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Assessment of patient's overall condition: sepsis, hemodynamic stability, nutritional status, HIV status, etc.
Wound evaluation (if necessary under anesthesia): location (abdominal, perirectal, anal canal, other), size, configuration,
depth (fistula?), unfavorable configuration, wound components (soft tissue, bone, foreign body, etc), culture results (MRSA,
fungi, etc).
Cofactors for Decision-Making Process
Retrospectoscope on intraoperative difficulties.
Current patient condition (general, local)?
Need for examination under anesthesia?
Chance to surgically improve wound condition?
Management
CONSERVATIVE
Wound opening, debridement, wound irrigation (shower, bath), wet-to-dry dressing changes, povidone-iodine
ointment mixed with granular sugar, perifocal hair removal (shaving, depilatory cream).
Wound-VAC, ie, vacuum-assisted wound dressing (if anatomically suitable): goals are to achieve a clean, manageable
wound and promote contraction of wound edges; reduced frequency of dressing changes (only every 2–4 days). Risks:
vacuum damage on bowel causing enterocutaneous fistula; loss of foam in depth of wound resulting in foreign body.
Antibiotics typically not indicated for adequate wound: only used to treat significant phlegmonous component or
hidden sepsis.
OPERATIVE APPROACH
Reexploration of wound with reexcision of the wound, debridement of necrotic material, opening of pockets, better
wound configuration.
Combination with well-vascularized muscle or myocutaneous flaps.
Creation of temporary colostomy (in selected cases).
Cross-Reference
Pain, perirectal (Ch. 1)
Sepsis (Ch. 1)
Liability in colorectal surgery (Ch. 2)
Contrast enemas (Ch. 2)
Small bowel follow-through (SBFT) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Enterocutaneous fistula (569.81) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
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McGraw-Hill Manual: Colorectal Surgery > Chapter 5. Operative Techniques >
TAMPONADE ANAL CANAL
Principle
Compression and tamponade of the anal canal in case of acute distal hemorrhage as bridging for stabilization until definitive
assessment or procedure is possible (Figure 5–1).
Figure 5–1.
Balloon tamponade of the anal canal.
Setting
Where needed, when no immediate access to OR.
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Alternatives
Examination and surgical hemostasis in OR.
Indication
Massive hemorrhage (postsurgical, spontaneous hemorrhoidal, or Dieulafoy hemorrhage).
Preparatory Considerations
None.
Surgical Steps
1. Patient positioning: any position.
2. Insertion of largest available Foley catheter into anal canal.
3. Insufflation of balloon with 60 mL of water/saline.
4. External traction on catheter to allow balloon to exert pressure on anal canal.
5. Placement of external pad pack (gauze, towels) around catheter (external counter pressure).
6. Placement of hemostat clamp to catheter (under tension) at level of external packing.
Anatomic Structures at Risk
Anal canal.
Aftercare
Hemodynamic stabilization, monitoring.
Antibiotic coverage as long as balloon in place.
Maximal length of tamponade: 24 hours.
Plan for definitive surgical care.
Complications
Continued bleeding, anal canal necrosis, infection.
Cross-Reference
Bleeding per rectum (Ch. 1)
Liability in colorectal surgery (Ch. 2)
Clinical examination (Ch. 2)
Complications—delayed wound healing (998.3) (Ch. 4)
Hemorrhoid office procedures (banding, sclerosing, infrared coagulation) (Ch. 5)
General perioperative management—anorectal (Ch. 7)
Comorbidities—liver disease (Ch. 7)
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INCISION/DRAINAGE OF PERIRECTAL ABSCESS (SIMPLE)
Principle
Decompression of perirectal abscess to allow resolution of acute inflammation and pressure (pain!). Management of fistula
only of secondary priority: if I&D is performed under general anesthesia, excision of the cryptoglandular origin and definitive
fistula procedure may be reasonable, but there is increased risk of creating tracts that are not truly there (inflamed tissue).
Setting
Outpatient, office (or inpatient, bedside/OR procedure in selected cases).
Alternatives
Nonoperative management: generally not indicated except if abscess spontaneously perforated.
Modified Hanley procedure for horseshoe abscess.
Indication
Every perirectal abscess.
Preparatory Considerations
Clinical assessment, ie, pain and local inflammatory signs; do not wait for fluctuance in perirectal area. Neither WBC nor
imaging studies are needed (except in very unusual circumstances).
In all patients receiving general anesthesia: at least rigid sigmoidoscopy.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position has several advantages—access to all perianal
compartments (including deep postanal space), superior view with comfortable access for surgeon/assistant,
decreased congestion of the hemorrhoidal plexus.
2. Disinfection.
3. Unless general anesthesia: local anesthesia of the skin over the maximal swelling.
4. Identification of drainage site: maximum swelling/erythema/tenderness, but as close to the anal verge as possible
(to keep possible fistula tract short).
5. Bovie available
excision of a skin disk; no Bovie available cruciate incision of the skin with scalpel and excision
of each corner. Pus has to flow, otherwise the correct site or level has not been reached.
6. Loculations: digital breaking is not indicated in an awake patient; but if under anesthesia provide active debridement
and adequate drainage (possible counter-incisions and drain placement if large cavity is found).
7. Search for fistula: not indicated in an awake patient; if under anesthesia
gentle assessment (but avoid creating
false tracts in altered tissue!): if positive
excision of cryptoglandular lesion and placement of seton (eg, vessel loop).
8. Hemostasis.
9. Loose insertion of iodoform gauze is acceptable but no major packing is needed.
10. Absorbing dressing.
Anatomic Structures at Risk
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Anal sphincter muscle.
Aftercare
Antibiotics: Simple abscess in healthy patient—no; abscess with significant phlegmon—yes; abscess in
immunosuppressed/diabetic patient—yes; signs of sepsis—yes (inpatient).
Open wound care: sitz baths or showers twice per day, after bowel movements.
Assessment of whether persistent fistula is present after 3–6 weeks. If absess was a recurrent one, fistula has to be
postulated.
Complications
Bleeding, urinary retention (sign of sepsis?), progressive infection, pelvic/perineal sepsis, persistence of perirectal fistula
(requiring subsequent surgery): ~50%.
Cross-Reference
Pain, perirectal (Ch. 1)
Perianal/-rectal abscess (566) (Ch. 4)
Pilonidal disease (cyst/sinus/fistula, 685.0/1) (Ch. 4)
Modified Hanley procedure for horseshoe fistula/abcess (Ch. 5)
Fistula-in-Ano—Fistulotomy vs Seton (Ch. 5)
General perioperative management—anorectal (Ch. 7)
MODIFIED HANLEY PROCEDURE FOR HORSESHOE FISTULA/ABSCESS
Principle
Decompression and drainage of ischioanal fossae and deep postanal space of Courtney with excision of primary
cryptoglandular origin and placement of drains/setons to allow resolution of acute inflammation and pressure (pain!): Figure
5–2. As these deep perirectal abscesses usually require general anesthesia, management of the fistula/primary fistula
opening generally is indicated.
Figure 5–2.
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Modified Hanley procedure with two lateral draining and one midline cutting seton.
Setting
Outpatient or inpatient, OR, general anesthesia.
Alternatives
Nonoperative management: generally not indicated except if abscess spontaneously perforated.
Simple I&D for perirectal abscess(es): elective management.
Endorectal advancement flap.
Collagen plug for perirectal fistula.
Indication
Horseshoe abscess or fistula.
Preparatory Considerations
Clinical assessment: bilateral abscesses or fistula openings, primary commonly in posterior midline, invisible abscess but
indurated/tender postanal space. Neither WBC nor imaging studies are needed (except in very unusual circumstances).
In all patients, at least rigid sigmoidoscopy once under anesthesia (emergency); in elective cases, prior colonic evaluation per
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guidelines.
Surgical Steps
1. Patient positioning: prone jackknife position.
2. In absence of previous colonic evaluation: at least rigid or flexible sigmoidoscopy.
3. For elective cases: pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general
anesthesia to improve relaxation of anal sphincter muscles.
4. Midline incision of skin and mucosa extending from tip of coccyx to primary fistula opening in posterior midline at
dentate line. Careful division of underlying connective tissue, just until muscle fibers become visible. Excision of
primary crypt at dentate line.
5. Starting at tip of coccyx, dissection is carried deeper, ie, through anococcygeal ligament. Sphincter complex is
pushed anteriorly and should not be divided.
6. Access to deep postanal space of Courtney: identification by anatomic location, presence of abscess (acute) or
granulation tissue (chronic), guidance from probe through primary opening.
7. From deep postanal space, blunt lateral dissection toward both ischioanal fossae. Extension to anterior end of the
acute inflammation/induration or to the preexisting fistula openings.
8. Secondary incisions (abscess) or excision/widening of secondary fistula openings. Debridement of abscess cavities
or fistula tracts with curette or gauze.
9. Primary opening: insertion of vessel loop (as cutting seton) from primary opening to postanal space/posterior
incision. Placement of three large silk ties to the loop such that it sits tight on the muscle but without tension.
Approximation of muscle and mucosal layer around seton, particularly if primary opening is significantly larger than the
loop.
10. Secondary openings: placement of Penrose drains (acute abscess) or also vessel loops (chronic fistula) from
postanal space to secondary opening(s). Securing of individual loops with three large silk ties.
11. Hemostasis.
12. Absorbing dressing.
Anatomic Structures at Risk
Anal sphincter complex, rectum.
Aftercare
Antibiotics: abscess/fistula in healthy patient—no; abscess with significant phlegmon—yes; abscess/fistula in
immunosuppressed/diabetic patient—yes; signs of sepsis—yes (inpatient).
Open wound care: sitz baths or showers twice per day, after bowel movements.
Removal of lateral drains in clinic after 2–4 weeks, possible prior downsizing before complete removal.
Once lateral drains are gone: tightening of cutting seton in monthly intervals.
Complications
Bleeding, urinary retention (sign of sepsis?), recurrent/progressing infection, pelvic/perineal sepsis, persistence of perirectal
fistula (requiring subsequent surgery).
Recurrent/persistent fistula (10–15%). Fecal incontinence: anal disconfiguration, sphincter weakness.
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Cross-Reference
Pain, perirectal (Ch. 1)
Perianal/-rectal abscess (566) (Ch. 4)
Perianal/-rectal fistula (565.1) (Ch. 4)
Pilonidal disease (Cyst, sinus, fistula, 685.0/1) (Ch. 4)
Hidradenitis suppurativa (705.83) (Ch. 4)
Fistula-in-Ano—Fistulotomy vs Seton (Ch. 5)
General perioperative management—anorectal (Ch. 7)
FISTULA-IN-ANO—FISTULOTOMY VS SETON
Principle
Fistulotomy (lay-open technique) for very superficial fistula with minimal resulting damage to sphincter muscle.
Alternatively, placement of setons into the existing fistula tracts to allow for adequate drainage of active suppurations. Two
different types of setons:
Cutting seton: placed around sphincter portion involved in a transsphincteric fistula with intent to have the seton
slowly erode through that sphincter portion (Figure 5–3).
Draining seton (single, multiple, short-term/long-term): placed into existing fistula tract solely to avoid future pus
accumulation and allow tract to close down onto seton. A draining seton may also be placed in preparation for future
fistula procedures, eg, collagen plug placement.
Figure 5–3.
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Seton management of transsphincteric fistula.
Setting
Outpatient, OR, general anesthesia.
Alternatives
Nonoperative management: generally not indicated if fistula is symptomatic.
Fistulotomy/fistulectomy.
Endorectal advancement flap.
Collagen plug for perirectal fistula, fibrin glue injection.
Modified Hanley procedure.
Indication
Fistula-in-ano.
Preparatory Considerations
Clinical assessment: identification of secondary (external) opening, potentially of primary opening; presence of bilateral
fistula openings or scars: horseshoe fistula; identification helpers—probing, peroxide injection, imaging (ERUS, MRI, etc).
Elective cases: partial/full colonic evaluation per guidelines.