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Op
erative Technique
26
3
4
1
Fig. 25–
Fig. 25–
2
62
A
-
n
m
Fig. 25 –7a
). Now by sharp
aps
f
W
-
.
y
h
ngerbreadths.
m
ap of anoderm so point A meets point
h
i-
;
Fi
.
5
noplasty for Anal Stenosis
ig. 25–
vertical incision at the posterior commissure, begin
ing at the dentate line and extending upward in the
rectal mucosa for a distance of about 1.5 cm. Then
ake a
extension of this incision on to the anoderm
inFigure 25 – 6. Be certain the two limbs of the
incision in the anoderm are separated by an angle of
t least 90° (angle A in
or a distance of about 1–2 cm. Take special care not
o injure the delicate anoderm during the dissection.
hen the dissection has been completed, it is pos
ible to advance point A on the anoderm to point B
n the mucosa
Fig. 25 –7b) without tension
Internal Sphincterotom
In most cases enlarging the anal canal requires divi-
ion of the distal portion of the internal sphincter
muscle. T
is may be performed through the same
ncision at the posterior commissure. Insert a sharp
scalpel blade in the groove between the internal and
xternal sphincter muscles. Divide the distal 1.0–
.5 cm of the internal sphincter. Then dilate the anal
Advancing the Anoder
Using continuous sutures of 5-0 atraumatic Vicryl,
(Fig. 25–7b; Fig. 25 – 8) and suture the anoderm
o the mucosa with a continuous suture that catches
a bit of the underlying sphincter muscle. When the
suture line
sion in the posterior commissure resembles a
25–7b
e anal canal
as been completed, the original inc
(Fig.
g. 25 –9). Insert a small Gelfoam pack into
Op
erative Technique
263
6
g
8
Fig. 25–
ig. 25–7ab
Fi
. 25–
2
64
A
F
E
-
A
.
Mineral oil (45 ml) is taken nightly for the fi
3
p
.
fl
uids in the recovery
-
-
S
n
atoma
A
)
4;74
.
noplasty for Anal Stenosis
POSTOPERATIVE CAR
Remove the gauze dressings from the anal wound. It
s not necessary to mobilize the Gelfoam because it
ends to dissolve in sitz baths, which the patient
should start two or three times daily on the day fol
lowing the operation.
regular diet is prescribed
rst 2–
ays. Thereafter a bulk laxative, such as Metamucil,
s prescribed for the remainder of the postoperative
eriod
Discontinue all intravenous
oom if there has been no postanesthesia complica
ion. This practice reduces the incidence of postop
rative urinary retention.
COMPLICATION
Urinary retentio
Hem
nal ulcer and wound infection (rare
ig. 25–8
REFERENCE
Khubchandani IT. Anal stenosis. Surg Clin North Am
199
:1353
26
Thiersch Operation for
Rectal Prolapse
SURGICAL LEGACY TECHNIQUE
INDICATIONS
The Thiersch operation is indicated in poor-risk
patients who have prolapse of the full thickness of
rectum (see Chapter 19). Other perineal operations,
including the Delorme procedure, are excellent alternatives in poor-risk patients and have largely supplanted this legacy procedure.
PREOPERATIVE PREPARATION
Sigmoidoscopy (barium colon enema) is performed.
Because many patients with rectal prolapse suffer
from severe constipation, cleanse the colon over a
period of a few days with cathartics and enemas.
Initiate an antibiotic bowel preparation 18 hours
prior to scheduled operation, as for colon resection
(see Chapter 1).
PITFALLS AND DANGER POINTS
Tying the encircling band too tight so it causes
obstruction
Wound infection
Injury to vagina or rectum
Fecal impaction
Achieving Proper Tension of the Encircling Band
Although some surgeons advocate that the encircling
band be adjusted to fi t snugly around a Hegar dilator,
we have not found this technique satisfactory.
Achieve proper tension by inserting an index fi nger
into the anal canal while the assistant adjusts the
encircling band so it fi ts snugly around the fi nger. If
the band is too loose, prolapse is not prevented.
OPERATIVE TECHNIQUE
Fabricating the Encircling Band of Mesh
Although Lomas and Cooperman preferred Marlex
mesh, we believe that Dacron-impregnated Silastic
mesh is preferable because of its elasticity. Cut a
rectangle of Silastic mesh 1.5 × 20.0 cm. Cut the strip
so it is elastic along its longitudinal axis. Figure
26 –1 and subsequent drawings illustrate Lomas and
Cooperman’s technique of using a tight roll of Marlex;
we now use a 1.5 cm strip elasticized Silastic. Except
for the nature of the mesh, the surgical technique is
unchanged.
Incision and Position
OPERATIVE STRATEGY
Selecting Proper Suture or Banding Material
Lomas and Cooperman (1972) recommended that
the anal canal be encircled by a four-ply layer of
polypropylene mesh. The band is 1.5 cm in width, so
the likelihood it would cut through the tissues is
minimized. Labow and associates (1980) used a
Dacron-impregnated Silastic sheet (Dow Corning No.
501-7) because it has the advantage of elasticity.
This operation may be done with the patient in the
prone jackknife or the lithotomy position, under
general or regional anesthesia. We prefer the prone
position. Make a 2 cm radial incision at 10 o’clock
starting at the lateral border of the anal sphincter
muscle and continue laterally. Make a similar incision
at 4 o’clock. Make each incision about 2.5 cm deep.
Inserting the Mesh Band
Insert a large curved Kelly hemostat or a large rightangle clamp into the incision at 4 o’clock and gently
265
2
66
T
p
m
h
-
-
p
m
p
passage around the anal canal. Keep the band fl
at.
nger
fi
nger, ask the assistant to insert a 2-0 Prolene suture
nger and remove the contami-
-
cient tension to be snug
fi
nger in the rectum
e
-
g.
1
hiersch Operation for Rectal Prolapse
Fig. 26–
ass the instrument around the external sphincter
uscles so it emerges from the incision at 10 o’clock.
Insert one end of the mesh strip into the jaws of the
emostat and draw the mesh through the upper inci
ion and extract it from the incision at 4 o’clock.
Then pass the hemostat through the 10 o’clock inci
ion around the other half of the circumference of
he anal canal until it emerges from the 4 o’clock
incision. Insert the end of the mesh into the jaws of
e hemostat and draw the hemostat back along this
ath (Fig. 26 –2)
band into the posterior incision. At this time the
ntire anal canal has been encircled by the band of
esh, and both ends protrude through the posterior
incision. During this manipulation be careful not to
enetrate the vagina or the anterior rectal wall. Also,
o not permit the mesh to become twisted during its
o it delivers the end of the mesh
e encircling band. Ask the assistant to increase the
ension gradually by overlapping the two ends of
mesh. When the band feels snug around the index
o maintain this tension. After the suture has been
nserted, recheck the tension of the band. Then
nated glove. Insert several additional 2-0 Prolene
nterrupted sutures or a row of 55 mm linear staples
o approximate the two ends of the mesh and ampu
ate the excess length of the mesh band. The patient
should now have a 1.5 cm wide band of mesh encir-
ling the external sphincter muscles at the midpoint
around an index
(Fig.
6 –3)
losur
Adjusting Tension
Apply a second sterile glove on top of the previous
into the anal canal. Apply a hemostat to each end of
Irrigate both incisions thoroughly with a dilute anti
biotic solution. Close the deep perirectal fat with
nterrupted 4-0 PG interrupted sutures in both
ncisions. Close the skin with interrupted or continu-
us subcuticular sutures of the same material(Fi
26 –4) Apply collodion over each incision.
Op
2
ig. 26–2
erative Technique
67
ig. 26–3
ig. 26–4
268 Thiersch Operation for Rectal Prolapse
POSTOPERATIVE CARE
Prescribe perioperative antibiotics.
Prescribe a bulk-forming laxative such as Metamucil
plus any additional cathartic that may be necessary
to prevent fecal impaction. Periodic Fleet enemas
may be required.
Initiate sitz baths after each bowel movement and
two additional times daily for the fi rst 10 days.
COMPLICATIONS
If the patient develops a wound infection it may not
be necessary to remove the band. First, open the
incision to obtain adequate drainage and treat the
patient with antibiotics. If the infection heals, it is
not necessary to remove the foreign body.
Some patients experience perineal pain following surgery, but it usually diminishes in time. If the
pain is severe and unrelenting, the mesh must be
removed. If removal can be postponed for 4–6
months, there may be enough residual perirectal
fi brosis to prevent recurrence of the prolapse.
REFERENCES
Kuijpers HC. Treatment of complete rectal prolapse: to
narrow, to wrap, to suspend, to fi x, to encircle, to
plicate or to resect? World J Surg 1992;15:826.
Labow S, Rubin RJ, Hoexter B, et al. Perineal repair of
rectal procidentia with an elastic sling. Dis Colon
Rectum 1980;23:467.
Lomas ML, Cooperman H. Correction of rectal procidentia
by use of polypropylene mesh (Marlex). Dis Colon
Rectum 1972;15:416.
Oliver GC, Vachon D, Eisenstat TE, Rubin RJ, Salvati EP.
Delorme’s procedure for complete rectal prolapse in
severely debilitated patients: an analysis of 41 cases. Dis
Colon Rectum 1994;37:461.
Williams JG, Rothenberger DA, Madoff RD, Goldberg SM.
Treatment of rectal prolapse in the elderly by perineal
rectosigmoidectomy. Dis Colon Rectum 1992;35:830.
27
Operations for Pilonidal Disease
INDICATIONS
Recurrent symptoms of pain, swelling, and purulent
drainage
PITFALLS AND DANGER POINTS
Unnecessarily radical excision
OPERATIVE STRATEGY
Acute Pilonidal Abscess
If an adequate incision can be made and all of the
granulation tissue and hair are removed from the
cavity, a cure is accomplished in a number of patients
with acute abscesses.
Marsupialization
During marsupialization a narrow elliptical incision
is used to unroof the length of the pilonidal cavity.
Do not excise a signifi cant width of the overlying
skin—only enough to remove the sinus pits. If this
is accomplished, one can approximate the lateral
margin of the pilonidal cyst wall to the subcuticular
layer of the skin with interrupted sutures. At the
conclusion of the procedure, no subcutaneous fat is
visible in the wound. Healing of exposed subcutaneous fat tends to be slow. On the other hand, the
fi brous tissue lining the pilonidal cyst contracts fairly
rapidly, producing approximation of the marsupialized edges of skin over a period of only several
weeks. There is no need to excise a width of skin
more than 0.8–1.0 cm. Conservative skin excision is
followed by more rapid healing. Of course, all granulation tissue and hair must be curetted away from the
fi brous lining of the pilonidal cyst.
Excision with Primary Suture
Allow several months to pass after an episode of acute
infection to minimize the bacterial content of the
pilonidal complex. Successful accomplishment of
primary healing requires that the pilonidal cyst be
encompassed by excision of a narrow strip of skin that
includes the sinus pits and a patch of subcutaneous fat
not much more than 1 cm in width. If this can be
achieved without entering the cyst, closing the relatively shallow, narrow wound is not diffi cult. Perform
the dissection with electrocautery. Hemostasis must
be perfect to ensure complete excision of the cyst and
any sinus tracts without unnecessary contamination
of the wound. If this technique has been successful,
postoperative convalescence is quite short.
It is not necessary to carry the dissection down to
the sacrococcygeal ligaments to ensure successful
elimination of the pilonidal disease. In essence, the
surgeon is simply excising a chronic granulomas surrounded by a fi brous capsule and covered by a strip
of skin containing the pits that constituted the original portal of entry of infection and hair into the
abscess.
Primary healing requires good wound architecture. If a large segment of subcutaneous fat is excised,
simply approximating the skin over a large deadspace may result in temporary healing, but eventually the wound is likely to separate. Unless the
surgeon is willing to construct extensive sliding skin
fl aps or a Z-plasty, excision with primary closure
should be restricted to patients in whom wide excision is not necessary.
OPERATIVE TECHNIQUE
Although it is possible to excise the midline sinus
pits and to evacuate the pus and hair through this
incision under local anesthesia, often the abscess
points in an area away from the gluteal cleft and
complete extraction of the hair prove to be too
painful to the patient. Consequently, in most cases
simply evacuate the pus during the initial drainage
procedure and postpone a defi nitive operation until
the infection has subsided.
269
2
70
O
ltrate the skin overlying the abscess with 1%
l
fi
cient size to evacuate the pus
m
M
fi
nes of the pilonidal cyst. If the patient has a
p
)
-
-
p
b
f
fi
ng the pilonidal cyst, remove all gran-
u
1
perations for Pilonidal Disease
Fig. 27–
idocaine containing 1 : 200,000 epinephrine. Make a
calpel incision of suf
nd necrotic material. Whenever possible, avoid
aking the incision in the midline. If it is possible to
xtract the loose hair in the abscess, do so; other-
wise, simply insert loose gauze packing.
arsupialization
First described by Buie in 1944, marsupialization
begins by inserting a probe or grooved director into
he sinus. Then incise the skin overlying the probe
with a scalpel. Do not carry the incision beyond the
on
ract leading in a lateral direction, insert the probe
into the lateral sinus and incise the skin over it. Now
xcise no more than 1–3 cm of the skin edges on
ach side to include the epithelium of all of the sinus
its along the edge of the skin wound
This maneuver exposes a narrow band of subcutane
us fat between the lateral margins of the pilonidal
st and the epithelium of the skin. Achieve com
lete hemostasis by carefully electrocauterizing each
leeding point.
A
ter unroo
lation tissue and hair, if present, using dry gauze,
he back of a scalpel handle, or a large curet to wipe
lean the posterior wall of the cyst
Fig. 27–1
Fig. 27–2) Then
ig. 27–2