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Internal hemorrhoid
1
Pectinate line
2a
2b
2c
Intersphincteric
line
3
6
External
hemorrhoid
4
Fibrous bands
Hemorrhoid
5
8
Pectinate
7
line
Anal verge
Hemorrhoid
clamp
9
13
Subcutaneous
portion of
external sphincter
10
Treatment of extensive hemorrhoidal mass
14
Mucosa
11
12
Treatment of thrombosed external hemorrhoid
15
Incision
16
Curette
483
PLATE
227
D P I
A—T F A
INDICATIONS e anatomy of anal region is shown in figure 1. Abscesses around
the anal canal arise from infection of the anal crypt of Morgagni (figure 2) and can
be either super cial perianal abscesses () or deeper ischiorectal abscesses ()
(figure 3). A perianal abscess is found adjacent to the anal canal, either on the
right or le side, anterior or posterior. e patient usually complains of pain that
may be, but not always, associated with a fever. e diagnosis is made by inspection
of the perianal area, which will reveal a red, angry, and o en uctuant abscess. A
digital examination should not be done due to the painful nature of the problem.
figure 3 shows the location of perianal and perirectal abscesses. Abscesses are clas-
si ed according to the spaces they invade. Most super cial perianal abscesses can be
drained safely in the o ce and do not require operative drainage. e most di cult
to treat are those that track proximally or circumferentially within the intersphincteric plane or within the ischiorectal fossa or postanal space. Examination under
anesthesia may be required to determine the location and extent of the abscess. An
ischiorectal abscess, however, is large, involves either the right or the le ischiorectal
space or the deep postanal space, and requires operative drainage.
PREPARATION For o ce drainage, the patient should be placed in the stan-
dard kneeling position on a Ritter table. For operative drainage, a prone, jackknife
position is best. If done in the operating room, a general or spinal anesthetic is
desirable.
OFFICE PROCEDURE For a perianal abscess, the skin over the abscess is
numbed with ethylene chloride. Injection of the site with Xylocaine is excessively
painful and unnecessary. Once the area is su ciently numbed, a stab incision
is made over the abscess to drain pus. is should be su ciently large to allow
adequate drainage. ere is no need to excessively probe this abscess. e incision
should be made as close to the anal canal as possible so that if a stula in ano does
develop, the stula tract will be as short as possible.
A. OPERATIVE DRAINAGE OF
ISCHIORECTAL ABSCESS
INDICATIONS Ischiorectal abscesses are drained immediately. Careful palpa-
tion o en shows evidence of uctuation not seen in the perianal tissue. Operation is not delayed until uctuation is obvious, because a perirectal abscess may
rupture through the levator muscle into the retroperitoneal tissue.
PREOPERATIVE PREPARATION No special preoperative preparation is required.
Antibiotic therapy is given.
ANESTHESIA General anesthesia with endotracheal intubation may be used;
however, regional anesthesia, either spinal or epidural, is satisfactory.
POSITION e prone or jackknife position is preferred for drainage.
INCISION AND EXPOSURE e common locations of ischiorectal abscesses
are shown in figure 3. Abscesses may be located extraperitoneally above the
levator ani muscle. Careful rectal and sigmoidoscopic examination should be performed to detect associated pathologic processes a er the patient has been anesthetized. An incision is made at the maximum point of tenderness (figure 3) and
placed either parallel or radial to the anus. If the abscess lies above the levator, the
incision is deepened radially to avoid nerves and blood vessels.
DETAILS OF PROCEDURE A er incision and drainage, the cavity is explored
with the index nger to ensure complete drainage and to ascertain that no foreign
body is in the ischiorectal space. A specimen of the draining material is obtained
for bacteriologic studies. Usually, there is no communication with the rectum.
If the abscess is small and a clear communication with the rectum is identi ed,
the tract may be excised. e outer opening must be su ciently large, for the
common error is to drain a large cavity through a comparatively small incision,
resulting in the development of a chronic abscess.
CLOSURE e cavity is lightly packed with a gauze tape.
POSTOPERATIVE CARE Moist compresses and sitz baths reduce in amma-
tion and promote rapid healing. Postoperative dressings to ensure healing from
the bottom are as important as the operation. An ischiorectal abscess is prone to
result in an anal stula; however, in about half of the cases, there will be primary
healing with proper postoperative care.
B. FISTULOTOMY
INDICATIONS e majority of anal stulae result from infection arising in a
crypt, extending into the perianal musculature, and then rupturing either into
the ischiorectal fossa or super cial perirectal tissues. Operative obliteration of the
stula is always indicated if the patient’s general condition is good.
ANATOMIC CONSIDERATIONS Treatment of anal stulae presupposes a
knowledge of anal anatomy, particularly of the sphincter muscles and their relation to the anal crypts. A study of figure 1 will clarify several important points.
As shown in figure 1, the external sphincter muscle can be divided into three
portions: the subcutaneous, super cial, and deep portions. e subcutaneous portion lies just beneath the skin and below the lower edge of the internal
sphincter (figure 1). e super cial and deep portions surround the deeper part
of the internal sphincter and continue upward to join with the levator muscle
(figure 1). e levator ani surrounds the anal canal laterally and posteriorly, but
it is absent anteriorly (figure 1). e longitudinal muscle of the anus is the continuation downward of the longitudinal muscle of the large bowel (figure 1). e
internal sphincter muscle is a bulbous thickening of the circular muscle coat of
the large bowel. e super cial external sphincter is palpated as a band surrounding the anal canal just beneath the skin (figure 1). Just above it is felt a slight
depression, the intersphincteric line, and the slight swelling above this point is the
lower edge of the internal sphincter (figure 1). If the nger is introduced into
the canal and hooked around the entire anorectal ring anteriorly, it contacts the
deep portion of the external sphincter, the levator being absent in this location
(figure 1). As the nger is rotated posteriorly, in contact with the midline of the
canal laterally, a distinct thickening is felt as the levator ani (figure 1) joins the
canal, and posteriorly the anal canal feels thicker than it does anteriorly. Incontinence will not occur if any portion of the external sphincter or levator muscle
remains intact.
Most stulae arise in the anal glands at the base of the crypts of Morgagni;
therefore, the abscess usually lies within the substance of the internal sphincter (
figure 2). It extravasates through the muscle, tending to follow the tissue
planes created by the bromuscular septa of the longitudinal muscle. Fistulae
rarely arise from perforations of the anal canal associated with foreign bodies or
abscesses, as in tuberculosis or ulcerative colitis. e internal opening may be
above the pectinate line and may traverse the entire sphincter or portions of the
levator (
technique (figure 14) to avoid incontinence.
there is a radial tract (figure 5a); if posterior, there is a curved track (figure 5b,
c, d). Simple anal stulae (figure 5a) follow a direct route in the anus. Compli-
cated stulae (figure 5b and c) follow a more devious route, o en horseshoe in
shape and with numerous openings. Most complicated stulous tracts open into
the posterior half of the anus. Should the stula have multiple sinuses, the main
exit will usually be posterior, even though one opening is anterior to the line
(
into the anterior half of the anus (figure 5a) (Goodsall’s rule).
PREOPERATIVE PREPARATION Local abscesses are drained if there is pock-
eting or cellulitis. If there is no severe local in ammation, a cleaning enema is
given the night before operation. No cathartic is necessary.
ANESTHESIA Inhalation anesthesia is the procedure of choice when dealing
with a complicated stula. Spinal anesthesia is satisfactory for simple stulae and
may be used for more complicated stulae; however, it provides such complete
relaxation of the musculature that palpation and recognition of the divisions of
the external sphincter and levator are sometimes impossible.
POSITION (See Plate .)
figure 3f). It may be necessary to operate in stages or to use the seton
Fistulae in ano usually follow Salmon-Goodsall’s rule. If located anteriorly,
figure 5, X–X); a single stulous opening anterior to X–X usually extends directly
1. TREATMENT OF SIMPLE FISTULAE
DETAILS OF PROCEDURE e anal canal may be dilated just enough to permit
introduction of a self-retaining retractor. e pectinate line is directly visualized,
and anal crypts that may reveal the internal opening are inspected. Gentle probing
of suspected crypts may reveal an unusually deep crypt, which, from the position
of its external opening, can be recognized as the source of the stula (
a normal pectinate line is found, with shallow crypts or no crypts at all, it is likely
to be a local perianal abscess with no direct communication with the anal canal.
figure 6). If
Some surgeons prefer to inject hydrogen peroxide into the external opening
to trace the stulous tract to its inner opening.
A er the internal opening of a simple stula has been identi ed, a probe is
introduced into the external opening and gently passed down the tract into the
internal opening (figure 7). Care is taken to avoid creation of a false passage.
e incision is made on the probe, and the tract is laid open (figure 8). It is not
necessary to excise the stula. e tract should lie open as shown in figure 9. In
a simple super cial stula, the entire tract may be stabilized with a probe as it is
excised with scissors with electrocautery.
2. TREATMENT OF COMPLICATED FISTULAE
DETAILS OF PROCEDURE For complex stulae such as a horseshoe stula with
an external opening anterior to the midanal line and an internal opening in the posterior midline, extensive incisions are avoided. e main posterior tract is identi ed
with a probe (
the involved crypt excised (figure 11). e anterior tracts are curetted and drained
via so rubber (Penrose) drains through secondary incisions along the tracts
(figure 12). e posterior tract is marsupialized (figure 13).
figure 10). A short posterior portion of the tract is unroofed and
CONTINUES
484
485
PLATE
228
D F A—L I
S F A
A. SETON PLACEMENT
DETAILS OF PROCEDURE If a large transsphincteric stula
involving a signi cant amount of external sphincter muscle is present, a
seton should be placed. e probe is rst passed from the external opening
to the internal opening, and a silk suture is tied around the groove in the
probe (figure 14). e probe with the suture is then pulled back through
the stula track, and the silk suture is tied tightly around the muscle. All
fat and skin are removed leaving the seton compressing sphincter muscle
only. Silk is an irritant, and with time the silk will cut through the sphincter
muscle. However, the stulotomy will be performed incrementally giving
time for the sphincter to heal. e stula is slowly drawn out by the seton.
is protects against incontinence, by preventing the sphincter muscle
from separating, as would happen during a stulotomy. A non-cutting
seton using a vessel loop is indicated in chronic perianal disease.
POSTOPERATIVE CARE e patient may be out of bed as soon as the
anesthesia has worn o . e patient is allowed a light diet, and there is no
attempt to restrain bowel movements. Stool so eners are prescribed. Sitz
baths may be started on the second day following operation. Patients may
be discharged the day of surgery and are seen within one week.
B. ENDORECTAL ADVANCEMENT FLAP
An alternative therapy for a complex stula is an endorectal advancement ap (figure 15). A ap with mucosa and submucosa is created to
include the internal opening (figure 16). e dissection is carried far
enough proximal until the ap can be advanced distally without tension.
e internal opening is excised, and then the ap is matured to the intersphincteric groove (figure 17). e external sphincter may be plicated to
close the stula opening and then the ap is sutured to the intersphincteric groove with interrupted absorbable sutures (figure 17). is e ectively treats a complex stula in ano with minimal risk of injury to the
sphincter muscles.
C. FISSURE IN ANO
INDICATIONS Fissure in ano is a common painful condition that can be
found in children and adults alike. ese wounds usually heal spontaneously in children but may require operative correction in adults. It is usually caused by constipation or a large traumatic bowel movement, and it
is almost always located posterior. e ssure, which runs between the
dentate line and anal verge, if deep enough exposes the internal sphincter
muscle. is causes considerable spasm and pain. Chronic ssures may be
associated with a hypertrophied anal papilla and a skin tag. Over a period
of time, the internal sphincter muscle hypertrophies, becoming more e ective in keeping the wound open, and preventing spontaneous closure of
the ssure. Topical salves and ber are usually e ective early on. Once the
wound becomes chronic, surgical repair is usually necessary.
PREOPERATIVE PREPARATION No preoperative preparation is neces-
sary. e cleaning enema, which is such an excruciating procedure to the
patient, is omitted.
ANESTHESIA Spinal, epidural, or local anesthesia is satisfactory.
OPERATIVE PREPARATION e eld is prepared with local antiseptic
solution. No attempt is made to dilate the canal and irrigate the rectum.
DETAILS OF PROCEDURE e patient is placed in the position as shown
and prepped and draped in the usual fashion. e prone jack-knife position
may be used. A Hill-Ferguson retractor is placed in the anal canal, and the
anal canal is inspected. e ssure is usually posterior and may be associated with a right posterior hemorrhoid (figure 18). e ssure and the
hemorrhoid, if necessary (figure 19), are excised and the anal mucosa and
anoderm closed with a running - chromic suture (figure 20). A lateral
internal sphincterotomy is performed to reduce sphincter spasm. A separate
incision is then made in the le lateral position, again excising the hemorrhoid in that location if necessary, to expose the hypertrophied internal
sphincter muscle. A partial lateral internal sphincterotomy is done in this
position. is wound is closed with a running - chromic stitch.
e procedure may be done as a closed technique. With the nger in
the anal canal, an -blade is inserted into the intersphincteric plane staying
below the dentate line (figure 21). e blade is then moved medially, dividing the inferior one-third to one-half of the internal sphincter (figure 22).
An open technique may be done. A skin incision is made (figure 23). A
hypertrophied band of internal sphincter is freed and elevated (figure 24).
e internal sphincter is then partially divided (figure 25). e wound
is le open. e sphincterotomy is done in the lateral position to avoid
creating a keyhole deformity, a complication of the procedure that can be
challenging to correct. is procedure removes the chronic ssure in ano
and releases the tension on the anal canal su ciently enough to allow the
ssure to heal.
POSTOPERATIVE CARE Patients are allowed out of bed and encouraged
to move their bowels as soon as possible a er operation. Daily sitz baths
and daily rectal examinations are indicated to ensure that granulations do
not build up and protrude into the anal canal. e patient should be kept
under weekly observation a er discharge until healing is complete. ■
486
487
PLATE
229
INDICATIONS Pilonidal cysts and sinuses should be completely excised or
exteriorized (figure 3a and b). Acutely infected sinuses should be incised
and drained, followed later by complete excision a er the acute infection
subsides. e more limited procedure of exteriorization (marsupialization)
is e ective when the sinus tract is well de ned (figure 3b). Regardless of
the various surgical approaches, such lesions may recur.
PREOPERATIVE PREPARATION In complicated sinuses with several
tracts present, a dye such as methylene blue may be injected for better identi cation, although if a careful dissection is carried out in a bloodless eld,
the surgeon can identify the sinus tracts. It is important that this be done
several days before operation to avoid excessive staining of the operative
area, which may occur if the injection is done at the time of operation.
ANESTHESIA Light general anesthesia is satisfactory. e patient’s posi-
tion requires that special care be taken to maintain an unobstructed airway.
Spinal anesthesia should not be used in the presence of infection near the
site of lumbar puncture.
POSITION e patient is placed on his or her abdomen with the hips ele-
vated and the table broken in the middle (figure 1).
OPERATIVE PREPARATION Two strips of adhesive tape are anchored
snugly and symmetrically about cm from the midline at the level of the
sinus and pulled down and fastened beneath the table (figure 2). is
spreads the intergluteal fold for better visualization of the operative area. A
routine skin preparation follows a er the skin is carefully shaved.
DETAILS OF PROCEDURE An ovoid incision is made around the opening
of the sinus tract about cm away from either side (figure 4). Firm pressure and outward pull make the skin taut and control bleeding.
An Allis forceps is placed at the upper angle of the skin to be removed,
and the sinus is cut out en bloc (figure 5). e subcutaneous tissue is
excised downward and laterally to the fascia underneath. Great care is exercised to protect this fascia from the incision, as it o ers the only defense
against deeper spread of infection (figure 6). Small, pointed hemostats
should be used to clamp the bleeding vessels in order that the smallest
amount of tissue reaction be incurred. Electrocoagulation may be used
to control bleeding and to keep the amount of buried suture material to a
minimum. Some prefer to avoid burying any suture material by using compression or electrocoagulation to control all the bleeding points. Extreme
care should be taken in the dissection of the lower end of the incision, as
many small, troublesome vessels are encountered frequently that tend to
retract when divided. A er careful inspection of the wound to make sure
that all sinus tracts have been removed, the subcutaneous fat is undercut
at its junction with the underlying fascia (figure 7). is undercutting
should extend only far enough to allow approximation of the edges without
tension (figure 8).
E P S
CLOSURE A er all bleeding points are controlled, the wound should
be thoroughly washed with saline. e chances for primary healing are
greatly enhanced if the eld is absolutely dry. If unexpected infection has
been encountered, the wound should be packed open. In uncomplicated
sinuses, the wound is closed a er all bleeding is controlled. Rather than
bury sutures, the skin can be closed and the dead space eliminated by a
series of interrupted vertical mattress sutures (figure 9). e suture is
introduced cm or a little more than the margins of the wound to include
the full thickness of the mobilized ap of skin and subcutaneous tissue.
A second bite includes the fascia in the bottom of the wound (figure 9).
e suture is then continued deep into the opposite ap. e suture is
directed back to the original side as it passes back through the skin margins (figure 10). When tied, this obliterates the dead space and accurately
approximates the skin margins (figure 11). e sutures should be placed at
intervals of not more than cm. Skin approximation must be very accurate,
since even a small overlap may be surprisingly slow to heal in this area. A
pressure dressing is applied with great care, and the sutures are allowed to
remain in place for to days.
EXTERIORIZATION When the sinus appears small and in the presence of
recurrence, a probe may be inserted into the sinus, and the skin and subcutaneous tissue divided (figure 3a). e entire sinus, including any tributaries, must be laid wide open and all granulation tissue wiped away repeatedly with sterile gauze or a curette. e thick lining of the sinus forms the
bottom of the wound. A wedge of subcutaneous tissue is excised to facilitate
the sewing of the mobilized skin margins to the thick wall of the retained
sinus. is ensures a cavity that can be dressed easily with a minimum of
drainage as well as discomfort to the patient. e raw margins of the wound
are held apart by a gauze pack until healing is complete (figure 3b). is
method has the advantage of being a procedure of less magnitude than
complete excision. e period of hospitalization and rehabilitation is shortened and insurance against recurrence enhanced.
POSTOPERATIVE CARE Complete immobilization of the area and pro-
tection against contamination are essential. Early ambulation is advisable,
but sitting upon the incision in a hard chair is not. e patient should be
encouraged always to sit on a cushion or to sit to the side on one buttock or
the other. e diet is restricted to clear liquids for several days, followed by
a low-residue diet to decrease the chances of contamination from a bowel
movement. When the sinus is packed open or exteriorized, the patient is not
immobilized. Regardless of the method used, frequent and repeated dressings are indicated to avoid possible early bridging of the skin with recurrence and prolonged discomfort and disability. e importance of keeping
all hair removed from the intergluteal fold until healing is complete cannot
be overemphasized. Depilatory agents may be used several times per month
provided that pretesting for sensitivity to the agent has been negative. ■
488
Adhesive
tape
1
Adhesive
tape
2
Sinus
4
Incision
3
A
External opening
External opening
B
5
Normal
fascia
6
9
7
Fascia
over coccyx
8
10
11
Coccyx
489
PLATE
230
INDICATIONS e common factors indicating amputation of a part of
the body are trauma, interference with the vascular supply, malignant
neoplasm, chronic osteomyelitis, life-threatening infections, inoperable
congenital limb deformity in children, the need to increase function, and,
occasionally, the cosmetic e ect.
PREOPERATIVE PREPARATION In the presence of trauma, it is rst neces-
sary to evaluate carefully the extent of tissue and vascular damage in terms
of possibly salvaging the extremity. With the recent advances in peripheral
vascular repair and gra ing, reestablishment of distal blood ow following
arterial injury, blockage by arteriosclerosis, or embolus is o en possible.
It is essential to combat shock with intravenous administration of uids
and colloid solutions until the patient’s general condition is improved suf ciently to withstand the operation. With diabetes or advanced vascular
disease, the usual strict medical measures are taken to regulate these associated diseases. If there is localized skin infection at the proposed level for
amputation, the procedure is delayed whenever possible. In the presence of
wet gangrene, packing the leg in ice or dry ice combined with the application of a tourniquet just below the site of proposed amputation not only
may lessen toxicity but also may decrease the incidence of wound infection,
since the lymphatics may be cleared before amputation. e threat of gas
gangrene may be a real one when the arterial supply to the extremity has
been severely compromised, either by intra-arterial occlusion or trauma
with inadequate debridement and a closed space infection.
ANESTHESIA Spinal anesthesia is commonly used for major amputation
of the lower extremities, inhalation anesthesia for major amputations of
the upper extremities, and plexus block or local in ltration anesthesia for
amputation of the ngers and toes.
POSITION (See Plate .) In amputations of the upper extremity, the
patient is placed near the edge of the table with the arm extended and
abducted to the desired position. For amputations of the lower extremity,
the leg may be elevated with several sterile towels under the calf.
OPERATIVE PREPARATION In the absence of infection, the extremity is
elevated to encourage venous drainage before a tourniquet is applied. e
tourniquet is placed above the knee for amputations of the lower leg and
foot, high in the thigh for amputations of the knee and lower thigh, and
above the elbow to control the brachial artery for major amputations of
the forearm. In cases of arteriosclerosis, the tourniquet should not be used
because of the possibility of damaging the blood supply to the stump. Sterile
elastic bands may be applied to the base of the digit for minor amputations.
e skin is prepared with the usual antiseptic solutions well above and
below the proposed site of amputation. In major amputations, the entire
extremity may be wrapped in sterile adherent plastic drapes to enable the
assistant to hold it and change its position as desired.
SITES FOR AMPUTATION e e ciency of modern prosthesis has elimi-
nated the time-honored “sites of election.” Generally, the pathology dictates
the site of amputation, with the goal of preserving all possible length. is
is particularly true of the upper extremity.
e rule of saving all possible length does not apply necessarily to the
lower extremity. However, whenever possible, the knee should be saved,
since it provides major functional advantages. Although the blood supply
to the upper extremity is usually adequate, the reverse is o en true for the
lower extremity. Furthermore, the problems of weight bearing and retaining adequate so tissue to cover the stump a ect the site of election of the
lower extremity, since an inadequate blood supply, o en a er failure of a
vascular bypass gra , is the most common indication for amputating the
lower extremity.
Since the profunda femoral artery tends to be the main channel a er
occlusion of the super cial femoral vessels or a femoral-popliteal bypass
gra , the site of amputation must be selected well within the zone adequately supplied by the vessel. Accordingly, the amputation is usually above
the knee. For this reason the supracondylar amputation (figure 1a) continues to be the most frequent site for amputation in the presence of arterial
insu ciency, although a below-knee one is preferred if possible. It can be
technically performed in a short time with the best assurance of primary
healing of the aps. Knee disarticulation (c) and transcondylar amputation
P A
(b) yield an enlarged, rounded end that is cumbersome and di cult to t
with a prosthesis.
e rule of saving all possible length does not apply to below-knee
amputation. Long leg stumps are not recommended because of their poor
tolerance of prostheses. Since the anterior margin of the tibia is usually beveled, there must be enough solid tissue with good blood supply to cover it,
as provided by a longer posterior ap. A short below-knee stump is preferable to knee disarticulation. A below-knee amputation longer than cm
is probably not any more functionally e ective, and poor circulation may
interfere with healing. A very short bula tends to migrate laterally and
may be removed in a short below-knee stump. In a longer stump, a little
bone gra between the bula and the tibia prevents migration.
Although ankle amputations have few indications, chie y trauma, the
Syme amputation lends itself to a very serviceable end-weight-bearing
prosthesis, but it has cosmetic disadvantages in females (figure 1d). ere
is general agreement that a most satisfactory foot amputation is the transmetatarsal. In the presence of vascular insu ciency to the lower extremity,
amputations about the ankle or foot should be performed cautiously for
secure indications, especially in the presence of infection, because they frequently heal poorly, necessitating secondary procedures.
Formerly, the junction of the lower and middle thirds of the forearm
was considered the optimum site for amputations; however, newer arti cial
limbs that include pronation and supination movements make it desirable
to save all possible length (figure 4). Length is again important in the
hand, where a partial amputation of the ngers or of all ngers, leaving an
opposing surface at the thumb for gripping, allows better function than can
be provided by any prosthesis. A stump of any length in the forearm will
give better function than an amputation above the elbow, and it eliminates
an elbow hinge in a prosthesis.
TYPES OF FLAPS As a general rule it is desirable to have the scar in the
posterior of the stump in the upper extremity, since the prosthesis bears
largely on the distal surfaces of the stump. e scar for end-bearing stumps
of the lower extremity should preferably be posterior to the end of the
stump. In minor amputations of the ngers and toes, long palmar and plantar aps are made to cover the stump with a thick, protective pad of tissue
(figures 2 and 5). Racket incisions are advisable for amputations of the
toes, since they may be extended upward to permit exposure of the metatarsals (figure 3), or they may be used for amputations of digits where all
possible length must be preserved. is is especially true for injuries of the
thumb (Incisions B, C, and D, figure 6). Racket incisions with removal
of the head of the metacarpal or metatarsal give a good appearance to the
extremity but considerably diminish the breadth of the foot or palm.
DETAILS OF PROCEDURE Su cient so tissue must be present to approx-
imate easily over the end of the bone, but excessive amounts are avoided,
since bulky so tissue hinders the tting of a prosthesis. Arteries and veins
should be tied individually. Nerves are divided at as high a level as possible.
Two Kocher clamps are placed on large nerves . cm apart before division
of the nerve. e nerve then is severed sharply just beyond the distal clamp,
and the nerve is doubly ligated with nonabsorbable suture just distal to
the clamps. All cut nerves develop neuromas; therefore, placement of the
cut end of the nerve is important. It should be remote from scar and away
from areas of pressure, since the neuroma becomes symptomatic when
pressure is applied.
e bone should be divided at a su ciently high level to permit the so
parts to approximate, producing a thick covering for its end. e sharp
margins of bone are beveled either with a rongeur or rasp.
CLOSURE All bleeding points are tied carefully so that, in the ordinary case,
drainage is unnecessary. e investing fascia rather than the deep muscles is
loosely approximated with interrupted nonabsorbable sutures. When there
has been considerable oozing or a moderate amount of infection distal to
the site of amputation, through-and-through drainage may be instituted. If a
guillotine type of amputation was carried out in the presence of a progressing infection, the wound is le open to be closed secondarily later, or the
extremity is reamputated later at a higher lever to permit primary closure.
POSTOPERATIVE CARE (See Plate .) ■
490
1
3
2
A
B
C
Optimum site
for division of
tibia and bula
A
Plantar ap
Long plantar ap
A
Skin ap
D
Skin ap
Rocket incision
B
6
4
Palmar ap
Rocket incision
C
Optimum site
for division
of elbow
Skin ap
Conserve all
possible length
A
Rocket incision
B
Rocket incision
D
5
Optimum site
for division
of wrist
Palmar ap
Skin ap
Palmar ap
E
491
PLATE
231
INDICATIONS Common indications for supracondylar amputation are
trauma, interference with blood supply, tumor, infections that are dangerous to life, the need for increased function, and so forth. Amputation
should not be performed unless all conservative measures have failed.
e amputation at the thigh is described in detail. is is a frequent site
following failure of reconstructive or bypass arterial procedures or in the
presence of unreconstructable circumstances as documented with proximal and distal arteriography.
PREOPERATIVE PREPARATION e preoperative preparation must of
necessity vary with the indications for amputation as outlined in the preceding section. Careful evaluation must be made to determine whether there
is a localized arterial obstruction, and arteriography is essential. If localized
obstruction is present, a proximal (e.g., an iliac stent or aortofemoral) reconstructive procedure may restore an adequate blood in ow, or a distal (e.g.,
femoropopliteal) bypass arterial gra may eliminate the need for amputation.
When infection is present, vigorous therapeutic measures are needed.
A er bacterial cultures with drug sensitivities are obtained, the appropriate antibiotic is administered. Should there be a localized skin infection at
the proposed level of amputation, the procedure is delayed if improvement
is possible. In the presence of an advancing infection a guillotine or open
amputation is done above the level of infection, with a subsequent de nitive amputation at a higher point of election.
ANESTHESIA Low spinal anesthesia is used most frequently, although
inhalation anesthesia may be administered unless the patient’s condition
contraindicates it.
POSITION e patient is placed with the hip on the a ected side out to
the margin of the table to allow full abduction of the thigh by an assistant,
and the calf or ankle may be elevated with several sterile towels. e hair is
shaved or dipped at the operative level.
OPERATIVE PREPARATION e thigh from the groin to well below the
knee is shaved carefully. e foot is held in abduction while the leg from
below the knee to high in the groin is cleaned with appropriate antiseptics.
A sterile sheet is placed beneath the thigh. e foot and lower leg up to the
knee are covered with a sterile sheet or plastic drape (figure 1). Unless
there is evidence of progressive infection, the extremity is elevated by the
assistant to encourage venous drainage.
INCISION AND EXPOSURE e type of ap that is used varies. With pro-
gressive infection of the lower leg, a circular incision is made for a guillotine amputation. However, when possible, anterior and posterior aps are
outlined with a sterile marking pen, ensuring an appropriate stump length
(figure 1). Either equal anterior and posterior aps are used or, more commonly, a larger anterior ap with a length ½ times the diameter of the
thigh at the level of the division of the femur.
A, S
e surgeon stands on the inner side of the thigh so as to visualize better
the main arterial and nerve supply, and outlines the selected incision. Since
the so parts retract considerably, the skin incision must extend at least
cm below the point where the bone is to be divided. e incision is carried through the skin and subcutaneous tissue down to the fascia over the
underlying muscles. All bleeding points are clamped and tied.
DETAILS OF PROCEDURE e surgeon must be familiar with the loca-
tion of the major nerves and vessels (figure 2). e rst blood vessel of
any size to be clamped and tied is the great saphenous vein, located on
the medial or posteromedial aspect of the thigh, depending on the level of
amputation (figures 2 and 4). e muscles, which should be divided at a
slightly higher level than the skin and fascia, retract upward so that the aps
will consist chie y of skin and fascia (figure 3). ose on the lateral and
anterior aspects of the thigh are divided rst, and the few bleeding points
found are clamped and tied.
The median incision into the muscle layer is made carefully until
the femoral vessels are exposed deep on the posteromedial aspect of
the thigh (figure 5). If a tourniquet has not been applied, the surgeon
should locate the major vessel by palpation or by its visible pulsation. If
a tourniquet has been used, the dissection is carried out directly until
the femoral vein is exposed. This is divided between half-length clamps.
Both artery and vein are tied separately (figure 6), and, if desired, a
transfixing tie may be added distal to the original ligature on the femoral artery.
e sciatic nerve is located next posterior to the femoral vessels and
is isolated from the surrounding tissues by a blunt-nosed, curved, halflength clamp passed beneath the nerve or the common peroneal and
posterior tibial branches, in the event of a high bifurcation of the sciatic
nerve. In an e ort to minimize the formation of an amputation neuroma,
the nerve is pulled down as far as possible, and a strong straight Ochsner
clamp is applied. A second similar crushing clamp is applied about mm
distal to the untied clamp and the nerve divided immediately below the
second clamp. e proximal clamp is removed, and the crushed area is
ligated with a heavy ligature of nonabsorbable suture. Fine ligatures are
avoided, lest the epineural sheath be cut through, permitting the formation of a neuroma. Absorbable ligatures are avoided since they may be
absorbed before the epineural sheath has united, causing the sheath to
reopen with the formation of a neuroma. e distal clamp is then removed,
leaving a crushed and attened short segment of nerve that tends to prevent the ligature from slipping o . e nerve is allowed to retract well
upward into the muscle layers. It should never be anchored to adjacent
structures. When the sciatic nerve has retracted upward, the tissues are
further freed from the posterior surface of the femur. e profunda femoris artery and vein must be secured and ligated in the posterior group of
muscles (figure 2).
CONTINUES
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