Operative Techniques




Tamponade Anal Canal



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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.




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.





Incision/Drainage of Perirectal Abscess (Simple)



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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



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%.





Modified Hanley Procedure for Horseshoe Fistula/Abscess



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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.



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 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.





Fistula‐in-Ano—Fistulotomy vs Seton



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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.



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.




Surgical Steps




  • 1. Patient positioning: prone jackknife position.
  • 2. For elective cases: pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve relaxation of the anal sphincter muscles.
  • 3. Insertion of anal retractor and circumferential examination of dentate line: identification of primary opening? If not visible: testing with injection of peroxide into secondary opening (avoid overflow spill) → appearance of bubbling at a primary opening?
  • 4. Careful probing of fistula tract with curved silver probe taking care to avoid creating new tract by forceful advancement. If insertion is not easy: placement of Kocher clamp to external opening and centrifugal traction (ie, away from anus) to straighten fistula tract while trying to insert probe again. If still no success: partial external fistulotomy to reassess course vs fistuloscopy (using ureteroscope). If primary opening cannot be found despite all attempts: removal or wide drainage of sinus, but unfortunately high chance of failure and reopening of a fistula later.
  • 5. Fistula tract successfully probed → assessment of the extent of sphincter involvement:

    • a. Fistulotomy: very superficial tract without relevant sphincter involvement (< 20%) → fistulotomy from secondary to primary opening along the probe (eg, with electrocautery).
    • b. Cutting seton: > 20% sphincter involved → cutting seton: devision of mucocutaneous layer between two openings without cutting through muscle (caveat: no cutting seton over intact skin), pulling in a suture tied to edge of gauze, scrubbing out fistula tract (with gauze or brush) → pulling in seton (eg, an elastic vessel loop), which is tied down with three sutures such that it just sits on the muscle without strangulating it.
    • c. Draining seton: > 20% sphincter involved but seton placement only to cool off suppuration, prevent recurrent abscesses (eg, long-term setons in Crohn disease), or mature fistula without immediate plan to eliminate fistula (but, eg, later fistula surgery with collagen plug): seton pulled into tract and tied to itself without division of mucocutaneous layer between primary and secondary opening.

  • 6. Hemostasis.
  • 7. No dressing needed.




Anatomic Structures at Risk



Anal sphincter complex, anal configuration (→ risk of keyhole deformity).




Aftercare



Open wound care until complete healing (fistulotomy), skin closure except for seton (cutting/draining seton): sitz baths or showers twice per day, after bowel movements.



Cutting seton: tightening of cutting seton in monthly intervals until it has eroded through the involved sphincter complex (leaving a scar behind): (Figure 5–3).




Complications



Bleeding, urinary retention (sign of sepsis?), recurrent infection, pelvic/perineal sepsis, recurrent/persistent fistula (10–15%). Fecal incontinence (benchmark < 5%): anal disconfiguration, sphincter weakness.





Fistula‐in-Ano—Endorectal Advancement Flap



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Principle



Closure of the primary fistula opening by means of a plication of the muscle layer and an overlying advancement flap to cover the site of the opening to induce an obliteration of the fistula tract once it is not fed anymore.




Setting



Outpatient, OR, general anesthesia.




Alternatives



Nonoperative management: generally not indicated if fistula is symptomatic.



Fistulotomy/fistulectomy.



Seton management.



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 primary opening; bilateral fistula openings or scars suggestive of horseshoe fistula; identification helpers—probing, peroxide injection, imaging (ERUS, MRI, etc).



Elective cases: partial/full colonic evaluation per guidelines.




Surgical Steps




  • 1. Patient positioning: prone jackknife position.
  • 2. 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.
  • 3. Insertion of anal retractor and identification of primary opening.
  • 4. Careful probing of fistula tract with silver probe.
  • 5. Insertion of anal retractor and reassessment of the fistula. Depending on local anatomy, placement of Lone Star retractor may prove advantageous.
  • 6. Limited excision of primary opening, removal of epithelialized tract within muscle layer, widening/excision of secondary opening.
  • 7. Closure of muscular defect with interrupted Vicryl sutures.
  • 8. Marking of U-shaped broad-based flap, 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.
  • 9. Suturing flap in place in two layers: deeper muscular layer (Vicryl), maturation of mucosal anastomosis with interrupted sutures (eg chromic).




Anatomic Structures at Risk



Anal sphincter complex, anal configuration (keyhole deformity).




Aftercare



Open wound care until complete healing of secondary opening: sitz baths or showers twice per day, after bowel movements.




Complications



Bleeding, urinary retention (sign of sepsis?), recurrent infection, pelvic/perineal sepsis, recurrent/persistent fistula (20–30%), creation of an ectropion, fecal incontinence.





Fistula‐in-Ano—Insertion of Collagen Plug



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Principle



Obliteration of the fistula tract by inserting and suturing in place a manufactured collagen plug through the primary fistula opening in the rectum. More durable than the fibrin glue injection, long-term data on this new method are pending.




Setting



Outpatient, OR, general anesthesia.




Alternatives



Nonoperative management: generally not indicated if fistula is symptomatic.



Fistulotomy/fistulectomy.



Seton management.



Fibrin glue injection.



Endorectal advancement flap.



Modified Hanley procedure.




Indication




  • • Transsphincteric fistula-in-ano.
  • • Not indicated: very superficial tract, very short tract, very large diameter tract, active suppuration.




Preparatory Considerations



Clinical assessment: identification of secondary (external) opening, potentially primary opening; bilateral fistula openings and scars suggestive of horseshoe fistula; identification helpers—probing, peroxide injection, imaging (ERUS, MRI, etc).



Elective cases: partial/full colonic evaluation per guidelines.




Surgical Steps




  • 1. Patient positioning: prone jackknife position.
  • 2. Disinfection.
  • 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. Insertion of anal retractor and identification of primary opening.
  • 5. Careful probing of fistula tract with silver probe.
  • 6. Limited excision/enlargement of secondary opening to facilitate drainage.
  • 7. Irrigation of tract with peroxide, otherwise no debridement or curettage.
  • 8. If internal opening is recessed: limited mobilization of mucosal edge.
  • 9. Rehydration of collagen plug for 2 minutes in antibiotic solution.
  • 10. Insertion of silver probe through secondary opening and pulling in a suture that is tied to end of rehydrated collagen plug.
  • 11. Pulling in plug from primary toward secondary opening until plug sits snugly.
  • 12. Transmuscular absorbable fixation suture to fix plug at primary opening, trimming of excess plug.
  • 13. Trimming of excess plug at secondary opening flush at skin level, no plug fixation.




Anatomic Structures at Risk



Anal sphincter complex.




Aftercare



Open wound care until complete healing of secondary opening: sitz baths or showers twice per day, after bowel movements.



Avoidance of strenuous activity, exercise, heavy lifting, intercourse for 2 weeks.



Avoidance of constipation or diarrhea.




Complications



Bleeding, urinary retention (sign of sepsis?), loss of the collagen plug, infection, pelvic/perineal sepsis, recurrent/persistent fistula (25–50%).





Excision of Pilonidal Cyst



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Principle



Elective excision of the pilonidal cyst and its associate fistulous tracts and pits. Multiple approaches are described with varying degrees of radicality, primarily open (Figure 5–4) vs primarily closed techniques.




Figure 5–4.



Primarily open excision of pilonidal cyst.





Setting



Outpatient, OR procedure.




Alternatives



Nonoperative expectant approach: quiescent disease, < 2 episodes.



I&D for acute flare-up with abscess.



Flap procedures.




Indication




  • • History of recurrent acute pilonidal disease (≥ 2 episodes).
  • • Chronic pilonidal sinus/fistula.
  • • Cancer (→ combined-modality treatment).




Preparatory Considerations



None except digital rectal exam.




Surgical Steps




  • 1. Patient positioning: prone jackknife or prone position, lateral taping of buttocks is not indicated.



(A) Primarily Open Technique




  • 2. Marking of symmetric elliptical skin incision, which incorporates all openings. Avoid proximity to anus (sphincter injury!).
  • 3. Incision of skin.
  • 4. Extirpation of whole specimen in such a way that a flat funnel-shaped wound results without undermining of wound edges.
  • 5. Marsupialization of wound edges is possible, but not needed if shape of wound is as required (see above).
  • 6. Hemostasis.
  • 7. Petroleum jelly gauze and absorbing dressing, no packing needed.



(B) Closed Technique with Lateral Approach




  • 2. Curved lateral incision, potentially with incorporation of eccentric secondary fistula opening.
  • 3. Undermining of subcutaneous tissue toward midline.
  • 4. Debridement of cyst and fistula tracts: it is not necessary to remove all indurated parts, just fistula as such.
  • 5. Excision of midline pits (eg, using punch biopsy).
  • 6. Debridement of fistulous tracts.
  • 7. Hemostasis.
  • 8. Closure of lateral incision and midline wounds with absorbable suture.



(C) Closed Technique with Midline Approach




  • 2. Marking of symmetric elliptical skin incision, which incorporates all openings. Avoid proximity to anus (sphincter injury!)
  • 3. Incision of skin.
  • 4. Extirpation of whole specimen in such a way that a flat funnel-shaped wound results without undermining of wound edges.



5. Hemostasis.




  • 6. Laying of 3–4 strong retention sutures from lateral, through the fascia at bottom of wound, to other side.
  • 7. Closure of wound in midline with interrupted sutures.
  • 8. Compression roll of a few gauzes over which lateral retention sutures are tied.




Anatomic Structures at Risk



Anal sphincter complex (at caudad end).




Aftercare



(A) Primarily Open Excision



No limit to physical activity. Daily showers/sitz baths, scrubbing of wound with cloth, removal of hair around wound (hair removal cream or razor).



(B) Closed Technique with Lateral Approach



Limited physical activity for 2–3 weeks.



(C) Closed Technique with Midline Approach



Strict limitation of physical activity for 2–3 weeks. Removal of compression roll after 7–10 days. Removal of stitches after 3 weeks.




Complications



Bleeding, infection, dehiscence (of closed wounds), recurrent fistula/sinus formation, delayed wound healing.





Excision/Fulguration of Anal Warts



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Principle



Surgical removal and/or destruction of anogenital condylomata. Electrocautery and laser are equally effective in terms of recovery time, pain, and scar formation, but laser is more expensive and associated with higher recurrence rate. Relatively limited number of warts can be treated with local anesthesia in the office; a larger extent requires systemic or regional anesthesia.




Setting



Outpatient, office or OR.




Alternatives



Nonoperative management: small extent, accessible (ie, typically external).



Wide excision with flap reconstruction: almost never primarily indicated, even in presence of confluent warts.



Laser destruction: more expensive equipment, no perioperative advantage, higher recurrence rates.




Indication




  • • Larger extent and/or number of external condylomata.
  • • Internal condylomata.
  • • Treatment-refractoriness with nonsurgical management.




Preparatory Considerations



Clinical assessment of all possible sites.



HIV status.



Rigid or flexible sigmoidoscopy to rule out concomitant STDs; full colonic evaluation per guidelines.




Surgical Steps




  • 1. Patient positioning: any position (prone jackknife, lithotomy, lateral) that allows access to affected sites, intraoperative change of position may be necessary.
  • 2. Disinfection.
  • 3. Safety precautions: small-pore surgical masks, suction-equipped electrocautery to minimize anecdotally reported hazard of HPV transmission to surgeon’s upper airways.
  • 4. Even if general anesthesia: preemptive injection of long-lasting local anesthetic.
  • 5. Insertion of anal retractor, assessment of internal involvement.
  • 6. Excision: careful grasping of individual warts with forceps and excision at their base with scissors or needle-tip Bovie. Process all removed tissues for pathology. Even primarily large and confluent-appearing warts often have multiple individual stalks and healthy skin areas may be preserved in between (Figures 5–5A and 5–5B).
  • 7. Fulguration with needle-tip Bovie: cauterization of smaller and flat warts, scratching off eschar, followed by repeat treatment.
  • 8. If fistula present, tract often colonized by condylomata → appropriate fistula treatment in conjunction with complete wart removal.
  • 9. Verification that all foci eliminated (internal and external).
  • 10. Hemostasis.
  • 11. Injection of 5 million units of interferon alfa (suspended in 5 mL of saline) diffusely into anoderm.
  • 12. No dressing needed.




Figure 5–5A.



Excision of confluent-appearing warts (separate stems as in a forest).





Figure 5–5B.



Excision/fulguration of warts.





Anatomic Structures at Risk



Anal sphincter muscle. Anoderm → risk of stenosis.




Aftercare



Open wound care: sitz baths or showers twice per day and after bowel movements.



Review of pathology: 10–20% incidence of carcinoma in situ → watchful waiting vs rebiopsy; rarely invasive cancer → wider reexcision vs other treatment modalities.



Follow-up in clinic every 3–6 weeks, every 3 months after wound healing.




Complications



Bleeding, infection (rare), delayed wound healing, recurrent wart formation (30–50%), incontinence to stool/gas, anal stenosis. Dyspigmentation.





Lateral Internal Sphincterotomy (LIS)



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Principle



Radial incision of internal sphincter muscle (open or closed technique) to achieve reliable reduction of the resting anal sphincter tone. LIS is the most successful of all treatment options for chronic anal fissures, but carries a risk of incontinence.



Sphincterotomy may be combined with excision of sentinel skin tag (external end of fissure) and/or hypertrophic anal papilla (internal end of fissure), or formal fissurectomy.




Setting



Outpatient, OR or office procedure.




Alternatives



Conservative management: stool management, topical nitroglycerin/calcium antagonist.



Botulinum toxin A injection.



Fissurectomy with/without midline sphincterotomy.



Fissurectomy with injection of Botulinum toxin A.



Fissurectomy with anal advancement flap.




Indication



Chronic anal fissure.



Contraindication: preexisting fecal incontinence. Caveat: careful decision for patients with underlying diarrhea (higher probability of fecal incontinence).




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.




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)%.





Overlapping Sphincteroplasty



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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.





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.



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.





Implantation of the Artificial Bowel Sphincter (ABS)



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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.



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.




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.





Hemorrhoid Office Procedures (Banding, Sclerosing, Infrared Coagulation)



Listen




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.




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.





Excisional Hemorrhoidectomy (Ferguson, Milligan-Morgan)



Listen




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 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.



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.



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%.





Stapled Hemorrhoidectomy/-Opexy—PPH



Listen




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 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.



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.




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%.





Anorectal Flaps



Listen




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.
  • 6. Radial closure of harvest site(s); alternatively leave harvest site open.




Figure 5–9A.



Anal stricturoplasty with house flap.





Figure 5–9B.



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.
  • 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.





Rectovaginal Fistula Repair—Advancement Flap



Listen




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.



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.





Rectovaginal Fistula Repair—Rectovaginotomy with Layered Closure



Listen




Principle



Complete transection of the perineal body between the rectal and vaginal fistula opening with excision of the epithelialized fistula tract and layered closure and reconstruction. Advantage: better exposure and more controlled closure of the various layers; disadvantage: more serious defect in cases of infection/dehiscence. Since a relevant rectovaginal fistula results in functional incontinence, transection/reconstruction of the sphincter muscle typically is well tolerated and not noticed as a disadvantage.



Method 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 before the repair or as a result of complications with dehiscence.




Alternatives



Placement of a cutting seton.



Endorectal advancement flap.



Insertion of collagen plug.



Interposition of muscle flap (bulbocavernosus, gracilis).




Indication



Symptomatic low to mid-level rectovaginal fistula, preferably preexisting sphincter defect.




Preparatory Considerations



Fecal diversion if patient is very symptomatic and local area is not ready for repair (< 3–6 months postformation).



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. IV antibiotic prophylaxis with continuation 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.
  • 4. Insertion of probe into fistula and division of whole perineal body with electrocautery. As various tissue levels are divided, marking corresponding tissues (eg, sphincter muscle) on either side with sutures.
  • 5. Excision of epithelialized fistula tract and mucosal mobilization on rectal and vaginal side.
  • 6. Layered closure, making sure both mucosal edges evert rather than invert. Reconstruction of sphincter muscle with 3–4 interrupted Vicryl sutures.
  • 7. Maturation of mucosal sides, closure of skin with subcuticular sutures.




Anatomic Structures at Risk



Sphincter muscle.




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.





Rectovaginal Fistula Repair—Muscle Flap Interposition



Listen




Principle



Perineal repair of the rectovaginal fistula with interposition of well-vascularized tissue to achieve separation of the two compartments and improve local wound healing. Typically indicated when local tissue quality is less than optimal (postradiation, postsurgical, recurrent fistula). Muscle generally is well suited as long as it can be adequately mobilized while maintaining its blood supply. Options for muscle flap include:




  • • Bulbocavernosus muscle (Martius flap).
  • • Gracilis muscle.
  • • Gluteus muscle.



Access through the perineum, separation of rectum and vagina with layered closure of each of them. Tunneled insertion of the muscle flap from its harvest site and interposition to keep the two sutured mucosal layers separate from each other. This type of local repair typically is reserved for high risk low- to mid-level fistulae. High fistula (colovaginal) typically is manageable without a flap. Fecal diversion commonly is not necessary unless the patient is very symptomatic.




Alternatives



Repair with endorectal advancement flap.



Placement of a cutting seton.



Rectovaginotomy with layered closure of defect.



Insertion of collagen plug.



Interposition of a collagen sheet.




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 postformation).



In elective cases, prior colonic evaluation per guidelines.



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.
  • 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, but obviously both sides will end up with a defect once rectovaginal fistula is transected.
  • 6. Limited excision of primary opening, removal of remnants of epithelialized tract within muscle layer.
  • 7. Layered closure and maturation of both mucosal sides, making sure both mucosal edges rather evert toward their lumen than invert.
  • 8. Muscle mobilization:

    • a. Bulbocavernosus muscle: paralabial longitudinal incision, dissection through relatively vascular tissue layer, identification and mobilization of bulbocavernosus muscle. Anterior transection, verification of preserved blood supply.
    • b. Gracilis muscle: three longitudinal medial incisions (or one complete incision), identification of muscle through proximal incision. Careful mobilization toward proximal neurovascular pedicle. Distal muscle mobilization. Disconnection of tendon as distally as possible.
    • c. Gluteus muscle: curved lateral parasacral incision, identification of posterior edge of gluteus muscle and its broad insertion to sacrococcygeal junction. Mobilization of a portion of muscle. Avoid avulsion of neurovascular pedicle near ischial tuberosity.

  • 9. Creation of tunnel from harvest site to perineum.
  • 10. Interposition of mobilized muscle flap and fixation of its tip on opposite side; loose fixation of muscle body in perineum to avoid shifting of its position.
  • 11. Irrigation of wound with diluted povidone-iodine (1:10). Hemostasis.
  • 12. Subcutaneous approximation sutures.
  • 13. Closure of skin incision(s).




Anatomic Structures at Risk



Integrity of rectovaginal septum. Vascular pedicles.




Aftercare



Stool management with softeners/fibers to avoid too soft/too hard bowel movements.

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Jan 14, 2019 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Operative Techniques
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