Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
.pdf
Hemostats: Straight and curved
Needle driver
Assorted forceps (eg, Adson-DeBakey)
Metzenbaum scissors
Electrocautery
Lidocaine with epinephrine 0.5% and injection equipment for anal block
Surgical Approach
Preoperative preparation: two-fleet enemas
Anesthesia: general/laryngeal mask airway
Position: lithotomy or prone depending on surgeon/anesthesia preference
(Fig. 8-1)
FIGURE 8-1 Lithotomy positioning exposing the perineum.
MILLIGAN-MORGAN (OPEN)
Technique
With the patient in the lithotomy position, examine the perineum to look
for other pathology and evaluate the hemorrhoidal columns (Fig. 8-2A and
B).
FIGURE 8-2 A. Traditional three column external hemorrhoids in the right anterior,
right posterior, and left lateral positions. B. Circumferential hemorrhoidal prolapse.
Hemorrhoids are rarely the same size and anoscopy can confirm the
largest or most problematic. Begin with that one and proceed sequentially.
Sometimes one or two of the three columns can be successfully managed
by elastic ligation.
Clean the inside of the anal canal first with a gauze soaked in betadine
solution.
Clean the skin over the perineum up to the scrotum or the vagina
anteriorly and the tailbone posteriorly. On the lateral side, the preparation
should go beyond the ischial tuberosity.
Perform an anal examination by placing a finger in the anal canal, and
sweep the anal canal for any abnormalities.
Insert a Hill-Ferguson anal retractor, perform a visual examination, and
record any abnormalities and location of the hemorrhoids.
To plan the procedure accordingly, make sure that there are enough skin
bridges (>1 cm of anoderm) between the excision of the three pedicles.
Mark areas of possible excision, if needed.
Inject 0.5% Marcaine with epinephrine under the hemorrhoid pedicles
using a small-gauge needle using about 5 mm at every pedicle (Fig. 8-3).
FIGURE 8-3 Perianal block with local anesthetic.
Wait for 5 minutes to allow for the block to set in.
Evaluate all the three pedicles (Fig. 8-4).
FIGURE 8-4 Three internal hemorrhoids (asterisks) are seen prolapsing from the
anal canal. Hemostat on the skin of the left lateral pedicle.
Apply one hemostat to the skin edge and one to the mucosa (Fig. 8-5).
Gently pull on the pedicle such that the skin is minimally tented.
Alternatively, a scalpel can be used for the incision.
FIGURE 8-5 Three hemorrhoid columns (asterisks) are demonstrated by hemostat
retraction.
Using a Metzenbaum scissor with the curve facing downward, cut at the
base of the skin lifting the pedicle and pushing the muscle and connective
tissue down toward the skin. This is progressed in small increments (Fig.
8-6).
FIGURE 8-6 A hemorrhoid is elevated with clamps and excised with scissors.
Secure hemostasis using an electrocautery as needed.
Continue this dissection until the pedicle is reached. Place a curved
hemostat to include the pedicle and the mucosa.
Suture tie the pedicle using 2-0 Polysorb/Vicryl sutures, making sure that
the suture is well tied.
Additionally, a free tie may be used distal to the suture tie.
Excise the pedicle. Check for bleeding.
Move to the next pedicle and repeat this procedure, making sure that the
two areas of incision have a skin bridge between the areas excised (Fig. 8-
7).
FIGURE 8-7 Milligan-Morgan hemorrhoidectomy with three hemorrhoidectomy
incisions left open. Arrows point to initial site of excision.
Maintain hemostasis using electrocautery.
For the Milligan-Morgan procedure, this ends the procedure. A longacting anesthetic may be injected 20 minutes after the previous injection
of lidocaine.
Place a dressing over the wound with an antibiotic cream on it.
FERGUSON (CLOSED)
Technique
Follow the steps as in Milligan-Morgan.
Using a 2-0 Vicryl or Polysorb suture, start at the pedicle and approximate
the mucosa by burying the pedicle and then use a continuous suture and
approximate the mucosa (Fig. 8-8).
FIGURE 8-8 Ferguson closed hemorrhoidectomy.
Using an Energy Device
When using an energy device like the Harmonic Scalpel (Ethicon,
Cincinnati, OH) or the short Ligasure (Medtronic, St. Paul, MN), the steps
to be followed are the same as described earlier; however, more care is
taken as the sphincter muscle is not visible and hence the skin should not
be tented to pull the muscle up.
The energy device should not be placed too close to the area where the
muscle lies at the base of the tented area.
The excision is carried out using small bites of the skin as the skin is quite
thick and does not cauterize and seal very well if large bites are taken (Fig.
8-9).
FIGURE 8-9 Using an energy device taking small bites from the skin to the pedicle.
On reaching the pedicle, make sure the entire area is cauterized and sealed
well. Once the pedicle has been cauterized, a few sutures of 3-0 chromic
catgut may be taken as interrupted sutures to reinforce the skin (Fig. 8-10).
FIGURE 8-10 Closing of the mucosa after an energy device was used to resect the
hemorrhoidal tissue.
Inject a long-acting bupivacaine, as described earlier.
Postprocedural Management
The patient is advised the following:
Pain management using pain medications of surgeons or patient’s choice
Stool softeners such as docusate sodium 100 mg twice daily
Fiber supplementation
Mineral oil 2 tablespoons as needed
Local application of lidocaine jelly 2% before and after a bowel
movement
Local application of metronidazole 0.75% cream 1-2 times a day
Sitz bath or use of an ice pack
Follow-up visit at 4-6 weeks and/or earlier if indicated
PEARLS AND PITFALLS
Соседние файлы в папке Библиотека им академика М.И. Перельмана