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Step 2: Preoperative Considerations
The patient must be thoroughly examined and appropriately selected for a stapled hemorrhoidectomy. Anal stenosis, cancer, proctitis, and radiation damage are contraindications. This procedure is most effective for larger circumferential grade III hemorrhoids that cannot be treated
by ligation owing to volume of tissue, and it is ineffective for grade IV hemorrhoids. Patients
should receive two enemas to cleanse the rectum and sigmoid colon. Perioperative antibiotics
and deep vein thrombosis prophylaxis are unnecessary for this short operation. The procedure
can be performed under a general anesthetic or with a regional anesthetic with intravenous
sedation and a perianal block with a local anesthetic. Patients should be informed that there
will be a severe rectal pressure for at least 24 hours after the procedure.
Chapter 22 • Stapled Hemorrhoidectomy 315
Step 3: Operative Steps
u
The patient can be placed in the prone-jackknife or lithotomy position based on the surgeon’s
preference.
u
After adequate general or local anesthesia has been induced, the anal canal and distal rectum
must be examined to confirm the diagnosis and the appropriateness of the anatomy for the
procedure.
316 Chapter 22 • Stapled Hemorrhoidectomy
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The external hemorrhoids are grasped with atraumatic clamps to evert the anal canal. The
anal dilator and obturator unit is inserted (Figure 22-1). The obturator is removed, leaving
the clear anal dilator in place. It can be secured to the perineal skin with sutures or by an
assistant.
u
The dentate line is identified through the clear sides of the operating dilator (Figure 22-2).
The operating anoscope is inserted, and a line is drawn on the anoscope at 5 cm above the
dentate line to mark the line for the purse-string suture (Figure 22-3). The purse-string suture
is placed 4 cm above the dentate line with eight stitches placed no deeper than the submucosa, starting posteriorly and ending posteriorly.
u
When the purse-string suture is in place, the index finger is placed through the purse-string,
and the suture is pulled to ensure there are no gaps in the purse-string (Figure 22-4).
u
The stapler anvil is passed above the purse-string suture, taking time to ensure the anvil is
above all of the purse-string (Figure 22-5), and the purse-string is tied securely but loosely
around the post of the stapler (Figure 22-6).
Figure 22-1
Dentate line
Figure 22-2
Dentate line visible
through clear dilator
Chapter 22 • Stapled Hemorrhoidectomy 317
Figure 22-3
Figure 22-4
Purse-string tied
securely around shaft
Figure 22-5 Figure 22-6
318 Chapter 22 • Stapled Hemorrhoidectomy
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The ends of the suture are brought through the side ports of the stapler to help create trac-
tion on the redundant mucosa captured by the purse-string suture (Figures 22-7 and 22-8).
The stapler is tightened as it is pushed up to the level of the purse-string, all the while pulling
down on the suture (Figure 22-9). The closed stapler is inspected, a finger is placed in the
vagina if the patient is female, and the trigger is fired. The stapler is held closed for 2 minutes
for hemostasis.
u
The hemorrhoidal doughnut is inspected (Figure 22-10) for completeness.
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After the stapler is fired, the staple line is closely inspected, and any bleeding is ligated with
suture. The staple line is reinforced at the three hemorrhoidal pedicles with a figure-eight
suture, which crosses the staple line to prevent and manage bleeding (Figure 22-11). Figure
is a diagram of the final position of the staple line, ideally 4 cm above the dentate line.
22-12
Step 4: Postoperative Care
The patient may be discharged the day of surgery if he or she is able to void. Patients should
be provided with adequate pain control and placed on a high-fiber diet. Appropriate stool
softeners are prescribed to prevent constipation.
Step 5: Pearls and Pitfalls
The placement of the suture line and subsequent staple line is paramount for success. A staple
line placed too low can result in substantial anal pain, and a staple line placed too high does
not effectively treat the symptomatic hemorrhoids. The low rectal mucosa should be resuspended in its normal anatomic position as an “anopexy.” Delayed postoperative bleeding
requires an examination under anesthesia because exposed submucosal vessels can lead to
significant blood loss. These can be suture ligated. Persistent pain, fever, or urinary retention
may be signs of perineal sepsis. Partial inclusion of the purse-string suture would result in only
partial hemorrhoidectomy. Partial capture of the rectal wall results in creation of a mucosal
bridge across the low rectum. Acute angulation of the stapler during closure can result in capture
of the side of the rectum and almost total occlusion of the rectum as the purse-string is pulled
to the side. Removal of the stapler without complete transection of the mucosa has been the
cause of massive hemorrhage and rectal perforation. This is a simple procedure; however, there
are severe consequences if the procedure is performed improperly. A learning curve of 10 cases
with a proctor present is recommended.
Selected Readings
Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal
hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum 2007;50:1297–305.
Senagore AJ, Singer M, Abcarian H, et al. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy
and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum 2004;47:1824–36.
Chapter 22 • Stapled Hemorrhoidectomy 319
Staple line at
Redundant
mucosa
Traction on suture
to pull mucosa
into stapler cavity
Figure 22-7
Figure 22-8
Figure 22-9 Figure 22-10
3–5 cm above
dentate line
Figure 22-11
Figure 22-12
Step 1: Clinical Anatomy
C H A P T E R
23
Open Lateral Internal
Sphincterotomy
Bashar Safar and Ira J. Kodner
The anal canal is enveloped by two muscles, the internal sphincter, which is innervated by the
autonomic nervous system, and the external sphincter, which has somatic innervation. The
external sphincter extends slightly beyond the internal sphincter at the anal verge, which allows
clear identification of the intersphincteric groove. The intersphincteric groove is a bloodless
plane that runs between the two sphincter muscles and extends up to the levator ani muscle.
Anal fissures occur in the anterior and posterior midline and result most commonly from a
combination of internal sphincter spasm and ischemia. Dividing the internal sphincter in
a lateral position allows the fissure to heal, although this is associated with a small risk of
incontinence.
Step 2: Preoperative Considerations
Anal fissures produce a distinctive set of symptoms. Good history taking and a thorough examination in the office are sufficient tools in most cases to establish a diagnosis. Most fissures are
idiopathic and are located posteriorly (80%) or anteriorly (20%), distal to the dentate line. An
unusual presentation and location should alert the treating physician to the possibility of other
pathology, such as Crohn’s disease, cancer, or sexually transmitted diseases, which would not
respond to therapies employed for chronic fissures.
320
Chapter 23 • Open Lateral Internal Sphincterotomy 321
When the diagnosis of anal fissure is established, the patient should be started on medical
management including agents that induce chemical relaxation of the internal sphincter, fiber
supplementation, sitz baths, and steroid suppositories. Medical management should be continued for at least 1 month, at which time more than two thirds of patients will have improved.
Surgical management may be recommended in patients who fail medical management with
persistent symptoms and fissure on examination. Most acute anal fissures respond to medical
management; however, a few persist and become chronic.
Lateral internal sphincterotomy is a procedure commonly employed in the management of
chronic anal fissure. Chronicity can be defined by appearance and timing. A chronic fissure is
defined by symptoms lasting longer than 3 months and an examination that reveals exposed
internal sphincter at the base of the ulcer, a sentinel pile, edema, and fibrosis. Lateral internal
sphincterotomy for chronic anal fissure is associated with a very high success rate with a small,
but significant, risk of incontinence, especially in women.
322 Chapter 23 • Open Lateral Internal Sphincterotomy
Step 3: Operative Steps
u
These procedures can be performed under conscious sedation with local anesthesia, spinal
anesthesia, or general anesthesia.
u
The patient is placed in the prone-jackknife position with the pressure points protected, and
the buttocks are taped apart to efface the anus using 3-inch silk tape. Sedation is administered
by the anesthesia staff, and an anal block is performed with local infiltration of the canal,
ischiorectal fossa, and pudendal nerves using long-acting local anesthetic (Figure 23-1).
u
The anal canal is examined using a curved Hill-Ferguson anoscope to confirm the diagnosis
and exclude other causes of anal pain. The hypertrophied band of the internal anal sphincter
is usually the length of the anal fissure ulcer split (Figure 23-2).
u
With the anoscope facing the left lateral or right lateral wall, the surgeon slides the index
finger across the anal canal from the dentate line to the anal verge to find the intersphincteric
groove.
u
A radial incision is made over the groove (Figure 23-3), and a clamp is inserted between the
two sphincters (Figure 23-4). The clamp is spread gently, and the tip of the clamp is elevated
through the incision to expose the hypertrophied fibers of the internal sphincter.
External tag
Posterior anal ulcer
Anal papilla
Figure 23-1
Figure 23-2
Chapter 23 • Open Lateral Internal Sphincterotomy 323
Figure 23-3
Intersphincteric groove
Figure 23-4
324 Chapter 23 • Open Lateral Internal Sphincterotomy
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The sphincter is divided under direct vision to the level of the dentate line or enough to
remove the hypertrophied band (Figures 23-5 and 23-6A-C).
u
Hemostasis is accomplished with electrocautery or pressure.
u
The incision is reapproximated with 3-0 absorbable suture. An antibiotic ointment and gauze
dressing is applied.
u
A closed sphincterotomy can be performed through the radial incision in the midlateral posi-
tion. A No. 11 blade is guided into the intersphincteric groove with a finger in the anal canal.
The knife is turned toward the lumen, and a sawing motion is used to divide the internal
sphincter hypertrophied fibers without damaging the overlying mucosa (Figure 23-7A
and B).
Figure 23-5