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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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A needle tip may be used for endorectal advancement flap.
Pezzer (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 approach to the fistula
(vaginal or rectal).
In lithotomy
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).
We typically secure the patient with a belt to prevent inadvertent
rolling.
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.
Techniques of Fistula Closure
Advancement Flaps
When the anal muscle is intact and the tissue is overall healthy, an
advancement flap can be considered.
Semicircular Advancement Flap
Typically, the patient is placed in the prone jackknife position, but for a
posterior fistula, we may rarely utilize the lithotomy position if we feel
visualization for mobilization may be improved.
With the patient prone, we use #1 sutures to efface the skin in at the 2, 4,
8, and 10 o’clock positions. More sutures can be placed if needed. This
allows visualization into the anal canal (Fig. 14-3).
FIGURE 14-3 Anal everting sutures are placed at 2, 4, 8, and 10 o’clock to efface the
anal canal.
A Hill-Ferguson lighted retractor is placed in the anal canal.
The fistula is identified, and a semicircular incision is made nearly 180degrees, starting just distal to the internal opening.
The mucosa is initially mobilized cephalad, but with progression inward, a
portion of the internal sphincter and then the full thickness of rectum are
mobilized. It can be bloody due to vessels in the rectovaginal septum, and
Bovie electrocautery or 3-0 absorbable sutures are utilized for hemostasis.
Mobilization is carried out until the reach comes down to cover the
opening without tension (Fig. 14-4).
FIGURE 14-4 Mobilization is carried cephalad until the rectal flap comes down easily.
The fistula tract is debrided. We only try to debride at the anal sphincter
level aggressively to avoid making the internal opening excessively large.
The internal opening is then closed in layers with 2-0 or 3-0 polyglactin
sutures (Fig. 14-5). We tend to close from side to side and then front to
back in at least two layers. This takes up dead space and relieves any
tension on the neodentate line anastomosis.
FIGURE 14-5 The tract is debrided and closed.
The tip of the flap is trimmed and sutured to the neodentate line (Figs. 146 to 14-10).
FIGURE 14-6 The distal end is trimmed off.
FIGURE 14-7 The flap is advanced down and sewn to the neodentate line.
FIGURE 14-8 The flap is advanced down.
FIGURE 14-9 Final sutures placed.
FIGURE 14-10 Final sutures placed.
Sleeve Advancement Flap
When there is excessive scar or stricture in the anal canal, a sleeve
advancement may be the best choice.
When consenting the patient and making your plans, it is important to
realize that if there is too much tension via the transanal mobilization, then
a transabdominal approach may be required.
Therefore, the patient and surgeon must be ready to mobilize via the
abdominal approach.
Mobilization starts at the dentate line, and a mucosectomy is done for the
proximal anal canal (Fig. 14-11).
FIGURE 14-11 A mucosectomy is done of the anal canal.
When the rectum is reached, then the dissection deepens into the same
plane used for an Altemeier procedure (Fig. 14-12).
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