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5 Perioperative Management
101
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Operative andAnesthetic
Techniques
AmyJ.Thorsen andJasneetSinghBhullar
6
Introduction
The medical and surgical management of anorectal disease represents a substantial portion of a
typical colorectal surgery practice. A variety of
diseases are encountered, ranging from the benign
processes of hemorrhoidal and cryptoglandular
stula disease to a range of premalignant and neoplastic lesions of the anorectum. For many of these
conditions, there is no consensus on optimal surgical approach or technique. An individual patient
may also present some challenges. Adequate operative and airway exposures can be difcult to optimize in the obese; a simple sphincterotomy under
local and sedation may not be appropriate for an
opioid tolerant patient. Although anorectal procedures may seem to be routine, a patient specic
operative plan will guide the surgeon, operative
team, and patient through a successful procedure.
In this chapter, we will review patient positioning, anesthetic techniques, and instrumentation that are employed in modern anorectal
surgical procedures.
A. J. Thorsen (*)
Colon and Rectal Surgery Associates,
Minneapolis, MN, USA
University of Minnesota,
Minneapolis, MN, USA
e-mail: athorsen@crsal.org
J. S. Bhullar
Department of Surgery,
UPMC Susquehanna Health, Williamsport, PA, USA
Positioning
Optimal patient positioning for anorectal surgery
involves selecting a posture that optimizes exposure to the operative site while maintaining adequate ventilation and perfusion during anesthesia
administration. Patient related factors, such as
BMI and cardiopulmonary disease, as well as
anesthetic technique contribute to determining
the best position. Although a surgeon may have a
preferred position for most anorectal procedures,
consensus among operative team members may
be the safest approach.
Many surgeons consider the prone-jackknife
position to be the gold standard for anorectal procedures (Fig.6.1). If the patient is to receive only
mild sedation and local anesthesia, self-positioning of the patient on the provided cushions may
best avoid injury. The patient is placed on the
operative bed face down. The head is placed in a
cradle with an occasional mild tilt to the side.
Care should be taken to keep the eyelids closed to
avoid corneal abrasions if the patient is positioned anesthetized. Adequate cushioning is provided from the clavicle to the iliac crests, usually
with two chests roles or occasionally pillows, to
allow adequate expansion of the lungs and diaphragm and minimal pressure on the abdomen.
The arms can be placed alongside the torso with
hands facing up, or exed above the head on arm
boards with a mild bend in the elbow and hands
facing down. A hip roll is used to prop the operative
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_6
103
104
Fig. 6.1 Prone jackknife position
Fig. 6.2 Taping of gluteal cheeks
eld up, and mild tilt of the head of the table
downward will help accentuate this. The buttocks
are taped apart with lateral traction (Fig.6.2). To
prevent plantar exion of the feet and toes, a pillow is placed under the ankles. The female breasts
A. J. Thorsen and J. S. Bhullar
should be adequately positioned on the chest
rolls, and the male genitalia should be checked to
avoid compression on the hip roll [1].
The advantages to the prone-jackknife position
include better visualization, illumination, and
retraction of the operative eld. An assistant standing opposite the surgeon can easily access the eld
to retract and aid as needed. These advantages may
lead to less blood loss in procedures such as the
perineal portion of a proctectomy. The prone position limits the anesthesia provider’s access to the
patients airway, can limit ventilation compared to
other operative positions, and can limit venous
return in patients who are pregnant or have signicant cardiac disease. Hence, patients with these
conditions or who need signicant sedation without the desire for endotracheal intubation may be
best suited for other operative approaches.
Lithotomy position is often preferred by anesthesia providers, given it allows optimal airway
access for any choice of anesthetic technique.
The patient is rst placed in the supine position,
usually with the arms secured bilaterally on arm
boards. The legs are then placed in stirrups, with
the thighs exed nearly ninety degrees (Fig.6.3).
The sacrum, knees, and feet are padded to prevent pressure ulceration and neurologic damage.
Lithotomy position can be advantageous to
the colorectal surgeon in procedures where the
dissection occurs posterior to the operative incision, such as transvaginal or transperineal
approaches to rectocele repair, or in mobilizing a
posterior endorectal advancement ap for cryptoglandular stula disease. Lithotomy also allows
better exposure to the groin and legs for harvesting Martius or gracilus aps to repair rectovaginal stulas. Although the operative workspace
between the legs limits accessibility for a surgical
assistant, use of an operative table or tray between
the surgeon and patient allows the surgeon to
have the necessary operative instruments near the
eld to allow the technician to focus on retraction
and exposure (Fig.6.4).
The left lateral or Sims’ position can be useful
in selected patients (Fig. 6.5). In the authors’
6 Operative andAnesthetic Techniques
Fig. 6.3 Modied
lithotomy position
a
b
105
practice, this position is most commonly used in
patients requiring emergency anorectal procedures in the third trimester of pregnancy, or in
patients having very minor procedures such as
botulinum toxin injections or sphincterotomy in
addition to lower endoscopy. Left lateral positioning may also be a good compromise in a
patient that cannot tolerate prone positioning and
anatomic exposure is limited in lithotomy. The
patient is placed on the left side, braced with
either a bean bag, brace, or sand bags for support
of the torso. The patient’s head is positioned at
the upper away corner of the bed and the torso is
angled to position the patient’s buttocks at the
edge or slightly over the edge of the bed. The left
arm is exed with the hand toward the head, and
the right arm allowed to lay in front of the chest
after support with an axillary roll. The knees are
bent, and a pillow is placed between the knees
and lower legs for adequate support and cushioning. With the hips at the most right lateral aspect
of the bed, and with tape retraction of the buttocks, the surgeon and assistant can usually both
access the operative eld.
106
Fig. 6.4 Lithotomy position
with buttocks extended over the
edge of the table
A. J. Thorsen and J. S. Bhullar
Fig. 6.5 Simm’s position
Anesthetic Techniques
The role of anesthesia is to provide the appropriate amount of relaxation, sedation, and pain relief
while maintaining vital life functions under the
stresses of the surgical procedure. When performing anorectal surgery, these goals may be best
achieved by joint efforts of the anesthesia provider
and surgeon. Hence, a preoperative discussion
between providers and patient should lead to the
most successful outcome. The amount of sedation required may vary vastly depending on the
6 Operative andAnesthetic Techniques
107
patient’s size, airway, and opioid tolerance as well
as the specic procedure being performed [2–8].
General Anesthesia
General anesthesia is the condition in which medications are used to provide sedation, amnesia,
analgesia and paralysis to the operative patient. In
addition to the patient not being able to respond or
recall painful stimuli, muscle paralysis prevents
airway protection and spontaneous ventilation;
hence endotracheal intubation or a laryngeal mask
airway must be employed. Patients may request
general anesthesia due to modesty or fear.
Anesthesiologists may prefer to administer
general anesthesia for patients with difcult airways, poor ventilation due to obesity, or high narcotic tolerance. This bias is especially true when
these patients must be placed in the prone position. The surgeon can take advantage of general
anesthesia in several situations. General anesthesia provides complete relaxation of the pelvic
oor, which is helpful in procedures such as
transanal excision, perineal rectosigmoidectomy,
sphincter or rectocele repair, and procedures to
correct high transphincteric stulas. General
anesthesia cannot be routinely used in the placement of sacral neuromodulation leads, given the
surgeon needs to assess the patient’s motor and
occasional sensory response to lead stimulation.
Disadvantages to general anesthesia include
increased anesthetic risks to patients with signicant cardiac and pulmonary disease, postoperative
nausea and vomiting, sore throat, headache, or
shivering, and the increased costs and complexity
of care in maintaining the patient compared to
lower levels of anesthesia. The use of anticholinergics, beta blockers, or sympathomimetics interfere
with normal bladder function and can contribute to
higher rates or postoperative urinary retention.
Regional Anesthesia
Given the visceral and somatic reexogenic
innervation of the anorectum, regional spinal
anesthesia is a popular anesthetic method for ano-
rectal procedures. The typical spinal saddle block
involves injection of a local anesthetic into the
subarachnoid space. For procedures performed in
the prone jack knife position, two different techniques are employed. A hypobaric block is
administered by injecting an anesthetic solution
of a lower density than cerebral spinal uid in the
subarachnoid space between L3–4. The patient is
then quickly placed in the prone jack knife position or the block can be performed in this position. A hyperbaric block uses low doses of heavy
local anesthesia allowing a quick onset of the sensory block as well as a longer lasting postoperative analgesia. The density of the anesthetic is
increased by adding glucose to the solution.
Cephalad spread of the block can be prevented by
keeping the patient seated for 5–10min prior to
prone-jack knife positioning. With either technique, the duration of the block will depend on
the local anesthetic that is utilized.
Spinal anesthesia is contraindicated in patients
who are anticoagulated or who suffer from disorders that affect normal coagulation. It is also contraindicated in patients who have increased
intracranial pressure or active infections near the
site where the block is administered. Caution
should be used in patients with underlying neurologic or signicant cardiac disease. The sympathetic blockade from a spinal can cause hypotension;
the uids used to treat this as well as the concomitant parasympathetic block on bladder function can
contribute to postoperative urinary retention. Spinal
headaches can occur in 0.1–36% of patients who
undergo intentional dural puncture. This occurs
when the leak of cerebrospinal uid from the puncture site exceeds the rate of its production. The
headache is described as severe, worse in the
upright position, and improved with the supine
position. It may occur up to 5days after the puncture. Symptoms are initially treated with hydration,
bed rest, and analgesics. If symptoms persist, the
anesthesiologist can administer a blood patch by
injecting a small amount of the patient’s blood in the
epidural space to clot and seal the leak. The incidence of spinal headaches decreases with the use of
smaller needles in administering the block.
Although spinal anesthesia usually provides
enough analgesia and relaxation for most anorectal
108
A. J. Thorsen and J. S. Bhullar
procedures, it is not uncommon for patients to
request additional sedation during the procedure
due to embarrassment, fear, positional discomfort,
or for the desire to be unaware of operative proceedings. Despite high satisfaction in patients who
choose this mode of anesthesia, many patients fear
the use of needles near the spinal cord and decline
this method for their procedure.
Monitored Anesthetic Care (MAC)
The use of sedation with local anesthesia may
allow the anesthetist and surgeon the greatest
amount of exibility in tailoring the degree of
anesthesia to the needs of the patient. A variety of
intravenous medications are utilized; the patient
may or may not experience awareness or memory
of intraoperative events. The incidence of postoperative nausea and emesis is decreased compared
to general anesthesia, which facilitates quicker
home discharge for day surgery patients.
The risks of MAC sedation, however, are similar to those of general anesthesia; cardiovascular
complications are comparable in both groups.
Respiratory depression is the most common cause
of mortality and neurologic morbidity. Hence,
MAC is contraindicated in patients who may have
difculty maintaining their airway or respiratory
function due to underlying body habitus, disease,
cognitive dysfunction, or operative positioning.
Local Anesthesia
Local anesthesia is the use of injectable medications in the operative eld to inhibit excitation of
nerve endings or conduction of sensation by
peripheral nerves. Depolarization of nerve cell
membranes and subsequent propagation of
impulses requires sodium inux into the cell.
Local anesthetics create temporary sensory loss
by reversibly binding and inactivating sodium
channels. Potency of the anesthetic is related to
the agent’s lipid solubility; the speed of onset of
action depends on its diffusion properties through
non-neurologic tissue; and the duration of action
is dependent on drug binding properties to
sodium channel proteins. Local anesthetics exist
in both ionized and non-ionized forms based on
the pH of the environment. Given the non-ionized drug is the component that can diffuse the
cell membrane, inammatory tissues with acidic
properties may delay the onset of the block and
contribute to it being less effective. Adding low
doses of an alkalinizing agent such as sodium
bicarbonate can enhance the onset of action.
Almost all local anesthetics are vasodilators,
which contributes to faster absorption and a
shorter duration of action. Hence it is common to
counteract this effect with the use of epinephrine
in the anesthetic solution.
The most common local anesthetics used in
anorectal surgery are lidocaine and bupivacaine.
Their properties are shown in Table 6.1.
®
Liposomal bupivacaine (Exparel
, Pacira
Pharmaceutocals, Parsippany, NJ) has recently
become available at some centers as an additional
local anesthetic agent. By encapsulating the drug
in a multivesicular phospholipid bilayer, a predictable time release of the anesthetic can be
achieved leading to increased stability and duration of action. The use of liposomal bupivacaine
in patients undergoing hemorrhoidectomy has
been shown to delay the rst use of opioid analgesics, decrease the overall use of opiates, and
improve pain scores at 72h postoperatively compared to 0.25% bupivacaine with epinephrine [8].
Table 6.1 Local anesthetic drugs
Agent Onset Duration Maximum dose Maximum dose with epinephrine
Tetracaine 1min 2–3h 20mg
Lidocaine 2–5min 30–45min 5mg/kg 7mg/kg
Mepivacaine 2min 1.5–3h 3mg/lb (400mg)
Prilocaine 2min 2h 8mg/kg
Bupivacaine 30min 2h 2mg/kg 4mg/kg
Procaine 5–10min 15–30min 10mg/kg
Liposomal
Bupivacaine
30min 48–72h 266mg (with 133mg
bupivacaine)
266mg
6 Operative andAnesthetic Techniques
109
A perianal block can be administered with
several different techniques. One method
involves puncture of the sphincter complex in
the anterior and posterior midline positions, and
distributing the anesthesthetic in a fan shaped
pattern from these sites. The perianal skin is also
circumferentially anesthetized. Diaz-Palacios
and Eslava-Schmalbach [5] describe a second
two-puncture technique: In the left lateral and
right lateral positions, the needle is advanced
through the skin, subcutaneous tissue, and submucosal space. Anesthetic is deposited as the
needle is withdrawn. A subcutaneous block is
then performed at both puncture sites, directing
the needle posteriorly and anteriorly; rm pressure to the anus is then applied for 3 min to
improve the spread of medication through the
tissues. Brunat etal. [7] describe a posterior perineal block performed by puncturing the skin
2cm posterior to the posterior midline to a depth
of 5 cm, accessing the presacral compartment
and blocking the anococcygeal nerves. The needle is then redirected laterally at a 45-degree
angle into each ischiorectal fossa to a depth of
5cm to block the inferior hemorrhoidal and posterior pudendal branches (Fig.6.6). The block is
completed by left lateral and right lateral supercial skin punctures to administer a subcutaneous block in a fan-like distribution on each side.
Bilateral pudendal nerve block with the use of a
nerve stimulator is described by several authors
but is not widely utilized in the United States. A
blinded block can be performed by palpating
each ischial tuberosity intrarectally with the nondominant index nger. Using a 22 gauge spinal
needle, 5–10cc of solution is injected around the
nerve medial to this landmark.
Complications from local anesthetics are rare
but should be recognized. Peripheral vasodilation and myocardial decompression should be
treated with intravenous uids and vasopressors.
Cardiac conduction abnormalities should be
noted and addressed. Neurologic toxicity manifested with restlessness, vertigo, tinnitus, and
slurred speech can progress to CNS depression
and seizures. In this situation, the airway should
be secured, ventilation should be optimized, and
seizure activity addressed with repeated dosing
diazepam.
Lighting
Proper lighting has always remained a critical
help in anorectal surgery. Weak or improper
lighting could result in dissection in the wrong
planes and troublesome bleeding which leads to
intraoperative and postoperative complications.
In many anorectal procedures, the rectum can
appear to be a deep, dark tunnel that is not easily
illuminated to satisfactory levels. Standard overhead lighting found in most operating rooms
does not sufce for anorectal surgery; even with
proper positioning, it is frequently eclipsed by
the head or hands of the operating surgeon and/
or the assistant preventing adequate visualization of the anal canal. To overcome this problem, it is recommended that the surgeon should
use either a good headlight (Fig. 6.7), lighted
retractors, or both as they are effective in maintaining adequate illumination for anorectal
procedures.
There are many commercially available beroptic headlights—some examples are Luxtec
(Luxtec Corporation, Technology Park,
Sturbridge, Massachusetts) and Cogent Light®
(Santa Clarita, California). Some cordless headlights are also available, but most have a restricted
battery life and the illumination is usually not at
par with the beroptic lights. A variety of beroptic illuminated retractors are also available
(Pilling Company, Fort Washington, PA).Fig. 6.6 Transanal placement of pudendal nerve block
®
110
A. J. Thorsen and J. S. Bhullar
Fig. 6.7 Welch Allyn headlight
It is recommended that at the start of the case
the surgeon should focus the headlight. Ideally a
properly adjusted headlight should focus the light
along the surgeon’s line of sight thus illuminating
the operative eld and preventing the surgeon’s
hand maneuvers from hindering adequate visualization. Additionally, as the beam of light
descends through the surgeon’s line of sight, the
shadow created by the surgeon’s head frequently
positioned between the standard overhead light
and the operative eld is eliminated thus allowing
better illumination of the operative area.
For a colorectal ofce practice, using a headlight is also recommended while examining
patients. The typical ofce examining room has
less adequate lighting than most operating rooms.
The use of a headlight in the examining room is a
good and easy solution of this problem. While a
variety of cordless headlights are commercially
Fig. 6.8 Lighted anoscopes
available, the authors have found the rechargeable
Welch Allyn (Welch Allyn, Inc., Skaneateles Falls,
NY) physician headlight to be an excellent and
inexpensive light source for anorectal examination
in the ofce setting (Fig.6.7). This bulb-type (nonberoptic) light allows focusing directly into the
anal canal. Good lighting is essential to provide
adequate illumination examining the patient, as it
may lead to incomplete or even inaccurate diagnosis that may alter overall management.
An alternative to using a headlight in the ofce
the lighter anoscope. The authors use the single
use, disposable, lighted anoscopes (Fig. 6.8)
which are commercially available in different
sizes—slotted and beveled versions (ANOSPECOBP Medical Lawrence, MA). The light is good
for 30–45 min and can be used for the ofcebased procedures like diagnostic anoscopy
(Fig.6.9) and hemorrhoidal banding (Fig.6.10),
without the need for a headlight. The authors nd
the slotted type of this anoscope to be very helpful
as it is open on one side, allowing easy identication of the hemorrhoid as it falls into the lumen.
These instruments also alleviate the logistic
problems of having the instruments sterilized for
6 Operative andAnesthetic Techniques
111
the patients. Single-use lighted anoscopes are
also found to be extremely helpful in evaluating
the hospitalized patient at the bedside.
Instrumentation
Instrumentation designed specically for anorectal
surgery can make a big difference between a
smooth and efcient surgery and its nemesis; the
awkward, frustrating, and frequently dangerous
procedure. The instrument selection is very important and is based on the setting (ofce vs. operating
room), the pathologic condition being treated, and
the surgeon’s preference. The basic instruments
needed for the anorectal surgery consist of anoscopes, speculums, retractors, and supporting surgical instruments, which include the needle holders,
sutures, forceps, suction and electrocautery.
Fig. 6.9 Ofce anoscopy
Fig. 6.10 Hemorrhoidal banding
Anoscopes
There is a big distinction between the instruments
that are used in the ofce and those used in the
operating room. The instruments used in the
ofce are generally smaller in caliber compared
to operative instruments to ensure patient comfort. They are adequate for diagnostic work but
do not offer enough exposure for most operative
maneuvers. Many practicing colorectal surgeons
use the Vernon-David anoscope (Becton,
Dickinson and Company, Franklin Lakes, NJ)
modied with the handle of the Hirschman anoscope as their ofce anoscope (Figs. 6.11 and
6.12). The conventional Hirschman anoscopes
are preferred by some surgeons.
The Hinkel-James anoscope (Sklar Medical
and Surgical Instruments, Issaquah, WA) is used
by many for rubber-band ligation of the hemorrhoids (Fig.6.13). It is longer and provides a larger
diameter orice through which to manipulate the
ligating instrument. Despite its length, it is tapered
to allow for excellent tolerance by the patient.
There are different types of hemorrhoidal banding instruments. The authors prefer a suction type
hemorrhoidal gun, which allows the surgeon to
hold the anoscope and hemorrhoid gun simultaneously (Fig. 6.14). Many surgeons prefer directly