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

7 7 0 S E C T I O N X • R E C T U M

Insert either scalpel or electrocautery through incision and cut the external sphincter longitudinally (Figure 68-3).

Longitudinal incision through external sphincter

FIGURE 68–3

3. CLOSING

3-0 Vicryl interrupted suture (optional)

STEP 4: POSTOPERATIVE CARE

Sitz bath

Stool softeners

STEP 5: PEARLS AND PITFALLS

Consider biopsy of fissure to exclude cancer or inflammatory bowel etiologies, especially if fissure is in a position other than posterior midline or if the patient is elderly.

SELECTED REFERENCE

1. Schwartz SI, Shires GT, Spencer FC, et al: Principles of Surgery, 5th ed. New York, McGraw-Hill, 1989, p 1303.

7 7 4 S E C T I O N X • R E C T U M

Use electrocautery or curettage to cauterize and remove inflammatory tissue and any foreign materials (usually hair) all along the pilonidal cyst and the accompanying sinus tracts

(Figure 69-4).

FIGURE 69–4

3. CLOSING

None

STEP 4: POSTOPERATIVE CARE

Wound dressing with moist gauze

STEP 5: PEARLS AND PITFALLS

Pilonidal sinus tracts may extend into surrounding spaces at multiple finger-like projections.

Search diligently for all tracts.

SELECTED REFERENCE

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations, 5th ed. New York, Macmillan, 1983, p 422.

C H A P T E R 70

INCISION OF FISTULA-IN-ANO

Dennis C. Gore

STEP 1: SURGICAL ANATOMY

See Figure 70-1.

Indication: anal fistula

Anus

Most anal fistulas originate from the crypts of Morgagni and extend with varying depth to the perianal opening.

Goodsall’s rule describes the relationship of the external opening to the internal origin of the fistula.

If the external opening is anterior and 3 cm or less from the anus, then the fistula tract courses directly toward the anus (see Figure 70-1).

If the external opening is anterior and 3 cm or more from the anus, then the fistula tract may curve to enter at the posterior midline.

If the external opening is posterior to the anus, then the fistula tract will curve to enter at the posterior midline.

STEP 2: PREOPERATIVE CONSIDERATIONS

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

Position: prone, jackknife

Anesthesia: general or spinal

Operative position preparation includes the following:

Ensure that genitals are not compressed by prone positioning.

Proctoscopy is advisable to exclude rectal disease.

Administer antibiotics before the procedure.

776

Goodsall's Rule

Exterior opening, posterior to anus

External opening, anterior and >3 cm from anus

Anus

External opening, anterior and <3 cm from anus

MC

FIGURE 70–1

7 7 8 S E C T I O N X • R E C T U M

STEP 3: OPERATIVE STEPS

1.INCISION

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

2.DISSECTION

Insert a probe through the external opening of the fistula and gently advance the probe to identify the fistulous tract (Figure 70-2).

With the probe in place, use a scalpel or electrocautery to incise skin overlying the fistulous tract (Figure 70-3).

Most anal fistulas arise from an anal crypt at the pectinate line; continue incision and exposure of fistulous tract to origin at anal crypt.

Use electrocautery or curettage to cauterize and remove inflammatory tissue along the fistulous tract (Figure 70-4).

Many anal fistulas extend internally to circumscribe the external and very rarely the internal sphincters. To complete the fistulotomy, the sphincter muscle can be cut, but the sphincter muscle can be transected in only one place without precipitating incontinence.