PROCEDIMEINTOS ANORECTALES BENIGNOS

Indications Hemorrhoidectomy Internal hemorrhoids: grade III and IV hemorrhoids, symptomatic combined internal and external hemorrhoids, bleeding, incarceration, or failure of conservative management. External hemorrhoids: acute thrombosis < 72 hours post-onset. Pilonidal Cyst Excision and Marsupialization Recurrent acute pilonidal infections. Chronic pilonidal sinus. Anorectal Abscess and Fistula Acute perirectal abscess. Anorectal fistula.

Contraindications Hemorrhoidectomy Absolute Anorectal Crohn's disease or Crohn's proctitis. Acquired immunodeficiency syndrome. Relative Portal hypertension. Pregnancy. Coagulopathy. Pilonidal Cyst Excision and Marsupialization The presence of cancer requires additional treatment. Anorectal Abscess and Fistula Multiple fistulous tracts in a patient with Crohn's disease may require additional studies of the colon and sphincter mechanism prior to definitive surgical treatment.

Informed Consent Hemorrhoidectomy Expected Benefits Resolution of hemorrhoids and symptoms. Potential Risks Common complications include significant postoperative pain, urinary retention, bleeding, incontinence, infection, and anal stenosis. Risk of bleeding is increased with emergent hemorrhoidectomy, during pregnancy, and in patients with portal hypertension or coagulopathy. Rectal perforation, rectovaginal fistula, and retroperitoneal and pelvic sepsis are rare risks of circular stapled hemorrhoidopexy and may be avoided with proper technique. Pilonidal Cyst Excision and Marsupialization Expected Benefits Resolution of cyst and infection. Prevention of recurrence. Potential Risks Primary cyst excision with marsupialization requires daily wound scrubbing and strict attention to shaving hair in wound proximity. Time to healing may be several months. Rate of recurrence is approximately 6%. Rate of wound breakdown is 2–3%. Anorectal Abscess and Fistula Expected Benefits Resolution of abscess or fistula. Potential Risks Common complications of surgery include: Fistula in ano. Abscess. Incontinence due to iatrogenic sphincter injury.

Equipment No special equipment is required for hemorrhoidectomy, pilonidal cyst excision, or the treatment of anorectal abscess and fistula. Circular Stapled Hemorrhoidopexy 33-mm hemorrhoidal circular stapler.

Patient Preparation Hemorrhoidectomy Thorough preoperative workup to confirm diagnosis, hemorrhoid grade, and symptomatic status is essential before recommending hemorrhoidectomy. If bleeding is the indication for hemorrhoidectomy, examination of the colon and rectum for other potential sources of bleeding may be indicated. In patients with portal hypertension, hemorrhoids must be distinguished from anorectal varices. The rectum may be evacuated with an enema immediately before the operation. Pilonidal Cyst Excision and Marsupialization Digital rectal examination should be performed to evaluate for a presacral tumor. The patient is examined to identify the location of pits and presence of infection or abscess. Surrounding hair is shaved after patient positioning on the operative table. Anorectal Abscess and Fistula A thorough preoperative workup is essential to confirm the diagnosis, evaluate the immune status of the patient, and determine the presence of an underlying disease process such as Crohn's disease that might require additional studies prior to surgical therapy. Preoperative anorectal examination to determine the complexity of the process may guide anesthetic choices and surgical planning.

Patient Positioning Hemorrhoidectomy The patient should be in the prone jackknife position with buttocks taped aside. The procedure is performed under general anesthesia or intravenous sedation with local anesthesia. Left anterolateral positioning and local anesthesia are suggested for pregnant patients. Pilonidal Cyst Excision and Marsupialization The patient should be in the prone jackknife position; lateral decubitus position may also be used. The procedure may be performed under general anesthesia or local anesthesia with intravenous sedation. Anorectal Abscess and Fistula The patient should be in the prone jackknife position with buttocks taped aside. The procedure is performed under general anesthesia, regional anesthesia, or intravenous sedation with local anesthesia.

Procedure Surgical Hemorrhoidectomy A Hill-Ferguson retractor is inserted to obtain exposure. Figure 26–1A: The internal hemorrhoid is grasped with forceps and retracted outward. A suture ligature is placed at the proximal aspect of the vascular pedicle. This suture should not be cut. Figure 26–1B: The internal hemorrhoid and external component are grasped with a clamp. Electrocautery is used to make a V-shaped incision in the mucosa around the hemorrhoidal bundle starting at the base of the internal hemorrhoid beyond the anal verge and continuing toward the ligated pedicle. The hemorrhoid is then carefully dissected from the underlying anal sphincter. Dissection should be continued cephalad in the avascular plane between the hemorrhoid and internal sphincter using Metzenbaum scissors or electrocautery. When the internal portion of the hemorrhoid is elevated off the sphincter muscle to the level of the pedicle, the pedicle should again be suture-ligated followed by excision of the hemorrhoid. Figure 26–1C: After the hemorrhoid is excised, the mucosal defect should be reapproximated using running 3-0 Vicryl or other absorbable suture of adequate tensile strength starting proximally at a site immediately adjacent to the suture-ligated base of the hemorrhoid. Figure 26–1D: The completed hemorrhoidectomy, showing reapproximation of the mucosal defect with running absorbable suture. Circular Stapled Hemorrhoidopexy A retracting anoscope and dilator is inserted and the obturator is removed. Upon removal of the obturator, prolapsed tissue should fall into the dilator lumen. The operating anoscope is then inserted and a purse-string suture is placed. Figure 26–2: A monofilament purse-string suture is placed 4–5 cm above the dentate line taking care to avoid suture gaps by starting the new stitch where the previous stitch exits. A circular stapler is carefully placed through the purse-string suture and the suture is tied down to the stapler rod. The suture ends are brought through the lateral openings in the stapler. The purse-string suture is retracted with moderate traction to pull the anorectal mucosa into the stapler and the stapler is closed. Tissue around the stapler should be examined before firing the stapler to ensure that the dentate line is not incorporated into the staple line. In women, a digital vaginal examination should be performed to ensure that the posterior vaginal wall is not tethered to the staple line. After firing, the stapler is kept in place for 20 seconds to ensure hemostasis. The stapler should then be removed carefully and the site inspected. Anoscopic examination will reveal persistent internal hemorrhoids as this technique does not completely excise hemorrhoidal tissue. Figure 26–2 Pilonidal Cyst Excision and Marsupialization A probe is inserted into the midline opening, and the skin superficial to the probe is opened with a scalpel or Bovie electrocautery. Secondary tracts are unroofed in an analogous manner. Curettage is performed at the base of the wound. Once all tract and pits have been exposed, a symmetric elliptical skin incision is marked that incorporates all openings. An en bloc excision of the cyst, pits, secondary openings, and areas of inflammation is performed with creation of a shallow funnel-shaped wound. Care should be taken to avoid undermining the wound edges. Figure 26–3: Marsupialization is performed by sewing the skin edges to the fibrotic base of the wound using a 2-0 absorbable suture in a continuous locking fashion. The goal of marsupialization is to minimize the wound size and prevent premature wound closure. After hemostasis is obtained, petroleum jelly gauze and a dry dressing are applied. Figure 26–3 Simple Abscess Drainage Figure 26–4: Classification system for anorectal abscesses. After the area of maximal erythema or fluctuance, or both, is identified, the perianal skin is prepared with povidone-iodine. A local anesthetic solution, typically lidocaine with epinephrine, is administered. A cruciate or elliptical incision is made and the skin edges are trimmed to allow adequate drainage and prevent closure of the skin prior to adequate granulation of the abscess cavity. The site is inspected to ensure hemostasis and the cavity is then lightly packed with gauze. Figure 26–4 Anorectal Fistula Figure 26–5: Classification of fistula in ano. A, Subcutaneous. B, Intersphincteric. C, Transsphincteric. D, Supralevator. E, Extrasphincteric. The perianal area is prepared with povidone-iodine. The external opening of the fistula is identified on the perianal skin. An anoscope is inserted to evaluate the anal canal and rectum and identify the internal opening of the fistula. A probe is gently passed from the internal opening of the fistula toward the external opening to determine the direction of the fistulous tract. If the internal opening is not easily identified, hydrogen peroxide can be injected through the external opening using a 10-mL syringe and an 18-gauge angiocatheter. If the injection is successful, the internal opening will be marked by the presence of bubbles. Careful palpation is performed to assess the involvement of the anal sphincter. If < 50% of the sphincter muscle is involved, a fistulotomy should be performed by passing the metal probe along the entire length of the fistula tract and dividing the tissue overlying the probe. Curettage is performed on the opened tract to remove epithelialized tissue. If > 50% of the sphincter is involved, a vessel loop should be attached to the probe, introduced through the fistula tract, and secured to form a seton around the sphincter. Figure 26–5 Postoperative Care Hemorrhoidectomy Postoperative care includes analgesia, stool softeners, fiber supplementation, and sitz baths. Pilonidal Cyst Excision and Marsupialization Wound care includes daily showers or sitz baths, cleansing of wound, and removal of all hair within 3–4 cm of wound edges. The wound should be packed wet-to-dry with normal saline twice daily. Anorectal Abscess and Fistula Antibiotics are generally not indicted in healthy patients with a simple abscess. Antibiotics should be given for abscesses in patients with immunosuppression, diabetes, valvular heart disease or prosthetic valves, extensive soft tissue cellulitis, and signs of systemic infection or sepsis. Wound care includes sitz baths twice daily and after bowel movements. Following abscess drainage, the cavity is lightly packed with a gauze tape. Patients should receive adequate analgesia and stool softeners. Potential Complications Hemorrhoidectomy Early Pain. Urinary retention. Bleeding. Infection. Fecal impaction. Late Anal stricture. Anal tags. Incontinence. Mucosal prolapse. Ectropion. Pilonidal Cyst Excision and Marsupialization Recurrent pilonidal sinus formation. Infection. Bleeding. Delayed wound healing. Anorectal Abscess Drainage Incomplete drainage may lead to recurrent anorectal abscesses, especially in patients with ischioanal and intersphincteric abscesses. Incontinence from iatrogenic injury to the sphincter. Necrotizing perineal infection occurs in < 1% of patients. Fistula in ano. Sepsis. Anorectal Fistula Fecal incontinence. Bleeding. Recurrent fistula. Pearls and Tips Surgical Hemorrhoidectomy Pudendal and perianal nerve block with local anesthetic may be administered to improve relaxation of anal sphincter muscles. If multiple hemorrhoidal piles are to be excised, be sure to retain an adequate tissue bridge between the various excision sites to reduce the risk of stricture. Circular Stapled Hemorrhoidopexy Procedure is best reserved for grade II and III hemorrhoids not adequately treated with banding and grade IV hemorrhoids if reducible under general anesthesia. Limit the purse-string suture to the mucosa and submucosa to avoid incorporating the muscular layer of the rectal wall or the vaginal wall. Bleeding from the staple line may be easily controlled by oversewing the bleeding point. Pilonidal Cyst Excision and Marsupialization To avoid sphincter injury, be aware of proximity to the anus. Anorectal Abscess A modified Hanley procedure is indicated for horseshoe abscess. Anorectal Fistula Avoid passing the probe through the external opening of a fistula to identify the tract as this may create a false passage. The Goodsall rule is often more accurate in women and may be misleading for external openings > 3 cm from the anal verge. The lay open fistulotomy technique may be used for intersphincteric and low transsphincteric fistulae. Seton placement is appropriate for high transsphincteric fistulae. References Cintron JR, Abcarian H. Benign Anorectal Hemorrhoids. In: Wolff BD, Fleshman JW, Beck DE, et al, eds. ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer; 2007:156–177. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am. 2002;82:1169–1185.[PubMed: 12516846] [Full Text] Vasilevsky CA, Gordon PH. Benign Anorectal Abscess and Fistula. In: Wolff BD, Fleshman JW, Beck DE, et al, eds. ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer; 2007:192–214.