CHAPTER 17 Procedures for Benign Anorectal Disease
HEMORRHOIDS
INDICATIONS FOR SURGERY
I. Failure of Medical Therapy: Hemorrhoids often improve with Sitz baths, avoidance of excessive straining, stool softeners, and fiber supplementation. Patients with symptomatic hemorrhoids that do not improve with conservative management are candidates for more aggressive treatment. First-, second-, and third-degree hemorrhoids refractory to medical treatment are often treated with rubber band ligation, which can be performed in the office. Extensive third- and fourth-degree hemorrhoids are rarely amenable to conservative management or rubber band ligation and are typically treated with hemorrhoidectomy.
PREOPERATIVE EVALUATION
I. History: Internal hemorrhoids are typically painless and may cause bright red bleeding or prolapse with defecation. Patients with external hemorrhoids may complain of swelling and discomfort. In the absence of thrombosis, pain should not be attributed to hemorrhoids and alternative diagnoses should be sought.
II. Physical Examination: Physical examination of patients with hemorrhoids should include a digital rectal examination and anoscopy. In the absence of prolapse, anoscopic evaluation of internal hemorrhoids may show redundant anorectal mucosa. In patients who present with bleeding, endoscopic evaluation must be undertaken to exclude colorectal cancer.
COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY
II. Patient Positioning and Preparation: The patient is placed in the prone jack-knife position (supine and flexed at the hips). The perianal region is prepared and draped.
III. Surgical Approach
A. Rubber band ligation:
2. With a band applicator, two rubber bands are applied to each hemorrhoidal cluster above the dentate line (Fig. 17-1).
B. Closed hemorrhoidectomy:
2. Enlarged hemorrhoidal tissues are excised with an elliptical incision. Care is taken to preserve the underlying muscle fibers of the anal sphincters.
3. When multiple bundles are excised, intervening bridges of anoderm are preserved to avoid subsequent stenosis.
C. Stapled hemorrhoidopexy: A circular anal dilator/stapler is inserted into the anal canal. A purse-string suture is placed through the mucosa and submucosa of the anal canal, 3 to 4 cm above the dentate line, to draw the hemorrhoidal tissue into the stapling device. The stapler is fired to excise a 4-cm ring of rectal mucosa (Fig. 17-3).
COMPLICATIONS
I. Perineal sepsis is a well-described complication of hemorrhoidectomy. Severe postprocedure pain, inability to void, and fever may herald the onset of sepsis and should prompt emergent evaluation.
II. Bleeding is common after hemorrhoidectomy. Bleeding is usually self-limited, but occasionally requires operative intervention.
III. Urinary retention is common after hemorrhoidectomy. Although it is typically self-limited, temporary placement of a urinary catheter is sometimes necessary.
ANORECTAL ABSCESS
BACKGROUND
The majority of anorectal abscesses result from infection originating in the anal crypts located at the dentate line. Abscesses are classified as perianal (60%), ischiorectal (20%), intersphincteric (10%), or supralevator (9%), depending on their location (Fig. 17-4). Deep postanal space abscesses represent a particular challenge. The deep postanal space is protected from view by the sacrum, and abscesses originating in this cavity may track circumferentially into the ischiorectal, intersphincteric, or supralevator space before they are diagnosed (Fig. 17-5). This pattern of spread results in what is known as a horseshoe abscess.
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