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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1513_Библиотеки_им_академика_М_И_Перельмана.pdf
Videoanoscope Assisted Stapled Hemorrhoidopexy
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integrity or weaker sections may enhance bleeding risk or lead to recurrences in
long term [13]; the resected ring may include deeper structures in the case of a
deeper purse string suture which may lead to bleeding, hematoma and pelvic
sepsis [14,15]. Various complications caused by difficulties in applying the
technique or technical errors have been described in the literature [1-5,7-9]. We
believe that principally the purse string suture is referred to by ―the technique‖
since the purse string suture stage ultimately requires the surgeon‘s talent during
stapled hemorrhoidopexy procedure and the stapler only resects and staples the
tissue collected inside the anvil regardless of how and where the purse string
suture was placed [2,3]. The above-mentioned problems can be overcome by
putting the purse string suture ideally. A previous study reported that placing the
stapler line with a constant distance from linea dentata of 22 mm reduced the need
for narcotic analgesics and caused the patients to return to work earlier [1].
Preventing the hemorrhoids to fill in the anoscope may help putting the purse
string suture more conveniently. It has been reported that purse string suture is put
more conveniently and almost ideally using modified anoscopes [2-5,8, 16]. We
modified the purse string suture anoscope for several times in our clinic and,
finally, invented the videoanoscope at 2006.
The videoanoscope has additional advantages over other modified anoscopes.
First of all, the sliding lid of the videoanoscope prevents the prolapse of loose
tissues to fill inside the anoscope and block the vision. The sliding lid is pulled
open to a distance that is determined according to the amount of mucosa desired
to enter the window by the surgeon [4]. In other words, the sliding lid helps the
surgeon to determine and check the amount of mucosa to be sutured. It has been
reported that submucosal injection of isotonic saline solution separates the rectal
mucosa and submucosa layers from muscularis propria helping the surgeon to
include only the mucosa and submucosa inside the resected ring [17]. Injection of
isotonic saline solution into the half moon-shaped mucosa and putting sutures can
be easily performed using the videoanoscope. The anoscope becomes half-open
upon removal of the sliding lid allowing the surgeon to fully visualize the surgical
area, check the purse string suture, and make interventions when needed.
Videoanoscope also allows capturing a close-up of the surgical area and
transferring the video to a monitor. Therefore, the operation field was extended
for the surgeon by using the monitor during the procedure. The primary assistant
doctor in the surgery team can assist the surgeon by watching the monitor rather
than by trying to look inside the anoscope which limits the movements of the
surgeon, and the surgeon can put the purse string suture by either looking at the
surgical area or watching the monitor. The fact that all stages of the surgery can
be visualized by not only the surgeon and the assistant doctor but also by all
Ali Dogan Bozdag
126
people in the surgery room serves advantages during both the purse string suture
stage and the bleeding control stage of stapler line. In addition, the fact that the
videoanoscope allows the surgery to be recorded may help to improve the
education of general surgery [4]. In conclusion, ―videoanoscope-assisted stapled
hemorrhoidopexy‖ is a more controlled method that is suitable with general
surgical principles and reliable due to its additional advantages over other
anoscopes.
Figure 1.Videoanoscope
Videoanoscope Assisted Stapled Hemorrhoidopexy
127
Figure 2.Videoanoscope consists of three pieces.
Figure 3.The front piece is made up of an open-top conical-shaped cylinder that narrows at
the tip
Figure 4.The second piece is a sliding lid used to open and close the top of the front piece.
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Figure 5. The back piece contains a hollow handle inside which a 10-mm telescope can be
placed.
Figure 6.The front and the back pieces are locked to each other.
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129
Figure 7.The front and back pieces are disassociated by rotating the front piece .
Figure 8.The patient is prepared for surgery in Jackknife position following spinal
anesthesia .
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Figure 9. External hemorrhoids of the patient who has grade IV hemorrhoidal disease.
Figure 10. External and internal hemorrhoids of the patient who has grade IV
hemorrhoidal disease .
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131
Figure 11.The needle of the 2/0 atraumatic propylene is inserted inside the videoanoscope
by opening the sliding lid.
Figure 12. The needle is taken out after passing through the inside of the videoanoscope
which is illuminated by the telescope .
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Figure 13. A lubricant is applied to the tip of the videoanoscope.
Figure 14. The videoanoscope is pushed by one hand towards the anal canal.
Videoanoscope Assisted Stapled Hemorrhoidopexy
133
Figure 15. The videoanoscope is inserted inside the rectum easily due to its ergonomic
structure.
Figure 16.The telescope is directed towards the back piece.
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Figure 17.The surgeon is prepared for putting sutures .
Figure 18.The telescope illuminates the inside of the videoanoscope .