Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_785_Библиотеки_им_академика_М_И_Перельмана

Although none of these conditions is a life-threatening emergency, they

The differential diagnosis is easy and possible even before examining the patient. > Figure 29.2 shows that each of the three conditions has a typical pat­tern of pain.

2–3 days.

Next, you want to examine the patient. This is done without resorting to a painful digital rectal examination. Place the patient in the lateral decubitus posi­tion or let the patient stand flexed forward with you sitting behind his or her buttocks. Gently spread the buttocks and look at the perianal region; now, you can easily visualize any perianal hematoma and often any fissure, sometimes even an abscess. If you see nothing, then assume that you are dealing with a pe­rianal abscess and continue as discussed separately in this chapter.

operative treatment. Your task is to interrupt the pain-spasm-pain cycle; the pain is caused by the fissure, which results in spasm of the internal sphincter, which in turn increases the pain. We would inject, using a fine needle, a few mil-

liliters of local anesthetic solution (e.g., marcaine) just under the fissure. The pain will disappear quickly and with it the anal spasm. Now, the patient will al­low you to insert a gloved finger into the anus. Gently introduce your finger coated with a generous dose of local anesthetic cream, dilating the anal canal gently. Do not try to make a further dilatation. Send the patient home and rec­ommend stool softeners and the old hot sitz baths. Some would recommend local application of glyceryl trinitrate or diltiazem cream to relax the internal sphincter’s spasm. If both creams are available, it seems the diltiazem should be preferred as it is equally effective and is less likely to provoke disturbing head­aches. Management of recurrent, persisting, or chronic fissures, whether by pro­longed applications of topical glyceryl trinitrate or diltiazem, by injection of botulinum toxin, or by a lateral internal sphincterotomy (which I prefer even now) is beyond the scope of emergency treatment.

Sometimes, the acute perianal abscess is evident: a localized, very tender reddish swelling at the anal margin. At other times, you have to palpate the anal margin to elicit localized pain. Be careful to make this maneuver as brief and delicate as possible; repeating it many times or pressing your finger against the painful zone can be considered an act of torture. If you elicit localized tender­ness, you do not need any other imaging technique to confirm the diagnosis, and you can treat it. In most cases, ordering a computed tomograph (CT) to diagnose a perianal abscess is a crime. However, in rare situations, when the abscess is situated above the levator ani or is retrorectal, with the patient presenting with dull perianal pain but no local findings on examination, then a CT of the pelvis may be diagnostic.

There is no need to pack the cavity of the well-drained abscess or to leave a drainage tube, except in big cavities. The patient will experience almost immedi­ate disappearance of pain and will be most thankful, although in subsequent

This is a relatively common occurrence in patients with grade III or IV hemorrhoids. The prolapsed hemorrhoids become irreducible because of swell­ing, and thrombosis frequently develops. The patient experiences intense pain and has serious difficulties sitting and walking. On examination you see the pro­lapsed piles (this is what the Brits call hemorrhoids)—blue with areas of mucosal necrosis.

Three options are available: nonoperative treatment, anal dilatation, and emergency hemorrhoidectomy. Most colorectal specialists prefer the last,

which is the quickest solution to the problem, although they admit that the swelling may lead to an excessive excision of anal mucosa and to the subse­quent development of anal stenosis. So, if you feel confident about your train­ing in anal surgery, proceed to hemorrhoidectomy but always consider that a few residual skin tags resulting from insufficient removal of perianal and mu­cosal folds is a better result than stenosis as a consequence of an overenthusi­astic excision. Some surgeons would remove the prolapsed piles with or without the addition of internal sphincterotomy to relieve the secondary anal spasm. A less-aggressive alternative to sphincterotomy would be the local application of glycerin trinitrate or diltiazem cream. If you are not too comfortable with emergency hemorrhoidectomy in this condition, you may safely resort to anal dilatation under general anesthesia; do it gently, especially in older people, and then reduce the prolapsed piles upward, where they belong. The third op­tion—nonoperative treatment—is preferred by many surgeons and consists of bed rest (with the buttocks elevated) and analgesia until spontaneous resolu­tion occurs. You can use sugar for accelerating this resolution [see Editorial Comment at the end of this chapter].

of extraperitoneal rectal injury suggested by the bullet trajectory must be con­firmed or refuted by clinical examination. Discharge of blood and palpation of a hole in the rectal wall are confirmatory. Until recently, management was based on three basic principles developed for war injuries and demonstrated to be very ef­fective in reducing mortality and morbidity: diverting sigmoidostomy, presacral drainage, and rectal washout. (Repair of the actual rectal wound was added when technically possible.) However, the routine use of these dogmas in civil injuries has been challenged in recent years. Suture repair of the rectum is a nice concept but has little to recommend it. Doing so through a transanal approach is not easy, and there is agreement that opening the pelvic peritoneum during abdominal explora­tion is indicated only to arrest hemorrhage from major vessels or for debridement in the face of extensive bony and soft-tissue damage. In most civilian rectal injuries, suture repair can be omitted without affecting morbidity and mortality (a similar situation exists in the case of full-thickness local excision of rectal tumors without suturing the rectal defect). Rectal washout has become the second victim of icono­clasts. Most recent series have omitted it with no change in results. The value of presacral drainage has also been questioned. Only proximal fecal diversion seems

Necrotizing perineal infections may be the consequence of neglected ano­rectal infections, but they also arise from trauma, skin infections and urethral in­strumentation. A urethral source implies Fournier’s gangrene—an eponym that has been incorrectly extended to the whole spectrum of this entity. But, more im­portant than etiology is prompt diagnosis and treatment.

The synergistic action of gram-negative bacteria, anaerobes, and Streptococcus causes rapid dissemination of the infection along superficial fascial and subcu­taneous planes, with secondary ischemic involvement of the skin. Pain may be the first symptom, but it may be vague. Swelling of the perineum, crepitus, local tenderness, and erythema of the skin—followed by its necrosis—are the typical elements found on examination.

of 20 ml of 0.5% bupivacaine, 10 ml of 1% lignocaine, 10 ml of normal saline, and a 6-cm needle, I inject 5 ml. of the local anesthetic mixture deeply behind the anus, peripheral to the external sphincter. Then, without totally removing the needle, I repeat the injection on both sides, with a 45° inclination (see > Fig. 29.3, steps 1–3). A second injection is done anteriorly (steps 4–6), with the same fanning. Finally, two more injections are made following a similar pattern at 3 and 9 o’clock (steps 7, 8).