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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 12-26 Ligation of intersphincteric fistula tract. Entering the
intersphincteric groove and the tract is dissected free.
A 2-cm length is commonly quoted, though this is related to the
anatomy of buttocks and size/height/length of the fistula/anal verge and
depth of the anal canal.
Gentle cephalad dissection in the bloodless intersphincteric groove is
carried out with a hemostat, tonsil, or right-angle clamp.
We place more emphasis on protecting the “white” fibers of the internal
sphincter, minimizing risk of an iatrogenic injury to the anal mucosa,
than the “red” fibers of the external sphincter.
Having a fistula probe in the tract aids in its identifications, and
circumferential dissection, with an aid of a fine-tipped right-angle clamp.
Having isolated the tract, we remove the probe, suture ligate both ends of
the fistula within the intersphincteric groove with 4-0 absorbable suture
(Fig. 12-27).
FIGURE 12-27 Ligation of intersphincteric fistula tract. Suture ligation of the tract.
The tract is then divided with a #15 blade (Fig. 12-28).
We find that there is a risk of the knots being dislodged if the track is
tied, as opposed to suture ligated.
FIGURE 12-28 Ligation of intersphincteric fistula tract. Division of the tract.
Integrity of the repair is confirmed by injecting normal saline or dilute
H2O2 into the external opening.
The intersphincteric incision is approximated with 3-0 absorbable vertical
mattress sutures.
Depending on the length of the track, the external opening is either left
widely open or drained with a mushroom catheter for 7-10 days.
OTHER PROCEDURES
Note: Other procedures that supplement the techniques described in this
chapter may be found in the following chapters:
Dermal advancement flap, Chapter 10 (Anoplasty for Anal Stenosis)
Modified Hanley procedure, Chapter 11 (Incision and Drainage of
Perirectal Sepsis)
Gracilis and Martius (ie, bulbocavernosus) flaps, Chapter 14
(Rectovaginal Fistula)
Rectourethral fistula, Chapter 15 (Perineal Repair of Rectourethral
Fistula)
Crohn perianal disease, Chapter 16 (Perianal Symptoms in Patients
with Crohn Disease)
Turnbull-Cutait, Chapter 20 (Turnbull-Cutait Abdominoperineal Pull
Through with Delayed Colo-Anal Anastomosis)
Laparoscopic diverting loop ileostomy, Chapter 41 (Abdominal Crohn
Disease: Surgical Management)
The following procedures are not described as they have essentially been
abandoned due to lack of efficacy.
Fibrin glue
Fistula plug
Suggested Readings
Bolshinsky V, Church J. How to insert a draining seton correctly. Dis Colon Rectum. 2018;61(9):1121-
1123.
Causey MW, Nelson D, Johnson EK, et al. A NSQIP evaluation of practice patterns and outcomes
following surgery for anorectal abscess and fistula in patients with and without Crohn’s
disease. Gastroenterol Rep. 2013;1(1):58-63.
Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the management of anorectal
abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2016;59(12):1117-1133.
Chapter 13
Hidradenitis Suppurativa
ANURADHA R. BHAMA
SCOTT R. STEELE
Perioperative Considerations
The prevalence of hidradenitis suppurativa (HS) is 0.1%-4% worldwide,
with the mean age of onset 20-24 years.
Multiple risk factors are known for HS.
Cigarette smoking and obesity
Dietary triggers including dairy products and highly refined simple
carbohydrates
The anal region is the second most commonly involved area after the
axilla; ∼30%-50% of patients with HS have perianal lesions as a location
of their disease (Fig. 13-1).
FIGURE 13-1 Severe hidradenitis disease in the perianal and groin.
A number of comorbid conditions can be present in patients with HS.
Acne
Inflammatory bowel disease
Spondyloarthropathy
Genetic keratin disorders
Squamous cell cancer
Local and small lesions can benefit from medical treatment, but recurrence
rates are high.
Antibiotics
Topical (eg, clindamycin)
Oral (eg, tetracycline, clindamycin, rifampin)
Monoclonal antibodies (eg, adalimumab, infliximab)
Indications for surgical treatment
Widespread disease is an indication for radical surgical excision with
possible need for reconstruction with a flap.
Acute abscess (incision and drainage [I&D])
Chronic or recurrent HS nonresponsive to medical therapy
Intolerance of medical treatment
Positioning
Positioning will depend on the location and extent of the disease.
Either prone jackknife or lithotomy positions can be utilized (Fig. 13-
2).
FIGURE 13-2 Lithotomy positioning.
Positioning may need to allow for harvesting of skin grafts or rotation of
flaps.
Changing of positioning for various segments of the operation may be
necessary.
Special Equipment
I&D/lay-open technique
Fistula probes
Electrocautery
Hydrogen peroxide
Angiocath on 10 mL syringe
Excision and grafting
Excision
#15 or #10 blade and scalpel
Electrocautery
Forceps
Grafting
Dermatome
Air-powered dermatome (Zimmer)
Electric-powered dermatome
Size of dermatome can be 1, 2, 3, or 4 in wide.
Skin mesher
Two types
With carrier—disposable carrier helps minimize risk of
damage to fragile grafts
Without carrier
Different ratios of meshing (1:1, 1:2, 1:3)
Telfa gauze soaked in epinephrine\ (1:1000 dilution)
Negative-pressure dressing (wound Vac)
Forceps
Suture or staples
Flaps
Standard soft-tissue operating set
Drain
Technique
I&D/lay-open technique
Use fistula probe to identify deeper tracts (Fig. 13-3A and B).
FIGURE 13-3 A and B. Identifying tracts using fistula probes.
If the tract is not obvious, you can use an angiocatheter to inject dilute
hydrogen peroxide into the opening and then bubbles will emerge from
any connected openings (Fig. 13-4).
FIGURE 13-4 Injection of hydrogen peroxide to identify tracts.
Excise and saucerize the tissue overlying the tract containing the fistula
probe (Fig. 13-5A and B).
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