DISCUSSION

Cobras are one in of 32 land venomous snake species, and are is quite
common in Vietnam, with approximately 30,000 cases annually, and its bites cause
about 5.9 - 33.8% of hospitalized injuries. The upper limbs, especially the hands,
are one of the most injured areas when patients are admitted to the hospital. Cobra
bites can provoke severe local intense inflammation, infection, tissue necrosis, and
with few acute life-threatening systemic neurotoxicity. The Effects of a venomous
cobra bite include a range of soft tissue necrosis and extensive infection. This is
accompanied by diffuse necrotizing fasciitis and thrombophlebitis of the
superficial venous system. In addition to the toxic effects of the venom, bacterial
infection from the bite wound further exacerbates the damage. Dorsal skin necrosis
causes exposure to the tendon structure, especially the extensors, joints, and bones.
Antivenom treatment has become wide open widely used, but the necrotic tissue
can still progressively worsen after antivenom its administration. The approach to
the complex nature of these injuries significantly complicates the treatment of the
injuries. The principles of treating of skin necrosis caused by cobra snakebites are
tissue debridement, antibiotics, and reconstruction coverage for the affected skin
and functional components. Reconstruction typically takes requires two or more
procedures. The first approach usually is involves debridement to remove necrosis
tissue and help the granulation process. Before applying the reconstructive
approach, VAC and antibiotics are used to protect the functional structure, such as
bone and tendon. Our patient had the particular presented specifically with of
tissue necrosis and local infection due to the snakebite. Necrotizing fasciitis starts
at the bite site, usually on the finger, and spreads to the hand and forearm. Radical
excision of necrotic skin and fat can lead to tendons, joints, and bone exposure,
depending on the extent of necrosis. Improper debridement can cause delayed
wound healing, thereby prolonging treatment time. All of our patients had the time
to use the received V.A.C system once after the debridement, and the average time
was. …day. Most of our patients (x, y%) have secondary wound infections, and we
use a combination of 2-3. The Antibiotics are used routinely to prevent the
infection from spreading, avoiding worsening the injuries.
The reconstructive procedures were scheduled. after the injuries became
proper. The Our first attempt to cover skin and soft tissue deficiencies, we chose
the a reconstructive material that should be had similar in texture, was thin, and
have had a smooth surface for to allow the tendon to glide freely. free gliding of
tendon movement. Autologous skin grafts have no indication in the wound which
has a tendon or bone exposure. Skin grafting also risks adhesion and contractions,
which results in poor hand function. There was a limited choice of regional flap
due to the spreading of the necrotizing fasciitis to the upper part of the extremities.
Distant flaps, such as inguinal or abdominal wall flaps, may be options, but they
come with disadvantages including prolonged surgical time, multiple stages,
patient discomfort, complex postoperative care, and poor aesthetic results. The
multi-staged procedure has a higher chance of success but increases the risk of
infection and wound dehiscence, contracture, and especially the extended
rehabilitation process. The free flap has been popular with the evolution of
microsurgical techniques and revealed unexplored potentials. One of those is a
single-staged operation for both coverage and tendon reconstruction. Therefore,
free flaps or microsurgical flaps are preferred in these cases. The free flap has been
popular with the evolution development of microsurgical techniques. Commonly
used microsurgical flaps, such as the ALT perforator flap, medial sural perforator
flap, latissimus dorsi perforator flap, and lateral arm perforator flaps, offer
advantages in flexibility, safety, and good defect coverage. advantages, However,
standard free flaps used in complex hand injuries, especially in the dorsum, may
not achieve optimal aesthetic results due to their incompatible thickness. Among
free flaps, the ALT fasciocutaneous flap is often indicated for finger and hand
injuries with the advantages of abundant tissue, appropriate skin quality, and long
vascular pedicles. Some surgeons use techniques to overcome flap bulkiness, such
as primary or secondary flap thinning techniques. While free flap thinning is a
good choice, it needs to be performed by experienced surgeons with proper
indications, especially for primary flap thinning. Flap thinning is performed 6-12
months after flap transfer, during which rehabilitation is difficult. While free flap
thinning is a good choice, it needs to be performed by experienced surgeons with
proper indications, especially for primary flap thinning. The success of primary
thinning depends on the skill of the surgeon's skill and the anatomical
characteristics of the perforators, such as the origin of the perforator, the direction
of the perforator to the skin, and the size of the retained fascia. Indications for
thinning the flap flap thinning need to be carefully considered in each case to avoid
the risk of flap necrosis. We have also been conducted on exploring the indications
for safely thinning the ALT flap.
For a long time, the use of free vascularized fascia in clinical settings has been
widespread, especially as a suitable alternative for hand reconstruction. Different
types of fascia flaps, such as the superficial temporal fascia flap, radial forearm
fascia flap, serratus anterior fascia flap, and Fascia Lata (FL) flap, are commonly
used. The radial forearm fascia flap or ulnar forearm fascia flap has good
advantages in terms of long, stable vascular pedicles. However, the amount of
tissue harvested is quite limited and extremely morbility have high morbidity. The
dorsal thoracic fascia or serratus anterior fascia lata flap can be harvested in large
quantities and with long vascular pedicles. Still However, the need to change
positions for changes in position and the difficulty in coordinating multiple teams
during surgery will prolong the procedure. prolongs the surgery time.