Surgery is indicated in mycetoma for localized lesions and for better response to medical treatment in patients with massive disease. The surgical options range from wide local, repeated bulking excisions to amputations. Localised eumycetoma lesions are amenable to surgical excision; however recurrence after surgery alone is high but it may be reduced with adjuvant medical treatment.
Amputation is indicated in advanced mycetoma not responding to medical treatment with severe secondary bacterial infection, and it can be a life-saving procedure. The amputation rate ranges from 10–25% in most series.
In underdeveloped countries, amputation is a serious social stigma and it has many social and economic impacts on the individuals and community. In most endemic areas, the artificial prosthesis is not available and if it is available it is locally made and of poor quality. Most of the amputees loss their jobs and become dependent on other members of the family.
Diagnostic surgical procedures are indicated to obtain tissue biopsy for histo- and immunohisto-chemical studies, and grains for microbiological identification.
Local anesthesia is contra-indicated as the disease extending along tissue planes is unpredictable. A bloodless operative field using a tourniquet is mandatory to identify the lesion margins to avoid bursting it, which can facilitate local disease spread, which is an important cause of recurrence.
The postoperative recurrence rate varies from 25 to 50%, and this can be local or distant at the regional lymph nodes. This could be due to the disease biology and behavior, inadequate surgical excision due to the use of local anesthesia and lack of surgical experience and drug compliance due to various reasons.