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112
Fig. 6.11 Vernon-David
anoscope
Fig. 6.12 Hirschman
anoscope
A. J. Thorsen and J. S. Bhullar
Fig. 6.13 Hinkel-James anoscope
Fig. 6.14 Suction hemorrhoidal banding gun
grasping the mucosa to be banded; in this case, a
McGivney hemorrhoid bander (Medline Industries)
with grasping forceps is used. An assistant must
provide exposure by holding the anoscope while
the surgeon controls the forceps and bander.
6 Operative andAnesthetic Techniques
Fig. 6.15 Pratt (left)
and Fenestrated (right)
speculum
113
Speculums
Speculums are usually used only in the operating
room for anesthetized patients (Fig. 6.15).
Different types of speculums—including bi- or
tri-valved are available. Speculums can pinch
mucosa and thus are poorly tolerated in an
unanesthetized patient. This limitation is particularly true of fenestrated speculums. The authors
recommend the nonfenestrated bi-valve type
instrument, such as the Pratt, as it is very useful
in evaluating the anesthetized anal canal. With
gentle dilation, it can be slowly opened to allow a
wide operative eld. Opening it to a mild degree
of tension allows the accurate and rapid identication of the caudal edge of the internal sphincter, which can be palpated as a rm cord. This
technique is very useful when performing internal sphincterotomies and during rectal mucosectomies. Nasal speculums can be useful in
instances of severe stenosis where a speculum the
size of a Pratt instrument (Sklar Surgical
Instruments, West Chester, PA) cannot be placed
in the anal canal.
The Fansler operative anoscope is preferred
by some colorectal surgeons for operative hemorrhoidectomy (Fig. 6.16). It provides an ample
operating eld to one side of the anal canal while
all other quadrants are tucked neatly behind the
lumen of the remainder of the instrument.
However, this instrument is too large to be used
in the unanesthetized canal. A lighted version of
this instrument is also available. The authors have
a preference of using the Pratt for the
hemorrhoidectomy as the amount of opening of
the anal canal can be controlled, unlike the
Fansler, which is helpful while suturing in the
anal canal.
Retractors
Many types of anal retractors, which are
available. The Sawyer (Medline Industries),
Hill-Ferguson (Sklar Surgical Instruments)
(Fig. 6.17), Ferguson-Moon (V. Mueller), and
other similar retractors are alike in providing an
anal “spoon” or “cup” which exposes about
40–50% of the circumference of the anal canal.
The small size of these retractors leads to minimal dilation and distortion of the hemorrhoidal
cushions but they may limit working room for
maneuvering instruments. Some colorectal surgeons prefer a Hill-Ferguson retractor for operative hemorrhoidectomies.
Using the Fansler anoscope (Novo Surgical,
Oak Brook, IL) (Fig.6.17) can lead to bleeding
vessels hidden by the tamponade of the instru-
114
Fig. 6.16 Fansler
anoscope
A. J. Thorsen and J. S. Bhullar
Fig. 6.17 Hill Ferguson retractor
ment. In such a situation, the judicious use of a
Ferguson-Moon or Pratt bivalve type retractor
often allows the identication and control of the
bleeding vessel as the anal canal is not subjected
to the same stretch and compression as with the
Fansler instrument.
Fig. 6.18 Buie-Smith retractor
Several self-retaining anal retractors, such as
the Buie-Smith (Medline Industries) (Fig.6.18)
and Parks’ (Fig. 6.19) are occasionally used in
transanal excisions and mucosectomies. It is generally thought that the frames of such retractors
can interfere with the instrumentation necessary
6 Operative andAnesthetic Techniques
Fig. 6.19 Parks’ retractor
Fig. 6.20 Lone Star Retractor (Cooper Surgical, Trumbull,
CT)
to accomplish the desired task; anal eversion
can be preferable in these situations (especially
with mucosectomies). Eversion can be accomplished by using four to six heavy silk sutures
placed at intervals from either the dentate line
or anal verge to well out on the buttocks.
The Lone Star Retractor (Fig. 6.20) has
become popular as it can perform the same
function and has conveniently packaged several
types of elastic retractor hooks. The Lone Star
Retractor is disposable, self-retaining and
adjustable, providing exposure in the perineum
for vaginal and colorectal procedures. The
authors nd this a critical tool in performing
more advanced anorectal surgeries, such as an
overlapping sphincteroplasty or perineal
rectosigmoidectomy.
115
Supporting Material
Other considerations include selection of proper
needle holders, suture material, needles, forceps,
clamps, and cautery equipment.
The needle holder must be personally selected
to the preference of the surgeon. In general, however, it must have adequate length to reach
beyond the depth of the retractor being used
while allowing the operator’s hand to remain
completely external to the anal canal. Thus, a
nine-inch instrument of medium weight is usually preferred.
Depending upon surgeon preference and type
of surgery being performed, absorbable suture
material of chromic catgut, vicryl or polydioxane
suture (PDS) is preferred. Suture removal is not
required and absorption is at a rate that will allow
wounds to open in case of infection rather than
serving as a site for abscess formation. The
authors prefer 3–0 suture for most hemorrhoidal
and anal canal work. Slower absorbing polyglycolic suture material is more frequently used for
low rectal work including transanal excisions and
anal anastomoses.
When suturing is conned to the perianal skin,
a cutting needle is preferred; when suturing the
rectal mucosa, a taper needle is preferred. For
hemorrhoidal surgery, when the incision to be
closed extends across both columnar and squamous epithelium, a taper-cut needle is preferred.
It is less likely to tear the rectal mucosa than is a
cutting needle and will still allow penetration of
the perianal skin.
Many surgeons use Debakey forceps (Sklar
Surgical Instruments) for tissue handling. Some
type of toothed forceps (e.g. Cushing) should be
readily available in instances of complicated and
edematous hemorrhoids and when operating for
stulae. An Allis or Babcock clamp is indispensable when operating in a scarred eld or in the
presence of brotic tissue. They are particularly
useful when elevating tissue, whether a hemorrhoidal cushion or a mucosal advancement ap.
To complete the basic anorectal surgery tray,
an assortment of probes for use in identication
and treatment of stulas is necessary (Fig.6.21).
It is helpful to have a malleable probe available
116
Fig. 6.21 Fistula
probes
A. J. Thorsen and J. S. Bhullar
in the operating room for investigating and documenting the pathway of a stula. A ne malleable probe with an eye at one end is helpful when
placing a seton. Lockhart-Mummery grooved
retractors (Sklar Surgical) are ideal for laying
open a stula once its course has been conrmed.
Special instruments and armamentarium are
needed when operating for stula in ano [9]. For
the initial identication of the stulous tract, a
22-sized Angiocath (Medline Industries) is used
to inject the external stulous opening. The
injecting liquid can be diluted hydrogen peroxide, milk or diluted methylene blue. All these
three have their advantages and disadvantages.
While the hydrogen peroxide can be easily identied in the anal canal and can also open small
stulous openings, excessive bubbling can
obscure the operative eld. Some colorectal surgeons use milk as it does not cause bubbling and
the white color can help with an easy identication of the internal stulous opening. Methylene
blue stains the stulous tract in addition to helping identify the internal opening but can cause
extensive staining of the anal canal and operative
eld.
Seton techniques occupy an important position in the treatment of anal stulas. A seton can
be any type of foreign material inserted through a
stulous track. Prolene suture, a Penrose drain,
silk suture, and rubber bands have been described
in the literature from all over the world. Previously
used cutting setons like silk have fallen out of
favor in view of sphincter damage resulting from
their use and most surgeons prefer a non-cutting
seton in their practice. Colored vessel loops are
presently the most common seton used in our
practices. These are made of soft rubber, which is
well tolerated by patients. This seton helps with
maturation of the stulous tract while also helping with adequate drainage. Vessel loops are easily available in most operating rooms and can be
made into a loose loop with silk suture.
The appropriate application of electrosurgery
to operations on the anal canal provides rapid,
effective hemostasis. The monopolar hand-activated bayonet-type cautery unit is particularly
helpful when performing hemorrhoidectomy. Its
use is ideal in allowing the simultaneous control
and cauterization of bleeding vessels. A bladetype unit is much more effective when cautery is
used for tissue cutting such as when elevating
aps or unroong chronically inamed stula
tracks. A needle tip cautery is helpful when
coring out stula tracks as described by Parks.
However, this tip does increase the risk of
“needle stick” injury. This is best avoided in
6 Operative andAnesthetic Techniques
117
high-risk patients and when practicing universal
precautions. Newer means of achieving hemostasis during hemorrhoid surgery include reusable
bipolar scissors and the disposable Harmonic
Scalpel® (Ethicon, Cincinnati, OH) and
LigasureTM vessel sealing device (Medtronic,
Minneapolis, MN). Advantages of the bipolar
scissors include precise application of electrical
current between the scissor blades, assisting in
the maintenance of a hemostatic hemorrhoidectomy. Ultrasonic and advanced bipolar energy
devices achieve hemostasis without thermal
injury to the tissue. While both instruments allow
a relatively “bloodless” eld, even during hemorrhoidectomy, they do increase the cost of the
operation. Their cost may be better justied when
performing a perineal rectosigmoidectomy, given
they save operative time by avoiding repetitive
clamping and tying of suture.
Gauze sponges are essential for keeping a clear
operative eld. Although suction is very helpful at
the operating table, surgeons make liberal use of
sponges in association with the cautery to control
hemostasis. The size of the sponge is critical to
effective use in the anal canal: unopened “4 X 4”
or laparotomy sponges are too large to pass through
the operative scopes, while “2 X 2” sponges cannot absorb enough blood to be helpful and are easily lost in the rectum. The 3in X 3in sponge is
helpful when operating in the anal canal and
should always be available in sufcient quantity.
References
1. Goldberg SM, Gordon PH, Nivatvongs S.Essentials
of anorectal surgery. Philadelphia: JB Lippincott;
1980. p.80.
2. Summeral WD, Beck DE. Anesthesia and intraoperative positioning. In: Kann BR, Whitlow CB, Margolin
DA, Vargas HD, Beck DE, editors. Improving outcomes in colorectal surgery. 2nd ed. Boca Raton:
Tayler and Freancis; 2018. p. 23–34.
3. Thorson AG, Blatchford GJ.Operative and anesthetic
techniques. In: Fundamentals of anorectal surgery.
2nd ed. Philadelphia: WB Saunders; 1998.
4. Dripps RD, Eckenhoff JE, Vandam LD, editors.
Introduction to anesthesia: the principles of safe practice. 7th ed. Philadelphia: WB Saunders; 1988. p.221.
5. Diaz-Palacios GA, Eslava-Schmalbach JH.Perirectal
block for out-patient anorectal surgery: a new technique. Biomedica. 2011;311:196–9.
6. Reshma PJ, Begani MM.Proctologic surgery as day
care: 8 year experience of a successful day care centre. Bombay Hosp J. 2008;50:179–83.
7. Brunat G, et al. Posterior perineal block with
ropivacaine 0.75% for pain control during and
after hemorrhoidectomy. Reg Anesth Pain Med.
2003;28:228–32.
8. Haas E, et al. A double-blind, randomized, activecontrolled study for post-hemorrhoidectomy pain
management with liposome bupivacaine, a novel local
analgesic formulation. Am Surg. 2012;78:574–81.
9. Subhas G, Singh Bhullar J, Al-Omari A, Unawane
A, Mittal VK, Pearlman R.Setons in the treatment of
anal stula: review of variations in materials and techniques. Dig Surg. 2012;29(4):292–300.
Functional Anorectal Disorders
BrianL.Bello, D.OwenYoung, andAnjaliS.Kumar
7
Introduction
drome, solitary rectal ulcer syndrome, hemorrhoids
and even fecal incontinence, commonly present as
Functional anorectal disorders generally arise from
or result in abnormal defecatory habits. Many anorectal manifestations, such as a non-relaxing
puborectalis muscle or anismus, rectal prolapse or
intussusception, rectocele, perineal descent syn-
Table 7.1 Treatment options for functional anorectal disorders
Medical Nonsurgical interventions Surgical
Anismus Fiber and bulking agents
Biofeedback
Perineal descent Fiber and bulking agents
Biofeedback
SRUS Fiber and bulking agents
PEG
Biofeedback
Sigmoidocele Biofeedback Sigmoidectomy
Botulinum toxin
Anal dilation
Perineal devices Posterior perineorrhaphy
constipation, though specic treatment is dictated
by the specic condition. This chapter discusses the
syndromes of anismus, perineal descent syndrome,
solitary rectal ulcer and sigmoidocele as well as
treatment options (Table7.1).
Puborectalis division/resection
Ostomy
Transperineal approach
Retroanal levator plate myorrhaphy
Ostomy
Ventral rectopexy
B. L. Bello
Colorectal Surgery Program, MedStar Washington
Hospital Center, Washington, DC, USA
D. OwenYoung
Pacic Medical Centers, Seattle, WA, USA
A. S. Kumar (*)
Washington State University, Elson S. Floyd
College of Medicine, Everett, Spokane, Tri-Cities,
Vancouver, WA, USA
© 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_7
119
120
B. L. Bello et al.
Anismus
Anismus—also called ‘puborectalis syndrome,’
‘spastic pelvic oor syndrome,’ ‘non-relaxing
puborectalis syndrome,’ and ‘dyssynergic defecation’—describes ineffective defecation in patients
in whom the puborectalis muscle does not relax.
Patients present with chronic constipation with
the feeling of incomplete evacuation, and often
times using digital maneuvers to facilitate defecation. On physical exam, the resting and squeeze
tone can be assessed. The patient should then be
asked to push to mimic defecation—the examiner
should feel the relaxation of the external sphincter
and puborectalis muscle. If this is absent, anismus
is suspected. The pathophysiology and diagnostic
evaluation for anismus is discussed in detail in
other sections of this textbook. Paradoxical contraction of the puborectalis muscle is a key nding
in anismus, although a subset of these patients
develop puborectalis hypertrophy, adding an
organic element to this functional disorder.
The initial treatment for anismus is dietary
ber and bulking agents, such as psyllium, methylcellulose, calcium polycarbophil or wheat dextrin. Laxatives and enemas may also be used.
Although simple and inexpensive, the efcacy of
these agents is unclear, as studies are confounded
by inclusion of all patients with chronic constipation or obstructive defecation without subset
analysis of anismus patients [1, 2].
Low-cost and low-risk, biofeedback therapy is
another cornerstone of anismus treatment.
Published results of successful outcomes with biofeedback therapy range widely between 8–93%
[3–8]. The variability is likely because many different selection criteria, treatment protocols, outcome measurements, and lengths of follow-up are
used in these studies. Moreover, not all patients are
able to nish the entire biofeedback treatment
course [9]. Nevertheless, recent prospective trials
demonstrate an advantage to biofeedback when
compared to placebo, diazepam, diet, exercise and
laxatives for anismus [10–13].
Botulinum toxin A (BTX-A) injection, available since the 1980s, is another option for treating anismus [14]. As with biofeedback, there is
marked variation in the literature in patient selection, technique, outcome measurement, and follow-up for botulinum treatment of anismus. The
original method describes placing the toxin into
both sides of the puborectalis and the external
anal sphincter, but subsequent modications
include the use of ultrasound or electromyography to help target injection sites. Wide ranges in
dosing are reported (6–100 units per injection)
[14, 15]. There is likely a role for repeat injections due to the temporary nature of BTX-A [15–
17]. Overall, treatment efcacy has been 25–95%
with both subjective and objective outcomes
[16–19].
A prospective randomized trial has examined
BTX-A versus biofeedback in anismus. BTX-A
was initially more successful (70% clinical
improvement versus 50% for biofeedback), but at
1 year the efcacy of both treatments was less
than 33% and there was no longer any signicant
difference [19], highlighting the potential for
repeat BTX-A injections.
For those patients who do not respond well to
biofeedback or BTX-A, puborectalis hypertrophy may need to be addressed as a component of
their therapy. Anal dilation may be a useful
adjunct in these patients. In one case series, 13
patients serially dilated themselves using dilators
of 20, 23, and 27mm for 10min each, every day
over 3months. This approach led to an improved
number of weekly bowel movements and
decrease in laxative use and enema use. Pressure
during straining was also decreased in follow-up
manometry. Zero of 13 patients had incontinence
at 6months [20]. However, there are no further
dedicated studies in the literature for anismus,
limiting the widespread use of this technique.
Surgical intervention for anismus is controversial and carries the potential for incontinence,
but may be useful in those patients with hypertrophic bers of the puborectalis. The original surgical approach, reported along with one of the
initial descriptions of anismus in 1964, involves
posterior division of the puborectalis muscle
[21]. This approach, as well as a modication
with only lateral puborectalis division, has been
overall disappointing in terms of high rates of
incontinence and minimal symptom improvement [22, 23].
Partial resection of the puborectalis muscle
has also been described. In one series of 149
patients, 90% were successfully treated [24]. In
this procedure, the puborectalis is approached
7 Functional Anorectal Disorders
121
through an incision from the posterior anal
verge to the tip of the coccyx. Approximately
1.5cm of the puborectalis in the posterior midline is excised and the remaining muscle ends
are ligated with suture [25]. It is important to
note that these studies were conducted over
10years ago and provided limited data on this
approach.
Alternatively, bilateral partial division of the
puborectalis has been described more recently. A
prospective study randomizing 60 patients with
anismus to biofeedback, BTX-A, or surgery
offers favorable surgical results. To address concerns about incontinence, the authors divided
only the inner half of the puborectalis on each
side. Clinical improvement was dened by no
straining, digitations, hard stool or sense of anorectal obstruction in addition to >3 BM a week.
At both 1 month and 1-year follow-up, surgery
showed more clinical improvement compared to
biofeedback and BTX-A (95% versus 50% and
75%, at 1month; 70% versus 30% and 35%, at
1year, respectively). In contrast to earlier studies, fecal incontinence was noted in only 10% of
patients [26]. More studies need to be done to
verify the clinical improvement and low incontinence rate in this study.
Finally, a diverting ostomy remains a consideration for severe anismus refractory to the other
treatments. Figure 7.1 proposes a simple treatment algorithm for anismus with primary focus
on nonsurgical management.
Perineal Descent Syndrome
Perineal descent syndrome (PDS) is marked by
bulging or ‘ballooning’ of the perineum during
straining (though rarely it can present at rest as
well). Perineal descent is the caudal movement of
the pelvic oor in reference to the pubococcygeal
line (the imaginary line between the tip of the
coccyx and the pubic symphysis). Generally, the
diagnosis of PDS is established in patients with
trouble defecating and perineal descent of more
than 3–5cm (Fig.7.2) [27, 28].
These patients have chronic constipation with
excessive straining; most patients are women and
up to 75% have undergone hysterectomy [29,
30]. They frequently describe a feeling of partial
rectal emptying that leads to continued, albeit
ineffective, efforts to evacuate; these efforts may
include digital self-disimpaction. Anterior rectal
wall prolapse may create discharge and perineal
irritation. The continued descent of the perineum
may cause stretch injury of the pudendal nerve
and neuropathy [31–34]. The chronic sequelae of
these repetitive behaviors cause a further weakening of the pelvic oor, exacerbating the underlying problem and leading to a ‘vicious cycle’
that in many instances culminates in fecal
incontinence.
Fig. 7.1 Treatment algorithm for anismus
Fig. 7.2 Perineal descent syndrome. The pelvic oor is
bulging well below the pubococcygeal line (solid line)
and curved arrow is direction of descent
122
Though a perineometer was historically used
to estimate perineal descent [35], defecography
has become the standard diagnostic tool. The
choice between conventional uoroscopic defecography and MR defecography has been studied.
Both are accurate in PDS diagnosis, though conventional defecography utilizes a physiologic,
upright position during straining (versus supine
in traditional MRI). This has to be balanced
against the advantages of MRI: multi-planar,
multi-compartmental images, direct depiction of
surrounding musculature, and absence of nonionizing radiation [36–39]. Recently, open MRI,
which allows MR defecography in the upright
position, has become more available. Several
studies have shown accurate assessment of PDS
using the open conguration [40, 41].
PDS is difcult to treat and can be frustrating
for both patient and clinician. Non-operative
treatments are preferred, and these focus on elimination of straining with dietary modication and
bulking agents, enemas, and biofeedback therapy
Fig. 7.3 Treatment algorithm for perineal descent syndrome. STAPL Stapled trans-anal prolapsectomy associated with perineal levatorplasty; STARR Stapled transanal
rectal resection; TRREMS Transanal repair of rectocele
and rectal mucosectomy with a single circular stapler
[42]. Perineal devices, such as the ‘Defecom’ and
‘Colorec’—modied commodes that have perineal support—may also be employed [43, 44],
though they are not widely available and have
little supporting data (Fig.7.3).
Success rates with biofeedback have ranged
from 29 to 80% [42, 44, 45]. Some literature suggests that biofeedback is more helpful in patients
with less severe perineal descent [44]. One study
found that the responders to biofeedback had a
mean descent of 3.3 cm compared to the nonresponders, whose mean descent was 4.9 cm
[42]. In fact, for patients with more severe descent
and fecal incontinence—which is usually a late
nding in patients with PDS—the initial benets
underwent abdominal sacral colpoperineopexy.
In this procedure, the lax perineal body is digitally elevated by the surgeon’s nger in the
vagina. Mesh is sutured to the posterior vaginal
wall far enough down to securely engage fascia
and then secured to the sacral promontory, thus
acting as a suspensory mesh (Fig.7.4a). This is
similar to a sacrocolpopexy. A culdoplasty (closing the space between the rectum and vagina) is
also performed. In short-term follow-up, symptoms improved in most patients [46]. A laparoscopic version of this technique was later
performed successfully in a patient with both
PDS and vaginal vault prolapsed (Fig.7.4b) [47].
of biofeedback seem to deteriorate between 6 and
30 months after treatment. These patients may
benet from additional biofeedback [45].
Surgery has no role to cure PDS.The multiplicity of surgical approaches underscores the
lack of an optimal operation; each has limited
efcacy and signicant morbidity.
Multidisciplinary collaboration is advisable. One
of the largest series in the literature has 19
patients diagnosed with vaginal vault prolapse
and varying degrees of perineal descent who
perineorrhaphy (apposing the levator muscles,
puborectalis, and sphincter muscle behind the
anal canal) [48], a transperineal approach (plication of the posterior rectum with xation to the
presacral fascia and reapproximation of the levators in the posterior midline) (Fig.7.4c) [49], and
retroanal levator plate myorrhaphy (suturing
together of the levator plates bilaterally between
the coccyx and the anorectal junction to restore
the anorectal angle) (Fig.7.4d) [50].
B. L. Bello et al.
Other perineal operations include posterior