuce if viable, should be preserved. Testicular sac eversion, if present, should be undone. The testicular coverings are stitched together on the medial surfaces and posteriorly moored to the tissues over Colles' fascia by a few catgut stitches. Efforts should always be made to provide skin cover for the testes at the primary operation. Repair by a thick split skin graft whenever possible is the treatment of choice. This was successfully employed in five cases of our series (Figs. 3-5). n another case thigh flaps and scrotal skin remnants were utilised. Even when small fragments of scrotal skin were present these were preserved and used for repair (Table ). These small remnants initially looked insignificant, but subsequently played a

4 00 B R T S H J O U R N A L OF P L A S T C SURGERY prominent part in the reconstructed scrotum when the split graft had contracted (Figs.,, D, and 5, B). Where the testes were completely denuded or damaged the use of a split skin graft for scrotal reconstruction was not feasible. n these cases reconstruction by local thigh FG. 3~ A FG. 3, B FG. 3, A Avulsion of scrotum and penile skin. A part of the avulsed skin is seen around the catheter. FG. 3~ B. - - T e n months after skin grafting of penis and testes. FG. 4, A FG. 4~ B FG. 4~ A.---Pre-operative appearance. N o t e the eversion of the testicular sac on right side and intact prepuce. FG. 4, B. - - S a m e case s h o w i n g small scrotal remnants posteriorly. flaps or implantation of the testes under the thigh skin as a primary procedure is advocated. The subcutaneous implantation of testes was done in two cases of this series. These persons remain contented and are not willing for scrotal reconstruction in spite of being apprised of the physiological drawbacks of their present state. For penile skin loss, split skin grafting of the penis was our method of choice and was used in ten cases. n three cases a flap was used (Table ). Non-hairy skin was

5 T R A U M A T C A V U L S O N OF S C R O T U M AND P E N L E S K N 0 selected for this purpose. We preferred to place the line of union of the graft on the Ventral surface of the penile shaft, making a " W " pattern to avoid a straight scar. A number of stitches were put in the bed of the graft along the longitudinal direction of the penis. Whenever it was present prepuce was utilised after eversion to give partial cover to the penis and the remaining skin loss was made up by split skin graft (Fig. 4, c). FG. 4~ C FG. 4~ D FG. 4, c. - - P o s t - o p e r a t i v e appearance after two years of skin grafting. T h e p r e p u c e has b e e n u s e d in repair. FG. 4~ D. - - S a m c case. Small scrotal r e m n a n t s seen in F i g u r e 4,B f o r m i n g considerable part o f t h e r e c o n s t r u c t e d s c r o t u m. FG. 5, A FG. 5~ B FG. 5, A. - - P h o t o g r a p h s h o w i n g avulsion of s c r o t u m, only a small triangular piece o f skin of s c r o t u m is intact anteriorly. FG. 5, B. - - P o s t - o p e r a t i v e appearance 6 m o n t h s after repair b y a split skin graft. nitially, the preputial cover looked oedematous but within a few months it became supple. The split skin graft provides good elasticity, flexibility and looseness, these being necessary in a penile cover (Fig. 6, B). A light pressure dressing was applied (Fig. 7) and this dressing was maintained for 6-8 weeks after the operation. Urine was drained for 8-1o days by an indwelling rubber catheter. All patients had sterile urine culture one month after the operation. This procedure worked well in our series although there was about o per cent. loss of the

6 O2 BRTSH JOURNAL OF PLASTC SURGERY skin graft due to infection in two cases, and these were regrafted. n children the split skin graft contracted tremendously due to difficulty in maintaining the dressings for a prolonged period ; therefore penile coverage by flap was carried out. FG. 67 A FG. 6~ B FG. 6, A.--Pre-operative photograph of penile skin avulsion. FG. 6, B.---Post-operative appearance. Two years after split skin grafting. FG. 7 Dressing for penis and reconstructed scrotum. Perineal and other skin losses could often be closed after undermining of the adjoining skin, but in three patients split skin grafting was found necessary. RESULTS These cases have been followed for a period varying from 5 months to 5 years. The cosmetic and functional results have been excellent. There has been contraction of the skin graft in all cases, but with the passage of time grafted areas have become supple. Erection was somewhat painful in the beginning in all the adult cases, but in 4-6 months it became painless with return of normal sexual function.

7 TRAUMATC AVULSON OF SCROTUM AND PENLE SKN 10 3 Seminal fluid in all adult cases of scrotal reconstruction showed normal count, motility and morphology except in one case where azoospermia was detected. SUMMARY Fourteen cases of peno-scrotal, penile and scrotal skin avulsion are presented. literature on the subject is reviewed. The most suitable types of repair in the various circumstances are detailed. Preservation and utilisation of prepuce and scrotal remnants is stressed. A technique for post-operative dressing is described. The REFERENCES BALAKRSHNAN, C. (1956). Br. ft. plast. Surg., 9, 38. BRUr,mR, J. M. (195o). Plastic reconstr. Surg., 6, 334. DOVGLAS, B. (1951). Ann. Surg., 133, 889. FERRS, D. O. (1949)- ft. Urol., 62, 523. GBSON, T. (1954). Br. ft. plast. Surg., 6, 283. GONZALES-ULLOA, M. C. (1963). Br. ft. plast. Surg., x6, 154. MAY, H. (195o). Plastic reconstr. Surg., 6, 134. McGREGOR ALTON, J. D. (1963). Tram. int. Soc. plast. Surg., Third Congress, Washington, p. 9o4. New York : Excerpta Medica Foundation. OWENS, N. (1942). Surgery, i2, 88. PFEFFER, D. B., and MLER, D. B. (195o). Plastic reconstr. Surg., 5, 520. ROTH, R. B., and WARREN, K. W. (1944). ft. Urol., 52, 162. WHELAN, E. P. (1944). Surgery Gynec. Obstet., 78, 649.