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Excisional hemorrhoidectomy (Ferguson technique).
(B) Excision of Thrombosed External Hemorrhoid (Figure 5–7b)
2. Local injection just underneath/around the thrombosed hemorrhoid.
3. Elliptic excision (rather than just incision) of external component (no extension into anal canal): enucleation of
thrombosed material.
4. Wound either left open or closed.
Figure 5–7B.
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Excision of thrombosed external hemorrhoid.
Anatomic Structures at Risk
Anal sphincter complex, anoderm.
Aftercare
Stool softeners, fibers, pain medication. Sitz baths.
Complications
Bleeding (1–6%), urinary retention (5–25%), infection (5–10%), pelvic/perineal sepsis, delayed wound healing, recurrent
hemorrhoids, incontinence to stool/gas (2–10%), anorectal stricture (up to 6%). Risk of needing colostomy: ~0.1%.
Cross-Reference
Prolapse (Ch. 1)
Anal fissure (565.0) (Ch. 4)
Hemorrhoids (455.X) (Ch. 4)
Hemorrhoid office procedures (banding, sclerosing, infrared coagulation) (Ch. 5)
General perioperative management—anorectal (Ch. 7)
STAPLED HEMORRHOIDECTOMY/-OPEXY—PPH
Principle
Stapled hemorrhoidectomy/-opexy, also referred to as Procedure for Prolapse and Hemorrhoids (PPH), has evolved as the
preferred surgical option for most symptomatic internal hemorrhoids. In contrast to the excisional hemorrhoidectomy
(Ferguson, Milligan-Morgan), this technique does not result in an external wound in the highly sensitive anoderm. Using a
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circular stapler, a 2-cm tissue ring of mucosa is excised with simultaneous reanastomosis above the dentate line. The
primary goal is not to remove the hemorrhoids, but rather to lift the anorectal mucosa and reposition the hemorrhoidal
cushions (Figures 5–8A and 5–8B). The improved venous outflow in combination with the interrupted submucosal blood
supply decreases the hemorrhoidal congestion.
Figure 5–8A.
PPH stapled hemorrhoidectomy: impact of suture placement on resulting specimen.
Figure 5–8B.
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PPH stapled hemorrhoidectomy: before and after, and rectangular specimen.
Setting
Outpatient, OR procedure.
Alternatives
Excisional hemorrhoidectomy (Ferguson, Milligan-Morgan).
Hemorrhoid banding and other office procedures.
Indication
Circumferential internal hemorrhoids grade III, confluent grade II/I with relevant symptoms that are refractory to banding.
Not indicated for grade IV (incarcerated) hemorrhoids, if patient is primarily concerned about external hemorrhoid
component, or for patients with anoreceptive intercourse (risk of injury from residual staples).
Preparatory Considerations
Colonic evaluation per guidelines.
Administration of two enemas before operation. Single shot IV antibiotic prophylaxis. Disinfection of rectum with povidone-
iodine solution.
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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 in addition to general anesthesia to improve
relaxation of anal sphincter muscles. Insertion of circular anal dilator facilitated without the (obsolete) manual stretch.
3. Insertion of anal dilator with transparent anal retractor. The latter serves to protect dentate line and is sutured to
the skin.
4. Insertion of suture anoscope for placement of a mucosa-only purse-string suture 4–5 cm above dentate line,
avoiding large suture gaps on luminal surface (Figure 5–8A), ie, new stitch starts right where previous stitch exits.
5. Digital rectal exam to check that purse string tightens easily, smoothly and circumferentially around finger.
6. Careful insertion of fully deployed circular stapler through staple line. Any resistance requires reassessment.
7. Purse-string suture is tied down to rod, and sutures ends are carried through lateral openings in stapler.
8. Closure of stapler to maximum while moderate traction on purse-string sutures aims at pulling a maximal amount
of tissue into stapler chamber. No force should be necessary for closure.
9. Safety steps before the maximally closed stapler is actually fired:
a. Sutures holding transparent circular anal retractor are divided and a thorough circumferential inspection
around stapler is performed to ensure that dentate line has not accidentally been incorporated into stapler.
b. In females, a vaginal examination is mandatory to ensure that posterior vaginal wall has not been
incorporated/tethered into staple line.
10. Stapler is fired and kept in place in closed position for 5 minutes to ensure good hemostasis: often, no further
intervention is needed; occasionally bleeding from staple line requires electrocautery or insertion of hemostatic suture.
11. Removal of stapler and examination of specimen (Figure 5–8B).
12. Although anal skin tags can be removed separately, the benefit of stapled hemorrhoidectomy will be gradually
diminished.
Anatomic Structures at Risk
Vagina, rectum, sphincter complex/dentate line.
Aftercare
Stool softeners, fibers, pain medication. No need for sitz baths.
Complications
Bleeding, urinary retention, infection, pelvic/perineal sepsis, thrombosed external hemorrhoids, recurrent hemorrhoids,
incontinence to stool/gas. Rectal perforation or rectovaginal fistula is rare if proper technique is used. Risk of needing
colostomy: ~0.1%.
Cross-Reference
Prolapse (Ch. 1)
Anorectal landmarks (Ch. 3)
Pelvic and anorectal innervation (Ch. 3)
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Anal fissure (565.0) (Ch. 4)
Hemorrhoids (455.X) (Ch. 4)
Hemorrhoid office procedures (banding, sclerosing, infrared coagulation) (Ch. 5)
General perioperative management—anorectal (Ch. 7)
ANORECTAL FLAPS
Principle
Relocation of healthy and elastic vascularized tissue from a donor site to the anorectal area in order to replace, augment, or
cover areas of pathology.
Setting
Inpatient (selected outpatient?), OR procedure.
Alternatives
Direct coverage.
Open wound care.
Indication
Anal stricture.
Mucosal ectropion.
Cloaca-like deformity.
Defect closure after wide local excision.
Preparatory Considerations
Complete bowel cleansing.
Prophylactic antibiotics.
Most flaps do not need preemptive colostomy
creation in selected cases only.
Surgical Steps
1. Patient positioning: prone jackknife position; buttock taping depending on planned flap configuration.
2. Management of local pathology: eg, radial incision of stricture, excision of ectropion to level of dentate line, wide
local excision, etc.
(A) House Flap (Single or Multiple) for Limited Pathology in Anal Canal (Stricture, Ectropion): Figures 5–9a and
5–9b.
3. Marking of planned house flap(s) with a pen: care to achieve sufficient width (> 1.5 cm, up to 3–4 cm).
4. Incision and mobilization with preservation of blood supply (ie, no undermining): flaps have an automatic tendency
to drop toward anal canal.
5. Fixation in receiver site with interrupted absorbable sutures and complete maturation internally and on flap sides.
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6. Radial closure of harvest site(s); alternatively leave harvest site open.
Figure 5–9A.
Anal stricturoplasty with house flap.
Figure 5–9B.
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Bilateral anal house flaps.
(B) Rotational S-Flaps for Extensive Defect Closure (eg, after Wide Local Excision)
3. Marking of planned large S-flaps with a pen with turning point in anus, care to extend sufficiently onto buttocks (8–
10 cm diameter).
4. Incision and mobilization with preservation of adequate tissue layer for blood supply.
5. Rotation of flaps toward anal canal.
6. Fixation in most remote corner at receiver site with interrupted absorbable sutures and complete maturation of
internal circumference.
7. Closure of radial side of flap using interrupted absorbable sutures with larger advancement steps on external side
than on flap side, which results in closure of donor site.
(C) Large Bilateral Gluteal Skin Advancement Flaps for Extensive Defect Closure (eg, after Wide Local Excision)
3. Marking of planned large gluteal skin flaps (> 15 cm lateral length) with vertical length of medial side equal to half
the circumference of a large anoscope.
4. Incision and mobilization with preservation of adequate tissue layer for blood supply.
5. Advancement of flaps toward anal canal.
6. Fixation of ends of medial side anteriorly and posteriorly at anal canal, symmetric approximation of contralateral
flap, followed by complete circumferential maturation of mucocutaneous contact zone with interrupted absorbable
sutures.
7. Closure of radial side of flap using interrupted absorbable sutures with larger advancement steps on external side
than on flap side.
(D) Bilateral X-Flaps for Reconstruction of Perineal Body in Cloaca-Like Deformity
3. Marking of planned flaps on skin with two cruciate lines to intercept in remnant of rectovaginal septum: care to
obtain bilateral triangular skin flaps with wide enough angle (~40 degrees) to avoid ischemic changes at tips.
4. Separation of rectovaginal septum and reconstruction of anterior side anal canal, posterior side of vagina,
sphincteroplasty.
5. Moving X-flaps toward opposite side (beyond midline), which results in augmentation of perineum.
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6. Securing flaps in place with interrupted absorbable sutures.
Anatomic Structures at Risk
Sphincter complex, blood supply to the flaps, sufficient mobility.
Aftercare
Regular diet as tolerated 6 hours postanesthesia. Maintenance of soft stools (fibers, antidiarrheal medication, etc) as before
surgery.
Limitation of activity.
Complications
Bleeding (surgeon-dependent).
Infection, abscess/fistula formation.
Flap necrosis, flap dehiscence
stricture formation.
Need for colostomy in case of unmanageable situation.
Cross-Reference
Constipation (Ch. 1), (Ch. 4)
Anal fissure (565.0) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
Bowen disease (235.5) (Ch. 4)
Complications—delayed wound healing (998.3) (Ch. 4)
General perioperative management—anorectal (Ch. 7)
RECTOVAGINAL FISTULA REPAIR—ADVANCEMENT FLAP
Principle
Excision of the primary opening, reapproximation of the underlying muscular layer, mobilization of flap to cover the opening.
Since the rectum is the high-pressure compartment (compared with vagina), the repair from a physics standpoint should be
performed on the rectal side; rare circumstances may justify a repair from the vagina. Local repair is appropriate for low to
mid-level fistulae. High fistula (colovaginal) needs to be ruled out or managed through an abdominal approach. Fecal
diversion commonly is not necessary unless patient is very symptomatic.
Alternatives
Placement of a cutting seton.
Rectovaginotomy with layered closure of defect.
Insertion of collagen plug.
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Interposition of muscle flap (bulbocavernosus, gracilis).
Indication
Symptomatic low to mid-level rectovaginal fistula.
Preparatory Considerations
Fecal diversion if patient is very symptomatic and local area is not ready for repair (< 3–6 months after formation).
In elective cases, prior colonic evaluation per guidelines.
Clinical examination often sufficient; combination with imaging studies if anatomy is unclear.
Administration of full bowel cleansing before operation. Single shot IV antibiotic prophylaxis, depending on findings, to be
continued for 5 days. Disinfection of rectum and vagina 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. Lithotomy position for transvaginal approach.
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. Insertion of anal retractor and reassessment of fistula. Depending on local anatomy, placement of Lone Star
retractor may prove advantageous.
4. Limited excision of primary opening, removal of epithelialized tract within muscle layer.
5. Closure of muscular defect with interrupted Vicryl sutures.
6. Marking of U-shaped broad-based flap, with base starting distal to primary fistula opening, extending laterally and
proximally (one quarter to one third of anterior circumference). Atraumatic raising of flap: after adequate mobilization,
flap should cover defect without any tension. Careful hemostasis; avoid traction or diffuse cautery damage to flap.
7. Suturing flap in place in two layers: deeper muscular layer (Vicryl), maturation of mucosal anastomosis with
interrupted sutures (chromic).
8. Vaginal side left open.
Anatomic Structures at Risk
Sphincter muscle, rectovaginal septum, dentate line.
Aftercare
Stool management with softeners, fibers to avoid too soft/too hard bowel movements.
Pain medication.
Sitz baths.
Complications
Bleeding, urinary retention, infection, flap dehiscence with reopening of potentially larger fistula, need for colostomy,
incontinence to stool/gas, delayed wound healing, pain. Rare: pelvic/perineal sepsis.
Cross-Reference