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►Содержание►
CHAPTER20
PerinealRectosigmoidectomy
JulieAnnVanKoughnett
PARTVI Sphincterotomy–Lateral
CHAPTER21
OpenLateralInternalSphincterotomy
SurajAlvaandBertramT.Chinn
CHAPTER22
ClosedLateralInternalSphincterotomy
SeanJ.LangenfeldandJoshuaI.S.Bleier
PARTVII PresacralTumors
CHAPTER23
TechnicalConsiderationsintheSurgicalManagementof PresacralTumors
SkandanShanmuganandNajjiaN.Mahmoud
PARTVIII LocalExcisionofRectalCarcinoma
CHAPTER24
StandardTransanal
StevenR.Hunt
CHAPTER25
TransanalEndoscopicOperating
DeborahS.KellerandSamAtallah
CHAPTER26
TransanalEndoscopicSurgery
LuanneM.ForceandDanaR.Sands
CHAPTER27
TransanalMinimallyInvasiveSurgery(TAMIS)forLocalExcision
MatthewR.AlbertandLawrenceLee
PARTIX Rectocele
CHAPTER28
RectoceleRepair:Transvaginal
NeerajaChandrasekaranandG.WillyDavila
CHAPTER29
Rectocele:TransanalRepair
SthelaM.Murad-RegadasandRodrigoA.Pinto
CHAPTER30
SurgicalTreatmentofRectocele:TransperinealRepair
GuillermoO.RosatoandCarinaM.Chwat
CHAPTER31
RectoceleRepairwithMesh
CliffordL.SimmangandJenniferK.Lowney
CHAPTER32
StapledTransanalRectalResection
NasiraAmtul,DavidG.Jayne,andAntonioLongo
CHAPTER33
Transtar
NasiraAmtul,DavidG.Jayne,andAntonioLongo
CHAPTER34
TRREMSProcedure—TransanalRepairofRectoceleandFull RectalMucosectomywithOneCircularStapler
F.SergioP.RegadasandF.SergioP.RegadasFilho
PARTX MuscleFlaps
CHAPTER35
GluteusMaximusTransposition
StephanieL.KoonceandMiguelA.MedinaIII
CHAPTER36
TransabdominalRectusFlaps
MartinI.NewmanandNathanEberle
CHAPTER37
GracilisMuscleFlaps
ChayaShwaartzandOdedZmora
CHAPTER38
VentralHerniaRepair
StevenG.Leeds
PARTXI AnalandPilonidalFlaps
CHAPTER39
House,Diamond,V-YFlaps
AnuradhaR.BhamaandScottE.Regenbogen
CHAPTER40
EndorectalAdvancementFlaps
MaherA.AbbasandMatthewJ.Sherman
CHAPTER41
SleeveAdvancementFlap
DavidJ.Maron
CHAPTER42
HouseFlapAnoplastyforBowen’sDisease
CaryB.AaronsandJoshuaI.S.Bleier
CHAPTER43
CleftLiftProcedureforPilonidalDisease
KimC.Lu
CHAPTER44
Incision,Excision,andWoundVACClosure
DeborahS.KellerandMichaelPendola
CHAPTER45
SurgicalManagementofAnogenitalHidradenitis
DanaM.Hayden
CHAPTER46
CondylomaAcuminata
MichaelJ.Grieco,MitchellA.Bernstein,andAlexisL.Grucela
CHAPTER47
AnalCarcinomaandMelanoma
AmyL.LightnerandMarkL.Welton
Index
PARTI
HEMORRHOIDECTOMY
Chapter1
FergusonHemorrhoidectomy
AnthonyJ.Senagore

INDICATIONS/CONTRAINDICATIONS

Themostfrequentsymptomsleadingtosurgicalinterventionfor hemorrhoidalsufferersarebleeding,protrusion,andanorectal discomfortandpain.
Bleedingtypicallybrightredblood(notedonthetoiletpaperordripping intothecommode).
Occasionallymassivebleedingwithverylargeinternalhemorrhoids. Prolapseofhemorrhoidsusuallywithbowelmovementsandmay
spontaneouslyreduce,requiremanualreduction,orbeirreducible dependingonstage;typicallyeithertoolargeforrubberbandligationor havefailedrubberbandligation.
Severe,constantpainisusuallyrelatedtoacutethrombosisofinternalor externalhemorrhoidsandassociatedwithapalpableperianalmass.
ThereareafewcontraindicationstoperformingaFerguson hemorrhoidectomyinapatientinadditiontomedicalcontraindications toasurgicalprocedure,thepresenceofulcerativecolitisorCrohn’s disease,orportalhypertension.Ahistoryofpelvicradiotherapycanbe consideredarelativecontraindicationaswell.
PREOPERATIVEPLANNING
Componentsinclude:
Examinationofthepatientwithhematocheziarequiresinspectionofthe perianum,anoscopy,andeitherrigidproctoscopyorflexible
sigmoidoscopy.Colonoscopycanbereservedbaseduponpatienthistory, age,orsuspicioussymptomatology.
TheauthorprefersexaminationinthemodifiedSim’sposition(left lateraldecubituswithkneesdrawntowardthechestandlowerlegs
extended).Thisapproachallowsrelativepatientcomfort,whileallowing thecliniciantoperformallcomponentsoftheanorectalexamination.
Acarefuldigitalexaminationoftheanalcanalanddistalrectumand prostateinmen.
Anoscopytoclearlyinspectthehemorrhoidaltissueandanalcanalwith assessmentofsize,degreeofprolapse,andbleedingtendency.
Assessmentofthethreestandardcolumns(rightanterior,right posterior,andleftlateral).
Proctoscopy/flexiblesigmoidoscopytoexcludeneoplasiaor inflammation.
p.1
p.2
Decisiontooperate
Thedecisiontoproceedtoexcisionalhemorrhoidectomyrequiresa mutualchoicebythephysicianandpatientthatmedicaland
nonexcisionaloptionshaveeitherfailedorarenotappropriate. Surgeryistypicallyemployedwhentheprimarysymptomissignificant,
intractablehemorrhoidalprolapse,associatedwithlargeexternalskin tagsthatimpairanalhygiene.
Preoperativepreparationisminimalifthepatientisgenerallyhealthy andtheprocedureistypicallyambulatory.
Thepatientontherapeuticanticoagulationshouldbemanagedin conjunctionwiththemanagingphysiciantocontroltheriskof
hemorrhagepostoperatively.
Theproceduresareusuallyperformedintheoperatingtheaterafter preoperativephosphateenematoclearthedistalrectumofstool.
ThemodifiedSim’spositionisthepreferredpositionbytheauthor. Anestheticselectionisusuallylefttotheanesthesiologistandpatient;
however,localanesthesiasupplementedbytheadministrationof intravenousnarcoticsandpropofolishighlyeffectiveandshortacting.
Avoidspinalanesthesiaduetoriskofurinaryretention. Itisimportanttocommunicatewiththeanesthesiologisttolimit
intraoperativefluidsto<500mltoreducetheriskofpostoperative urinaryretention.
Administerpreemptiveanalgesiawithnonsteroidalanti-inflammatory drugs(NSAIDs),acetaminophen,andgabapentinpriortoarrivalfor
surgeryandthesameregimencanbecontinuedpostoperatively.

SURGERY

Instrumentationforexcisionalhemorrhoidectomy:
Theclassicinstrumentofperformanceofanexcisional hemorrhoidectomyhasbeencoldscalpelwithorwithoutscissor
dissection.Theapproachishighlyeffectiveandoflowcostcompared withotherdevices.Avarietyofenergydeviceshavebeenusedwith varyingclaimsofsuperiorspeed,reducedbleeding,andlesspain.Each ofthedevicesaddsexpensewhichinthecurrentreimbursementmilieu canverynegativelyimpacteconomicefficiencycomparedwiththe scalpel/scissortechnique.Thedataremainhighlydebatedandthe author’spreferenceistousecoldsteel.
Nd-YAGlaser—Althoughcapableofexcisinghemorrhoidaltissue,the devicewasfoundtobeslower,morecostly,andactuallydelayedhealing
ofthewoundleadingtoincreasedpainandisnolongerrelevantforthis procedure.
Monopolarelectrocautery—Thedeviceisaneffectiveexcisionaltool capableofimprovedhemostasiscomparedwithascalpel.Itcanallow
transectionofthehemorrhoidalpediclewithoutsutureligationatthe expenseofgreatertissuetraumaduetolateralthermalspread.
LigasureTM(Medtronic,Minneapolis,MN)—Abipolarcauterydevice capableofsimultaneoustissuedivisionandsealingandbloodvessel
coagulation.ThemethodattemptstoduplicatetheFergusonapproach, buttheremaybeinconsistenttissuecoaptation.Theproposedbenefitsof fasterORtimes,suturelesstechnique,andlesspainhavenotbeen clearlydocumented.
Harmonicscalpel—Thedeviceemploysarapidlyreciprocatingbladeto generateheatforcoagulationandtissuetransection.Thedeviceis
relativelyexpensiveandhasnotdemonstratedsignificantclinical advantagestooffsetthatcost,primarilyduetotheassociatedthermal tissueinjury.
PatientPositioning
Theauthor’spreferredpositionforFergusonhemorrhoidectomyisthe leftlateral,modifiedSim’sposition.Thispositionallowsforeasysurgical accesstotheanalcanalwhileallowinganesthetizingwithaneasyaccess totheairway.Attheendofthecase,thepatientcanbequicklyandsafely rolledbackontotheirgurneyfortransporttotherecoveryarea.Some
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