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Preparatory Considerations
Trial of nonsurgical management unless incapacitating symptoms.
In elective cases, colonic evaluation per guidelines (before or with procedure).
Administration of 2 enemas before operation. Single shot IV antibiotic prophylaxis. Disinfection of rectum with povidone-
iodine solution.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—
superior view with comfortable access for surgeon/assistant, decreased congestion of hemorrhoidal plexus.
2. Pudendal/perianal nerve block with 15–20 cc of a local anesthetic alone (office sphincterotomy), or in addition to
general anesthesia to improve relaxation of the anal sphincter muscles.
3. Visualization and assessment of fissure (posterior or anterior midline): bare sphincter muscle fibers, signs of
chronicity, eg, deep central aspect, elevated wound edges, formation of a sentinel skin tag, hypertrophic anal papillae.
(A) Open Technique
4. Right lateral radial incision (ie, in between hemorrhoidal piles) from the anal verge, 1–1.5 cm in length, division of
connective tissue overlaying the sphincter complex.
5. Identification of internal anal sphincter clearly (white fibers, internal to intersphincteric groove).
6. Loading of IAS fibers onto clamp, division of fibers with electrocautery between clamp's branches, slowly to avoid
bleeding.
7. Proximal extent of sphincterotomy should not exceed level of proximal end of fissure in anal canal.
8. Careful hemostasis
9. Wound irrigation and closure with running 2-0 chromic suture.
(B) Closed Technique
4. Identification of intersphincteric groove at right lateral quadrant (ie, in between hemorrhoidal piles).
5. Tangential insertion of Beaver-blade knife into intersphincteric groove.
6. Once inserted, the knife is turned 90 degrees to the inside.
7. Division of internal sphincter (blind or guided by digital exam). Avoid mucosal injury (risk of fistula).
8. Massaging of divided sphincter should reveal a submucosal gap.
9. Closure of the lancing site.
Both Techniques—Possible Combination with Fissurectomy or Skin Tag Excision
10. Readjusting of anal retractor to fissure site.
11. Radial excision of fissure or fissure edges with inclusion of external sentinel skin tag.
12. Lateral mobilization of mucosa to allow sufficient mobility.
13. Closure of inside up to anal verge with running 2-0 chromic suture, making sure to achieve good hemostasis.
14. The most external part of the wound is left open for possible drainage.
Anatomic Structures at Risk
External anal sphincter, hemorrhoidal plexus.
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Aftercare
Stool softeners, fibers, pain medication, sitz baths.
Complications
Bleeding, urinary retention, infection, pelvic/perineal sepsis, delayed wound healing, persistent fissure, incontinence to
stool/gas: 5(–15)%.
Cross-Reference
Pain, perirectal (Ch. 1)
Anal fissure (565.0) (Ch. 4)
Anorectal flaps (Ch. 5)
General perioperative management—anorectal (Ch. 7)
OVERLAPPING SPHINCTEROPLASTY
Principle
Repair of a sphincter defect in a patient with symptoms of fecal incontinence and sphincter defect identified clinically or ERUS
(Figure 5–6A). Depending on the size of the defect, closing the muscle circle is necessary to allow translation of axial muscle
contraction into a centripetal narrowing force to the anal canal. Scar tissue at the muscle ends should not be excised as it is
the better tissue for holding the repair stitches than the actual muscle itself. Important not only to recreate the muscle ring
but to also reconstitute the length of the high-pressure zone. No advantage to separate suturing of IAS and EAS.
Figure 5–6A.
Overlapping sphincteroplasty: preoperatively patulous, postoperatively closed.
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Setting
Inpatient (possible outpatient in selected cases), OR procedure.
Alternatives
Conservative management: elimination of other incontinence-triggering factors if possible; stool management, fibers,
antidiarrheals, scheduled enemas, physical therapy.
Colostomy, Malone antegrade colonic enema (MACE), graciloplasty, ABS, sacral nerve stimulation.
Acute sphincter injury: direct repair with end-to-end approximation without overlap.
Indication
Fecal incontinence and identified sphincter defect. Impact of pudendal neuropathy controversial.
Preparatory Considerations
Colonic evaluation per guidelines, as well as in patients with altered stool quality (with biopsies).
Anophysiology studies for objective preoperative assessment.
Administration of full bowel cleansing vs two enemas only before operation. IV antibiotic prophylaxis, continued
postoperatively for 3–5 days. Disinfection of rectum with povidone-iodine solution.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages:
superior view with comfortable access for surgeon/assistant, decreased congestion of hemorrhoidal plexus.
2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Careful examination of area including anoscopy and vaginal palpation to rule out preexisting/hidden rectovaginal
fistula.
4. Transverse incision to perineum (as anterior as possible).
5. Dissection of rectovaginal septum to level of puborectalis muscle. Injury to rectum and/or vagina must be avoided.
6. Ends of sphincter muscle are identified on both sides and mobilized as much as necessary, as little as possible. Too
lateral dissection should be avoided to limit pudendal denervation: bleeding may indicate proximity to pudendal nerve
branches. Residual muscle contractility can be checked by direct muscular stimulation with cautery.
7. Overlap repair using three interrupted 2-0 Vicryl sutures that are first prelaid (Figure 5–6B), then consecutively tied
such that one sphincter end moves in front of the other. Free overlapping edge of anterior sphincter end is
approximated to rest of reconstructed circle with a running 2-0 Vicryl suture. Possible reapproximation of puborectalis
muscles with interrupted sutures toward center.
8. Irrigation of wound with diluted povidone-iodine (1:10). Hemostasis.
9. Repair should result in a concentric appearance of anus with radial folding all the way around. After overlap, digital
rectal exam must be avoided: anus is never (!) too tight.
10. Closure of wound in a transverse direction: a few interrupted Vicryl stitches for adaptation of subcuticular tissue
and 4-0 Monocryl to close off skin. Alternatively: sagittal closure of transverse incision to rebuild some perineal body.
Figure 5–6B.
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Overlapping sphincteroplasty: direction of sutures to achieve nice overlap.
Anatomic Structures at Risk
Pudendal neurovascular bundle, sphincter muscle.
Aftercare
Stool softeners, fibers, pain medication, potentially mild laxative. After bowel movement: wiping to be avoided, rather
rinsing, short sitz baths. Area to be kept dry, unless managed with open wound care.
After 6 weeks, consider supportive physical therapy.
Complications
Bleeding, urinary retention, infection, pelvic/perineal sepsis, formation of rectovaginal fistula, delayed wound healing,
inability to provide improvement of fecal control or recurrent fecal incontinence, need for colostomy.
Cross-Reference
Discharge (Ch. 1)
Incontinence (Ch. 1)
Anophysiology studies (Ch. 2)
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Fecal control (continence) (Ch. 3)
Fecal incontinence (787.6) (Ch. 4)
Implantation of the artificial bowel sphincter (ABS) (Ch. 5)
Physical therapy/biofeedback training (Ch. 6)
General perioperative management—anorectal (Ch. 7)
IMPLANTATION OF THE ARTIFICIAL BOWEL SPHINCTER (ABS)
Principle
Implantation of an ABS device is a possible option for patients with treatment-refractory incontinence in whom the sphincter
muscle cannot be repaired or otherwise optimized. It is the only truly dynamic functional solution allowing a patient to decide
when or when not to move the bowels. Successful implantation is associated with a dramatic improvement in quality of life.
Challenge: risk of infection or device erosion (acute, chronic) which originally resulted in a nearly 40% explantation rate, but
increasing experience, standardization of the technique, and antibiotic prophylaxis have reduced the risk to < 10%.
Setting
Inpatient, OR procedure.
Alternatives
Continuation of conservative treatment.
Sphincter repair: repeat sphincteroplasty.
Sphincter replacement: graciloplasty.
Neuromodulation: sacral nerve stimulation.
Reduction of stool load: irrigational stoma (eg, appendicostomy) for Malone antegrade colonic enema (MACE).
Diversion: colostomy.
Indication
Treatment-refractory incontinence with sufficient tissue quality and perianal space to take and embed device.
Absolute contraindications: any active inflammation, any open wound, lack of sufficient tissue (eg, rectovaginal septum), poor
tissue quality (eg, very rigid and indurated tissue).
Relative contraindications: history of radiation therapy.
Preparatory Considerations
Colonic evaluation per guidelines.
Complete bowel cleansing.
Discussion of better side for valve implantation: typically opposite to patient's dominant hand.
Triple antibiotic prophylaxis: vancomycin, levofloxacin or cefoxitin, metronidazole.
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Disinfection of vagina and rectum with povidone-iodine solution.
Sterile in-and-out bladder catheterization at beginning of case.
Surgical Steps
1. Back table preparation: sterile filling of system components with normal saline, complete removal of air bubbles
placement of device in antibiotic solution until implantation.
2. Patient positioning: modified lithotomy. Meticulous prepping and draping.
(A) Cuff Implantation
3. Insertion of povidone-iodine–soaked vaginal pack into rectum.
4. Perianal incision: preferably two small anterolateral incisions (alternatively: one anterior transverse incision;
bilateral vertical incisions).
5. Nontraumatic careful dissection around anal canal: damage to rectum or vagina to be avoided.
6. Cuff sizer for measurement of approximate circumference and length of anal canal.
7. Cuff placement: using large curved clamp, air-free cuff is inserted around anal canal with pillow facing toward
canal: start at incision on side of planned valve implantation
posterior hemicircumference anterior
hemicircumference
locking cuff by threading tubing through adapter hole and pulling adapter hole over cuff button.
8. Connect tubing with tunneling instrument and pass along inguinal fold to suprapubic incision.
9. Subcutaneous sutures (avoid damage to cuff), subcuticular skin closure, skin glue.
10. Removal of anal pack.
(B) Balloon Implantation
11. Suprapubic incision, transverse division of rectus fascia, separation at linea alba to access and free up prevesical
space using blunt dissection.
12. Placement of prepared balloon in prevesical space and filling with 55 mL of recommended filling solution (saline).
(C) Cuff Pressurization
13. Temporary connection of cuff and balloon tubing using a straight connector.
14. Removal of tubing clamps
wait 60 seconds for cuff to pressurize.
15. Reclamp tubing to the cuff and the balloon with silicone-shod mosquito clamps, followed by aspiration of all
remaining fluid from balloon:
calculation of volume in cuff and tubing.
16. Refill balloon with 40 mL of filling solution and reclamp tubing.
(D) Implantation of Control Pump
17. Use of Hegar dilators to create a dependent pocket in soft tissue of labium or subdartos pouch of scrotum
(opposite to patient's dominant hand).
18. Place pump in the pouch with deactivation button facing outward such that it is easily palpable.
19. Connection of all components.
20. Closure of suprapubic incision.
Anatomic Structures at Risk
Rectovaginal septum, vagina, anal canal.
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Aftercare
Antibiotics per prophylaxis protocol.
Stool regularity, avoidance of fecal impaction. No need for sitz baths, but rinsing off of stool smearing. Preemptive skin care.
Avoidance of (longer) sitting, intercourse, digital rectal exam.
Depending on intraoperative tissue quality, device remains in deactivated state (ie, empty cuff) for 6–12 weeks to allow
complete resolution of operative edema and formation of fibrotic capsule.
Complications
Infection, device erosion with external or rectovaginal perforation and fistula formation need to remove device, risk to
need temporary colostomy.
Perianal skin maceration while deactivated.
After activation: high incidence of constipation until patient become used to new management.
Cross-Reference
Fecal incontinence (787.6) (Ch. 4)
Pediatrics—congenital malformations (751.2) (Ch. 4)
Overlapping sphincteroplasty (Ch. 5)
HEMORRHOID OFFICE PROCEDURES (BANDING, SCLEROSING,
INFRARED COAGULATION)
Principle
Local office treatment to achieve shrinkage of engorged hemorrhoidal piles (right anterior and posterior, left lateral) tissue.
Setting
Outpatient, office procedure.
Alternatives
Excisional or stapled hemorrhoidectomy PPH.
Whitehead hemorrhoidectomy.
Conservative management.
Indication
Symptomatic internal hemorrhoids grades I, II and III. Caution: ASA medication, anticoagulation, immunosuppression.
Preparatory Considerations
In elective cases, prior colonic evaluation per guidelines.
Administration of enemas if rectum is full of stool. Single shot antibiotic prophylaxis in high-risk patients.
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Surgical Steps
1. Patient positioning: any position, but prone jackknife position with best view and access.
2. Insertion of oblique-angle anoscope and consecutive exposure of hemorrhoidal piles.
(A) Banding
3. Verification of dentate line.
4. Positioning of loaded hemorrhoid ligator at proximal base (apex) of hemorrhoid.
5. Application of suction, traction (depending on device).
6. Firing of gun while suction/traction is maintained.
7. Verification of correct rubber band position proximal to dentate line.
8. Repeat procedure for remaining hemorrhoidal piles: simultaneous banding of three piles is acceptable.
9. Patient observation for 15–30 minutes: if development of pain
rubber band removal with hook-blade.
(B) Sclerosing
3. Verification of dentate line.
4. Syringe filled with sclerosing agent: 5% ethanolamine oleate, 1% ethoxysclerol, 5% phenol in oil, etc.
5. 25 G spinal needle (length factor!).
6. Submucosal injection of 1–2 cc into each hemorrhoid (caveat: intramucosal or deep injection may result in
ulceration/sloughing).
7. Repeat procedure for remaining hemorrhoidal piles.
8. Patient observation for 15–30 minutes.
(C) Infrared Coagulation
3. Verification of dentate line.
4. Pointing infrared coagulator to proximal base of hemorrhoid.
5. Delivery of 3–4 applications for 1.0–1.5 seconds.
6. Repeat procedure for remaining hemorrhoidal piles.
7. Patient observation for 15–30 minutes.
Anatomic Structures at Risk
Anoderm (below dentate line).
Aftercare
Stool softeners, fibers, pain medication, sitz baths.
Complications
Bleeding (immediately, after 4–7 days), urinary retention, infection, pelvic/perineal sepsis, delayed wound healing (persistent
ulceration), recurrent hemorrhoids.
Cross-Reference
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Prolapse (Ch. 1)
Anal fissure (565.0) (Ch. 4)
Hemorrhoids (455.X) (Ch. 4)
Excisional hemorrhoidectomy (Ferguson, Milligan-Morgan) (Ch. 5)
General perioperative management—anorectal (Ch. 7)
EXCISIONAL HEMORRHOIDECTOMY (FERGUSON, MILLIGAN-MORGAN)
Principle
Radial mucocutaneous excision of enlarged hemorrhoidal piles (right anterior and posterior, left lateral) with proximal suture
ligature of vascular pedicle. Mucocutaneous defect closed (Ferguson) or left open (Milligan-Morgan). In very large and
circumferential hemorrhoids, it may be preferable to combine the right anterior and posterior pedicle into one lateral
excision,
For thrombosed external hemorrhoid: diminutive form of excision.
Setting
Outpatient, OR procedure (office procedure may be safe in selected cases).
Alternatives
Stapled hemorrhoidectomy PPH.
Whitehead hemorrhoidectomy.
Hemorrhoid banding and other office procedures.
Indication
Internal hemorrhoids:
– Grade (II–)III with significant external component.
– Irreducible, ie, grade IV hemorrhoids.
– Involvement of less than all three piles.
– Hemorrhoidectomy in patients with anoreceptive intercourse.
Thrombosed external hemorrhoid (< 72 hours postonset, occasionally longer if particularly large).
Preparatory Considerations
In elective cases, prior colonic evaluation per guidelines.
Administration of two enemas before operation. Single shot IV antibiotic prophylaxis. Disinfection of rectum with povidone-
iodine solution.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—superior
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view with comfortable access for surgeon/assistant, decreased congestion of hemorrhoidal plexus.
(A) Classical Excision of Internal/External Hemorrhoids (Figure 5–7a)
2. Pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Insertion of dry sponge followed by slow traction on sponge will reveal tissue prolapse.
4. Insertion of Hill-Ferguson retractor.
5. Proximal suture ligature of vascular pedicle, suture not cut, but tagged.
6. Grasping of hemorrhoid and external component with two clamps.
7. V-shaped incision at base of hemorrhoid, beyond anal verge, dotting of line with electrocautery toward ligated
pedicle. Important to retain adequate tissue bridge between various excision sites, otherwise risk of stricture.
8. Careful dissection to edge of sphincter muscle. All muscle fibers need to be carefully pushed away from
hemorrhoidal tissue. Staying in correct plane will limit bleeding. Which dissection tool is used (scissors, electrocautery,
harmonic knife, laser) is a matter of preference, not of scientific superiority.
9. Once level of pedicle is reached, suture ligature is again tied around base and specimen is subsequently amputated.
Completion of hemostasis.
10. Milligan-Morgan: wound left open. Ferguson: wound closed with running absorbable suture, burying stump of
vascular pedicle in proximal end, leaving only very last little segment on the outside open for possible drainage.
11. The other hemorrhoid piles are address in analogous fashion. It is most important to leave enough tissue in-
between: as long as wounds can be closed while medium-size retractor is in place, the risk for a stricture seems
minimal.
Figure 5–7A.