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RECOMMENDEDREFERENCESAND READINGS
BruscianoL,AyabacaSM,PescatoriM,etal.Reinterventionsaftercomplicatedorfailedstapled
hemorrhoidopexy.DisColonRectum2004;47:1846–51. BurchJ,EpsteinD,Baba-AkbariA,etal.Stapledhaemorrhoidectomy(haemorrhoidopexy)forthe
treatmentofhaemorrhoids:asystematicreviewandeconomicevaluation.HealthTechnol
Assess2008;12:1–193. BurchJ,EpsteinD,Baba-AkbariA,etal.Stapledhaemorrhoidopexyforthetreatmentof
haemorrhoids:asystematicreview.ColorectalDis2009;11:233–44. CheethamMJ,MortensenNJ,NystromPO.Persistentpainandfaecalurgencyafterstapled
hemorrhoidectomy.Lancet2000;356(9231):730–3. GoligherJC.SurgeryoftheAnus,RectumandColon.5thed.London:BailliereTindall,1984. JayaramanS,ColquhounPH,MalthanerRA.Stapledversusconventionalsurgeryfor
hemorrhoids.CochraneDatabaseSystRev2006;(4):CD005393. JongenJ,BochJU,PeleiksHG,EbersteinA,PfisterK.Complicationsandreoperationsinstapled
anopexy:learningbydoing.IntJColorectDis2006;21:166–71. LongoA.Treatmentofhemorrhoidsdiseasebyreductionofmucosaandhemorrhoidprolapse
withacircularsuturingdevice:anewprocedure.In:6thWorldCongressofEndoscopic
Surgery(IFSES);June3–6,1998;Rome. MolloyRG,KingmoreD.Lifethreateningpelvicsepsisafterstapledhaemorrhoidectomy.Lancet
2000;355:810. TuckerH,GeorgeE,BarnettD,etal.NICEtechnologyappraisalonstapledhaemorrhoidopexyfor
thetreatmentofhaemorrhoids.AnnRCollSurgEngl2008;90(1):82–4. NyströmPO,QvistN,RaahaveD.Randomizedclinicaltrialofsymptomcontrolafterstapled
anopexyordiathermyexcisionforhaemorrhoidprolapse.CBrJSurg2010;97(2):167–76. ThahaMA,CampbellKL,KazmiSA,etal.Prospectiverandomisedmulti-centretrialcomparing
theclinicalefficacy,safetyandpatientacceptabilityofcircularstapledanopexywithclosed
diathermyhemorrhoidectomy.Gut2009;58(5):668–78. TjandraJJ,ChanMK.Systematicreviewontheprocedureforprolapseandhemorrhoids(stapled
hemorrhoidopexy).DisColonRectum2007;50:878–92.
Chapter4
Ultrasound-Guided Ligation/MucosalPexyfor Hemorrhoids
JosephT.GallagherandBethAnnShanker
INDICATIONSANDCONTRAINDICATIONS
Transanalhemorrhoidaldearterialization(THD)utilizesananoscope coupledwithaDopplertransducertoidentifyandsutureligatethe terminalbranchesofthesuperiorhemorrhoidalartery(Fig.4-1).Ifthere isaprolapseofhemorrhoidaltissue,amucopexyisalsoperformedto addressthispathology.
FIGURE4-1Cartooncross-sectionoftheTHDdevice
performingDoppler-guidedligation.
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AccordingtothePracticeParametersforManagementofHemorrhoids publishedin2010,THDwasrecommendedasanoptiontotreatgradesII andIIIhemorrhoids,andthepotentialbenefitofdecreasedpaindueto lackofexcisedtissuewasrecognized(Figs.4-2and4-3).
FIGURE4-2A.BeforeTHD.B.AfterTHD.
FIGURE4-3AfterTHD.
TheauthorproposesthatTHDmayalsobebeneficialinpatientswith bleedingorprolapsedgradeIIorIIIhemorrhoids,whocannotstoptheir therapeuticanticoagulation,butarehealthyenoughtoundergoasurgical procedure.Thisistheauthor’spreferredtechniquetotreathemorrhoids inpatientswithanemiaduetohemorrhoidalbleeding,cirrhoticpatients, anddialysispatients.TheauthoralsousesTHDinolderandyounger patients,addingminimalorselectivemucosalpexyandrelyingon Dopplerligation.
Thereareafewcontraindications,includingnecroticgradeIV hemorrhoids,rectalprolapse,anorectalsepsis,significantdistalrectal scarringfromprevioussurgeriesorprocedures,andactiveproctitis.The authorrecommendsavoidingstartingandcompletingamucosalpexy alongtheanteriormidlineinwomentoeliminateanycomplicationswith thevagina.
PREOPERATIVEPLANNING
Priortoanyhemorrhoidalprocedure,thepatientshouldundergoa standardevaluationforrectalbleedingorchangeinbowelhabitscausing constipationordiarrhea.Itisimportanttoexaminethepatient preoperativelyusingananoscope/flexiblesigmoidoscopyand,if indicated,usingamirrorwhilethepatientstrains,whileseatedona toilet.Thepatientshouldbequestionedaboutthetimespentinthe bathroom,thepresenceofan“oilslick”ontopofthewater,andstool frequencyandconsistency.Itiscommonto“cure”hemorrhoidsand incontinencebyavoidingdairy(milk,icecream,andcheese).
Patientsshouldbeonabowelregimenwithhealthytoiletinghabits priortothesurgery.Thisgoalincludespreventingconstipationand passingsoftstools,withminimalstraining.Constipationpriorto hemorrhoidalsurgeryisariskfactorforpostoperativecomplications. Similarly,diarrheashouldbeaddressedwithpreoperativeevaluationand resolvedwithappropriatemanagement.
Priortothesurgery,thepatientisinformedaboutperioperativecare andinstructions,includingdietaryfiberrecommendations,sitzbaths, andagoaltominimizenarcoticusepostoperatively.
Expectationsregardingthisprocedurealsoneedtobeclarified. AlthoughTHDhasreducedpostoperativepainandthustheneedfor narcoticuseascomparedwithexcisionalhemorrhoidectomy,itisnota “pain-free”procedure.Theauthorinformspatientsthatwith80% likelihood,theirwoundswillbehealedby1weekcomparedwiththecase oftraditionalexcisionalhemorrhoidectomy,whereinonly80%healing occursby2weeks.Thepatientshouldstillexpecttotaketimeofffrom workandactivities.
Onthedayofsurgery,werecommend1–2fleetenemaspriortothe procedure.

SURGERY

TheTHDsystem(thebrandweuse)isananoscopespecificallycoupled withaDopplerprobewithultrasoundwavescapturinglarge-diameter arteriesinthemucosalandsubmucosallayersoftherectalwall.The Dopplerprobeisalignedwithanoperativewindowthatallowsaneedle topassthroughatapredetermineddepthtopreciselyligatetheidentified arterialbranches.
Thepatientisplacedintheproneposition;however,lithotomy positioningcanbeusedaswell.Sedationisestablishedwithpropofol, andananalblockisadministered.IVfluidsarelimitedtoatotalof250 mlfortheday.Ideally,forhemorrhoidcases,only250mlsalinebagsare used.
TheTHDscopeisintroducedintotheanalcanalwiththetipreaching approximately6cmfromtheanalverge.TheDopplersignalsidentifythe vascularpedicleassociatedwiththehemorrhoidalcushions.Usingthe pivotholeintheprobe,a2-0absorbablebraidedstitchona5/8inch needleisplacedintothesubmucosallayertoligatethearterialsupply (Fig.4-1).Usingtheknotpusherhelpspreventanairknotfortheligation stitch(Fig.4-4).TheTHDscopeandthepivotholeonlyallowfora maximumdepthof6mm,avoidingpenetrationoftheentirerectalwall. Monofilamentsuturescannotbesubstitutedbecauseofthechancesof thesuturesbreakingduringthepexyportionoftheprocedure.
FIGURE4-4Usingtheknotpusher.
Ifhemorrhoidalprolapseoccurs,thentheslidingcomponentofthe THDscopeisremoved.Thesutureiscontinuedtoruninanonlocking fashioninastraightlinetoapointjustabovethedentateline.The Debakeypickupshelpguidethepexysuture,ensuringtherunningsuture staysstraightandnottoodeep(Fig.4-5).Thismaneuveralsohelps reducetissueredundancyobstructingvisualization.Thesutureisthen tied,completingthemucopexy.Themucopexyneedstobecompletein ordertoavoida“bowstring”andincreasethechanceforarecurrence (Figs.4-6to4-7).THDforhemorrhoidtreatmentwithmultiplemucosal pexiesincreasestheoperativetimeandcarriesalearningcurvethatis longerthanthatassociatedwiththetraditionalhemorrhoidssurgical techniquesandtheprocedureforprolapsedhemorrhoids(PPH).The analcanalisinspectedforhemostasis.Iftherearenocontraindications, Ketorolacisalsoadministeredintramuscular(IM)intheprepped surgicalfieldforadditionalpaincontrol.
FIGURE4-5UsingaDebakeypickupsinordertokeepit
straight,nottoodeep,andhelpswithvisualization.
FIGURE4-6Abowstring.Anincompletemucosalpexy.
FIGURE4-7Pexywithoutabowstring.Theknotsare
kissing.

COMPLICATIONS

Analgesicusehasbeenreportedtobelowerthanthatfollowingexcisional hemorrhoidectomy.However,ifmucopexyisperformedincorrectlyand resultsinsuturingdistaltothedentateline,thepatientwillexperience increasedrectalpain.Localischemiaofthemucosaandsphinctermuscle incorporatedintothepexymayalsocauseadditionaldiscomfort.
Incompletemucosalpexyandleavinga“bowstring”willleadtoearly recurrence.Ittakesalotofforceandawarenesstoavoidthis complication.Ifthereisabowstringpresent,themucosalpexycanbe oversewnandtiedagainwithouta“bowstring.”Lockingthesuturewill preventadequatemucosalpexy.Themucosalpexyshouldbeinastraight line,incorporatingmucosaequivalenttothewidthoftheindexfinger. Careshouldbetakentoavoidincorporatingasignificantwidthofthe distalrectum,whichcausestoomuchtensiononthepexyandincreases theriskofnecroticulcerformation.Theunderlyingsphinctermechanism shouldnotbeincorporatedwithinanyofthemucosalpexysuturesto avoidnecrosisformationofanotherswollenhemorrhoidduringthe postoperativeperiod(Fig.4-8).Thisresolveswithtime,however.
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