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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 12-8 Set of curettes to debride the tract.
00-silk ties
Silicon, radio-opaque yellow (mini) vessel loop, 1.3 mm wide and 0.9 mm
thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick (Fig. 12-9)
FIGURE 12-9 Silicon vessel loop for draining seton.
Monopolar electrocautery
We routinely use 40 cut/60 coagulation settings, pure or blend
A needle tip may be used for endorectal advancement flap (ERAF)
Pezzer (mushroom) drains, size ranging from 10 to 32Fr (Fig. 12-10)
FIGURE 12-10 Pezzer (ie, mushroom) drains, size ranging from 10 to 32Fr.
¼ and ½ in Penrose drains
Hydrogen peroxide diluted 50-50 with sterile normal saline, placed in a
10-mL syringe with a 14-gauge angiocatheter or a blunt-tip needle
Positioning
Positioning of the patient is dependent on the site of the internal opening,
with prone jackknife being optimal for anterior internal opening and
lithotomy for fistulas with a posterior internal opening.
In lithotomy (Fig. 12-2):
Emphasis on ergonomics cannot be understated. The edge of the
operating table may need to be moved in the caudal direction, to
ensure that the chair and feet of the operating surgeon are not
restricted by the base of the operating table. In addition, the patient’s
buttocks overhanging the edge of the operating table.
In prone jackknife:
We place two shoulder rolls under the chest (taking special care to
protect the breasts) and a foam pillow (Kraske roll) under the pelvis
(taking special care to protect the genitals from pressure injury) (Fig.
12-4A).
We typically secure the patient with a belt to prevent inadvertent
rolling (Fig. 12-4bB).
We use tape to laterally retract the buttocks, with or without
benzoin.
Excessive tape traction will result in iatrogenic tearing (fissuring) of the
anoderm—avoid.
Setons
Draining setons are used as a bridge to definitive repair (commonly
performed 6 weeks after insertion), or as semi-permanent drainage for
refractory fistulas or where definitive repair is contraindicated (eg, severe
perianal Crohn disease).
If the seton breaks and falls out, and the track is completely epithelialized,
it may not need to be replaced. However, the patient should be informed
of the risk of abscess and recurrent symptomatic fistula, heralded by a
change in symptoms such as pain or increased drainage, respectively.
Cutting setons may be used as a “slow fistulotomy” in selected cases. This
is rarely indicated.
Technique
Draining Seton
A standard perianal block is performed (Fig. 12-11) by identification of
the pudendal nerve as it traverses by the ischial tuberosity. Additional
perianal anesthetic may be placed around the sphincter complex itself.
FIGURE 12-11 Perianal block using local anesthesia.
Having identified the track using the Lockhart-Mummery fistula probes,
we secure a 00-silk tightly onto the probe and then sequentially exchange
this for an 00-silk tie and a yellow vessel loop (Fig. 12-12).
The yellow vessel loop is the smallest size to ensure adequate drainage
and is well tolerated by the patients.
FIGURE 12-12 Draining seton in place using a silastic vessel loop.
Place a hemostat on each end of the vessel loops for traction.
We overlap the two ends of the seton and assess tension.
The draining seton needs to be flat/tight enough to prevent difficulty
toileting and chafing, but loose enough to avoid skin erosion.
The correct amount of tension typically corresponds to a surgeon’s
fingertip inserted between the seton and the skin.
As the seton typically springs back after it is secured, the elastic
properties of the vessel loop need to be considered when securing it in
place.
We secure the seton by overlapping the two ends of the vessel loop with a
surgeon’s knot and an additional throw of a silk tie in a square formation
(Fig. 12-13). The knots are kept flat, and the ends of the suture and tubing
are cut short to reduce potential patient discomfort (Fig. 12-14).
If the knots are tied with excessive pressure, they may cut through the
vessel loop.
FIGURE 12-13 Different methods of securing the ends of the draining seton.
FIGURE 12-14 Two views of draining setons in place the ends overlapping and
tied together with low-profile knots.
Two yellow vessel loop setons, a blue vessel loop, or a ¼ in (rarely ½ in)
Penrose drain may be utilized for drainage of a wider caliber tracks.
Additional examinations under anesthesia and debridement may be
required in these cases.
A commercially available Comfort Drain (A.M.I. Inc.) is a knot-free ring
and may be utilized to form a draining seton. This device avoids the need
to overlap the tubing and silk ties and their knots. The smaller diameter of
the Comfort Drain tubing raises concerns of inadequate drainage. We do
not typically use this product.
Cutting Seton
As stated earlier, we rarely use cutting setons, and they should be used
only in very selected cases that either have failed other methods or have
unique conditions to warrant implementation.
They are associated with a higher rate of changes in continence and
should be especially avoided in patients deemed at risk.
The theory behind a cutting seton is that it gradually erodes through the
sphincter, allowing fibrosis to take place above it along the path (the
analogy of a hot knife slicing through a block of ice, with the ice reforming from top down as the knife advances down).
In such cases, a “draining” seton can be converted to a cutting seton in
the clinic as long as next step is performed.
Following identification of the track, the skin and subcutaneous tissue are
divided (as in left panel, Fig. 12-15) down to the level of the sphincter
muscle.
FIGURE 12-15 Division of the skin and subcutaneous tract with seton in place
through the fistula.
The superficial aspect of the wound may be saucerized to prevent the skin
healing over the top of the seton.
The seton is tied tightly around the muscle. We prefer to use a yellow
vessel loop rather than a silk tie, as the elasticity of the vessel loop enables
easier tightening. The two ends of the vessel loop are placed under tension
using a hemostat. A silk tie is applied to approximate the seton.
The vessel loop configuration is different from the draining seton (Fig.
12-13), with the two ends of the vessel loop secured to each other in a
parallel manner.
The cutting seton is adjusted weekly or every other week in the clinic.
This is performed by putting traction on the two ends of the vessel loop
and tying proximal to the previous knot. Some surgeons use a hemorrhoid
rubber band instead of a proximal silk tie.
Fistulotomy
This technique has the highest cure rate for fistula-in-ano of
cryptoglandular origin.
It is the preferred option for an intersphincteric fistula.
For a transsphincteric fistula, the role of fistulotomy is more controversial.
In a young male with a low, posterior transsphincteric fistula, a
fistulotomy will result in a high degree of success and a low risk of
incontinence.
For certain populations, this should be used with caution. For example, in
a high transsphincteric fistula or an anterior transsphincteric fistula in a
female with a compromised sphincter due to a prior vaginal delivery, a
fistulotomy may result in incontinence, potentially irreparable.
Care should be taken when performing a posterior midline fistulotomy
with a long track resulting from a fistula-in-ano as a keyhole deformity
may result.
PEARLS AND PITFALLS
The anal sphincter is of different length in both men and women, and
the muscle bulk is significantly more deficient anteriorly in women.
Previous obstetric injuries, perianal sepsis, and anorectal surgery may
have further reduced muscular reserve of the anal sphincter. Likewise,
proceed with caution in patients who have previously had a fistulotomy
or sphincterotomy; these patients may benefit from preoperative
assessment with anorectal manometry, endoanal ultrasound, and
consideration of a cutting seton, flap, or ligation of intersphincteric
fistula tract (LIFT) procedure.
Technique
Following reassessment of sphincter involvement, a Lockhart-Mummery
fistula probe is inserted into in fistula track (Fig. 12-16). This is typically
performed by exchanging the seton for the probe with the use of a silk tie.
FIGURE 12-16 Fistulotomy with passing of the probe and dividing some of the lower
sphincter muscle.
After passing the probe through the entirety of the track, bending the tip of
the probe prevents it from falling out (Fig. 12-17).
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