Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 66

HEMORRHOIDECTOMY

Dennis C. Gore

STEP 1: SURGICAL ANATOMY

Internal hemorrhoids arise proximal to the pectinate line and are insensate. These can be banded. External hemorrhoids arise distal to the pectinate line and are sensitive to touch. These are best treated with excision (Figure 66-1).

Indications are as follows:

Rectal bleeding attributed to the hemorrhoid

Persistent anal pain and pruritus

STEP 2: PREOPERATIVE CONSIDERATIONS

A cleansing enema and oral mineral oil should be given several hours before the procedure.

Ensure any bleeding tendencies are corrected.

Anesthesia: spinal or general

Position: prone; jackknife

Operative preparation includes the following:

Before the hemorrhoidectomy, proctoscopy is advisable to exclude any rectal disease.

Ensure that genitals are not compressed by prone positioning.

Place a Foley catheter in the midgut.

STEP 3: OPERATIVE STEPS

1.INCISION

Adherent tape is placed along the medial aspect of the buttocks then retracted laterally.

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2. DISSECTION

Place anal retractor opposite the hemorrhoid.

Grasp hemorrhoid with Babcock clamp and retract.

Place 2-0 Vicryl suture at the internal base of the hemorrhoid and ligate, thereby occluding venous backflow; leave a long segment of suture (Figure 66-2).

Internal hemorrhoid

Pectinate line

MC

External anal sphincter muscle

External hemorrhoid

FIGURE 66–1

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STEP 4: POSTOPERATIVE CARE

Sitz baths

Repeat oral mineral oil

STEP 5: PEARLS AND PITFALLS

Excise no more than three hemorrhoids at one operative setting. Removal of excessive anal tissue may lead to stricture.

Ensure in cases of rectal bleeding that other sources of gastrointestinal bleeding, such as colon cancer and diverticular disease, are excluded before the hemorrhoidectomy.

Hepatic cirrhosis and other bleeding disorders should be addressed and thoroughly corrected, or the planned procedure should be aborted.

SELECTED REFERENCE

1. Zollinger R Jr, Zollinger R: Atlas of Surgical Operations, 5th ed. New York, Macmillan, 1983, p 416.

C H A P T E R 67

DRAINAGE OF PERIRECTAL ABSCESS

Dennis C. Gore

STEP 1: SURGICAL ANATOMY

See previous chapters for anatomy of the anus.

STEP 2: PREOPERATIVE CONSIDERATIONS

Indication: abscesses requiring emergent drainage

Position: prone, jackknife

Anesthesia: spinal or general

Operative preparation includes the following:

Administer antibiotics before procedure.

Ensure that genitals are not compressed by prone positioning.

Proctoscopy is advisable to exclude any rectal disease such as Crohn’s disease.

STEP 3: OPERATIVE STEPS

1.INCISION

Adherent tape is placed along the medial buttocks then retracted laterally.

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Use scalpel or electrocautery to incise over the most prominent point of the abscess

(Figure 67-1).

2. DISSECTION

Using manual inspection, ensure the abscess is completely drained.

Irrigate abscess cavity copiously.

Use electrocautery judiciously to ensure hemostasis.

If hemostasis remains a concern, then the abscess cavity can be packed with moist gauze.

Abscess lanced

FIGURE 67–1

3. CLOSING

None

STEP 4: POSTOPERATIVE CARE

Mineral oil is given orally when feasible.

Sitz bath

STEP 5: PEARLS AND PITFALLS

Many abscesses are associated with anal fistulae. Fistulotomy may reduce abscess recurrence.

SELECTED REFERENCES

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations. New York, Macmillan, 1983, p 418.

2. Schwartz SI, Shires GT, Spencer FC, et al: Principles of Surgery, 5th ed. New York, McGraw-Hill, 1989, p 1305.

C H A P T E R 68

LATERAL SPHINCTEROTOMY

Dennis C. Gore

STEP 1: SURGICAL ANATOMY

See previous chapters for anatomy of the anus.

STEP 2: PREOPERATIVE CONSIDERATIONS

Indication: anal fissure

Preoperative planning: a cleansing enema and oral mineral oil should be given several hours before procedure.

Position: prone, jackknife

Anesthesia: spinal or general

Operative preparation includes the following:

Administer antibiotics before procedure.

Proctoscopy is advisable to exclude any rectal disease.

Ensure that genitals are not compressed by prone positioning.

STEP 3: OPERATIVE STEPS

1.INCISION

Use two strips of strong adhesive tape placed 8 to 10 cm from midline, then retracted laterally and down and secured to the lower operating table. This tape placement allows retraction of the buttocks laterally.

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