Colon and Rectal Surgery Anorectal Operations [1 ed.] 1605476447, 9781605476445

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Steven D. Wexner James W. Fleshman

MasterTechniques in General Surgery Also available in this series:

Master Techniques in Breast Surgery December 2010 Kirby I. Bland, MD V. Suzanne Klimberg, MD

Master Techniques in Colon and Rectal Surgery: Anorectal Operations November 2011 Steven D. Wexner, MD James W. Fleshman, MD

Coming Soon

Master Techniques in Hernia Surgery September 2012 Daniel Jones, MD

Master Techniques in Stomach Surgery September 2012 Michael S. Nussbaum, MD Jeffrey H. Peters, MD

Master Techniques in Hepatobiliary and Pancreatic Surgery December 2012 Keith Lillemoe, MD William Jarnagin, MD

Master Techniques in Esophageal Surgery March 2013

James Luketich

COLON AND RECTALS ORECT OPERATIONS

Y:

Edited by

Steven D. Wexner, MD, FACS, FRCS, FRCS(Ed) Chairman, Department of Colorectal Surgery Chief Academic Officer and Emeritus Chief of Staff, Cleveland Clinic Florida Weston, Florida

James W. Fleshman, MD Professor of Surgery at Washington University in St. Louis Chief of Colon and Rectal Surgery Chief of Surgery Barnas Jewiah West County Hospital St. Louis, Missouri

Professor and Associate Dean for Academic Affe.irs Florida Atlantic UDive:rsity, Boca Rat011, Florida Professor and Assistant Dean for Clinical Education Florida International Univeul.ty College of Medicine Miami, Florida Professor of Surgery, Ohio State UDive:rsity Columbll8, Ohio Affiliate Professor Department of Surgery, Division of General Surgery University of South Florida College of Medicine Thmpa, Florida Affiliate Professor of Surgery UDive:rsity of Miami, Miller School of Medicine

Series Editor

Josef E. Fischer, MD William V. McDermott Professor of Surgery Harvard Medical School Chairman of Surgery, Emeritus Beth Inael Deaconess Hospital Boston, Massachusatta Chairme.n of Surge:ry Christian R Holmes Professor of Surgery Emeritus University of Cincinnati College of Medicine Cincinnati, Ohio

Illustrations by: BodyScientific Intemationai,uc. • . Wolters Kluwer I Lippincott Williams &Wilkins Health

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All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, induding photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, exc:ept for brief quotations embodied in c:ritic:al articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Colon and rec:tal surgery : anorectal operations/ edited by Steven D. Wexner, James Fleshman. p. ; em. - (Master techniques in general surgery) Indudes bibliographical references and index. ISBN 978-1-80547-844-5 (hardback: alk. paper) I. Wexner, Steven D. II. Fleshman, James. III. Series: Master techniques in general surgery. [DNLM: 1. Rectal Diseases-surgery. 2. Anal Canal-surgery. 3. Colon-surgery. 4. Rectum-surgery. WI 650] 617.5'55--dc23 2011040556 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in ac:cordanc:e with c:urrent recommendations and practice at the time of publication. However, in view of ongoing research, c:hanges in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to chec:k the pac:kage insert for eac:h drug for any c:hange in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medic:al devices presented in the publication have Food and Drug Administration (FDA) dearance for limited use in restricted research settings. It is the responsibility of the health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams It Wilkins on the Internet: at LWW.com. Lippincott Williams It Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST. 10 9 8 7 6 5 4 3 2 1

Dedication

Since books are tools by which teaching occurs, I dedicate this book to my loving sons, Wesley and Trevor who certainly taught me at least as many things as I have taught them. This book is also dedicated to that very special person who taught me the true meaning of life. Steven D. Wexner

Contributors

Maher A. Abbas. MD. FACS. FASCRS Chief, Colon and Rectal Surgery Chair, Center for Minimally Invasive Surgery Kaiser Permanente Los Angeles Assistant Professor of Surgery University of California, Los Angeles Los Angeles, California Herand Abcarian. MD. FACS Chairman Division of Colon and Rectal Surgery John H. Stroger Hospital of Cook County Professor of Surgery University of Illinois at Chicago Chicago, Illinois Jason W. Allen. MD Colon & Rectal Surgery Resident Cook County Colon 8r: Rectal Surgery Residency Training Program University of Illinois at Chicago Medical Center Chicago, Illinois S.Aiva,MD Clinical Assistant Professor Division of Colon and Rectal Surgery UMDNJ-Robert Wood Johnson Medical School, New Brunswick Edison, New Jersey David N. Annrtrong. MD. FRCS. FACS. FASCRS Program Director Georgia Colon and Rectal Surgical Clinic Atlanta, Georgia Cornelius Baeten. MD. PhD Professor of Colorectal Surgery Academic Hospital Maastricht The Netherlands Joshua I.S. Bleier. MD Assistant Professor of Surgery Division of Colon and Rectal Surgery University of Pennsylvania Hospital of the University of Pennsylvania Philadelphia, Pennsylvania S. 0. Breukink, MD Colorectal Surgeon Academic Hospital Maastricht The Netherlands

Federica Cadeddu. MD Assistant Professor Department of Surgery Division of General Surgery Tor Vergata University Hospital Rome, Italy Bertnm Chinn. MD Clinical Associate Professor Program Director, Colon and Rectal Surgery Fellowship Division of Colon and Rectal Surgery UMDNJ-Robert Wood Johnson Medical School, New Brunswick Edison, New Jersey

G. Willy Davila. MD Chairman, Department of Gynecology Head, Section of Urogynecology and Reconstructive Pelvic Surgery Cleveland Clinic Florida Weston, Florida Kurt G. Davis. MD Chief, General and Colon and Rectal Surgery Department of Surgery William Beaumont Army Medical Center El Paso, Texas C. Neal Ellis. MD Professor of Surgery Chief of Colon and Rectal Surgery University of South Alabama Mobile, Alabama James W. Fleshman. MD Professor of Surgery at Washington University in St. Louis Chief of Colon and Rectal Surgery Chief of Surgery Barnes Jewish West County Hospital St. Louis, Missouri Robert D. Fry, MD Emilie and Roland deHellebranth Professor of Surgery Chief, Department of Surgery, Pennsylvania Hospital Chair, Division of Colon and Rectal Surgery University of Pennsylvania Health System Pennsylvania Hospital Philadelphia, PA

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Contributors

Stanley M. Goldberg. MD University of Minnesota Division of Colon and Rectal Surgery Minneapolis, Minnesota Brooke Gurland. MD. FACS Cleveland Clinic Department of Colorectal Surgery Cleveland, Ohio Daniel 0. Herzig. MD. FACS. FASCRS Assistant Professor Department of Surgery Division of General Surgery Oregon Health &: Science University Hospital Portland, Oregon Tracy Hull. MD. FACS Department of Colorectal Surgery Cleveland Clinic Cleveland, Ohio Steven R. Hunt Assistant Professor of Surgery Section of Colon and Rectal Surgery Department of Surgery Washington University St. Louis, Missouri David Jayne. BSc. MBBCh. FRCS, MD Senior Lecturer &: Consultant Surgeon John Goligher Colorectal Unit Leeds Teaching Hospitals NHS Trust St. James University Hospital Leeds, United Kingdom Hermann Kassler. MD. PhD Professor of Surgery Department of Surgery University of Erlangen Erlangen, Germany Ira J. Kodnar. MD Solon &: Bettie Gershman Professor, Surgery Division of General Surgery Section of Colon and Rectal Surgery Director, Center for Colorectal and Pelvic Floor Disorders (COPE) Washington University School of Medicine St. Louis, MO Jorge A. Lag ares-Garcia. MD. FACS. FASCRS Program Director, Colorectal Surgery Residency Program Clinical Assistant Professor of Surgery Warren Alpert Brown University School of Medicine Providence, Rhode Island Clinical Instructor of Surgery Boston University Boston, Massachusetts R.I. Colorectal Clinic, LLC Pawtucket, Rhode Island

Paul Antoine LeHur. MD Head of the Department of Digestive and Endocrine Surgery Clinique de Chirurgie Digestive et Endocrinienne (CCDE) Institut des Maladies de l'Appareil Digestif (IMAD) Professor of Digestive Surgery School of Medicine of Nantes Nantes, France Antonio Longo. MD Colorectal Surgeon Department of Coloproctology St. Elizabeth Hospital Wien, Austria Ann c_ Lowry. MD. FASCRS. FACS Clinical Professor of Surgery Division of Colon and Rectal Surgery Department of Surgery University of Minnesota Minneapolis, Minnesota Kim C. Lu. MD. FACS. FASCRS Assistant Professor Department of Surgery Division of General Surgery Oregon Health &: Science University Hospital Portland, Oregon Najjia N. Mahmoud. MD Associate Professor of Surgery University of Pennsylvania Division of Colon and Rectal Surgery Philadelphia, PA David J. Maron. MD. MBA Assistant Professor of Surgery University of Pennsylvania Division of Colon and Rectal Surgery Penn Presbyterian Medical Center Philadelphia, Pennsylvania Klaus E. Matzal. MD Head Section Coloproctology Department of Surgery University Erlangen Erlangen, Germany Giovanni Milito. MD Associate Professor Department of Surgery Division of General Surgery Tor Vergata University Hospital Rome, Italy Husain Moloo. MD University of Ottawa The Ottawa Hospital Ottawa, Ontario, Canada

Contributors Sthela M. Murad-Regadas, MD, PhD Adjunct Professor Department of Surgery School of Medicine of the Federal University of Head of the Anorectal Physiology Unit Clinic Hospital Ceara, Brazil Abdel Rahman A. Omer, MBBS. MS. PhD, FRCS (Eng), RCS, MASCRS, FISUCRS, FRCS {Gen) Lead Consultant Colorectal, Laparoscopic and General Surgery Colorectal Surgical Unit The Ipswich Hospital NHS Trust Ipswich, United Kingdom Pablo E. Piccinini, MD, MAAC, MSACP Staff Colorectal Surgeon Professor in Surgery Department of Surgery Hospital Universitario CEJiv:fiC Buenos Aires, Argentina Rodrigo A. Pinto, MD Surgical Associate Division of Colorectal Surgery Department of Gastroenterology University of Sao Paulo, School of Medicine Sao Paulo, Brazil Fabio M. Potenti, MD. FACS, FASCRS Affiliate Associate Professor of Clinical Biomedical Sciences Charles Schmidt College of Medicine Florida Atlantic University Affiliate Associate Professor Herbert Werthein College of Medicine Florida International University F. Sergio P. Regedas, MD, PhD Titular Professor of Digestive Sw:gery School of Medicine of the Federal University of Ceara Vice President of the Brazilian Society of Coloproctology Ceara, Brazil Bruce W. Robb, MD Assistant Professor Department of Surgery Indiana University School of Medicine Indianapolis, Indiana Guillenno Rosato, MD. MAAC. MSACP, FASCRS Staff Colorectal Surgeon Professor in Surgery Department of Surgery Hospital Universitario Austral Buenos Aires, Argentina David A. Rothenberger, M.D. Deputy Chairman and Professor Department of Surgery University of Minnesota Minneapolis, Minnesota

Theodore J. Saclarides, MD Professor, Department of Surgery Rush University Medical Center Chicago, Illinois Dana R. Sands, MD Cleveland Clinic Florida Weston, Florida Oliver Schwandner, MD Department of Surgery and Pelvic Floor Center Caritas Krankenhaus St. Josef Regensburg, Germany lan KH Scot. MChir, MD, FRCS Emeritus Consultant Colorectal and General Surgery Colorectal Surgical Unit The Ipswich Hospital NHS Trust Ipswich, United Kingdom Anthony J. Senagore, MD, MS, MBA Chief, Division of Colorectal Surgery Skirball Chair of Colorectal Diseases Keck School of Medicine at the University of Southern California Los Angeles, California Matthew J. Shennan, MD, MS, FACS, FASCRS Colon &: Rectal Surgeon Kaiser Permanente Orange County Assistant Professor of Surgery University of California Irvine, California Marc A. Singer, MD Clinical Assistant Professor Section of Colon and Rectal Surgery North Shore University Health System Evanston, Illinois Clifford Simmang, MD Surgeon University of Texas Colon and Rectal Surgeons Dallas, TX Michael Solomon, MBBCh, BAD, MSc, FRACS Colorectal Surgeon Head, Surgical Outcome Research Centre The Royal Prince Alfred Hospital Clinical Professor Discipline of Surgery The University of Sydney Sydney, Australia Paul R. Sturrock, MD Assistant Professor of Surgery Department of Surgery Division of Colon and Rectal Surgery University of Massachusetts Medical School Worcester, Massachusetts

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Contributors

T. Weidinger. MD Department of Surgery University of Erlangen Erlangen, Germany Steven D. Waxnar. MD. FACS. FRCS. FRCS{Ed) Chairman, Department of Colorectal Surgery Chief Academic Officer Emeritus Chief of Staff Cleveland Clinic Florida Weston, Florida Professor and Associate Dean for Academic Affairs Florida Atlantic University Boca Raton, Florida Professor and Assistant Dean for Clinical Education Florida International University College of Medicine Miami, Florida Professor of Surgery Ohio State University Columbus, Ohio Affiliate Professor Department of Surgery, Division of General Surgery University of South Florida College of Medicine Tampa, Florida Affiliate Professor of Surgery University of Miami, Miller School of Medicine Miami, Florida

Caroline Wright. MBBS. MS. FRACS Colorectal Surgeon The Royal Prince Alfred Hospital Senior Lecturer Discipline of Surgery The University of Sydney Sydney, Australia Andrew P. Zbar. MD {Lond). FRCS (Ed). FRACS Conjoint Professor of Surgery Universities of New England and Newcastle New South Wales, Australia Oded Zmora. MD Colon and Rectal Surgery Department of Surgery and Transplantation Sheba Medical Center Tel Hashomer, Israel Sa.kler School of Medicine Tel Aviv University Tel Aviv, Israel

Foreword

We live in a high technology world where the "miracles" of modern surgery make headline news around the globe. It is no longer surprising to hear of yet another start-up medical technology company that promises a new surgical device that will save countless lives, improve outcomes, and significantly decrease pain and suffering. People find themselves mesmerized by watching "key hole surgery" broadcast in high definition to their home television and find it surprisingly elegant and bloodless compared to their prior mental picture of surgeons at work. So it is perhaps understandable that many patients today go online to find surgeons and institutions offering the newest approaches and latest technology. It seems as though the modem surgeon armed with high tech devices and digitalized equipment should be invincible. Indeed, it is easy for surgeons to be inappropriately swept up by the siren song of technical innovation. In this kind of world, one might question the utility of yet another surgical textbook, especially one devoted to operative technique. Fortunately, editors Steven Wexner and James Fleshman have created a unique publication that is a far cry from the traditional textbook of the past. The list of contributing authors includes seasoned master surgeons schooled in traditional techniques and highly innovative researchers and entrepreneurs who are exploring new frontiers of surgical technology. Over the course of their busy clinical careers, the editors themselves have successfully bridged both perspectives. Their unique experiences are apparent in this new, tightly edited and highly practical textbook that emphasizes tried and true open techniques and new, less invasive techniques. Drs. Wexner and Fleshman understand that surgical outcomes are dependent on many factors including clinical acumen and mature judgment to guide individualized decision-making. But they also know that surgeons must master basic operative skills and develop a full reservoir of different techniques that can be used to fit the demands of the case at hand. As importantly, they know that no matter how revolutionary or exciting, technology has its limits. Innovation is providing new tools but it is the surgeon's skill in deciding what tools to use and the way in which they are used that determines the surgical outcome. Operative technique remains critical to minimize patient morbidity, cure cancer and other life-threatening conditions, and preserve function and quality of life. All colon and rectal surgeons will find this book to be a valuable adjunct to their practice. The artist's color drawings are superb and anatomically correct. The text is easy to read, very focused, and useful for busy surgeons. I congratulate the editors for bringing this book to us. David A. Rothenberger, MD August 1, 2 011

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Preface

The Mastery of Colorectal Surgery textbook is a two volume compendium that demonstrates virtually all of the currently employed techniques for abdominal and anorectal surgery. All of the chapters have been written by internationally acclaimed experts, each of whom was given literary license to allow the book to be more creative and less rigorously formatted. Although some techniques are self-explanatory and the authors therefore concentrated their verbiage upon results and controversies surrounding a particular technique, other procedures are described in a more algorithmic manner. Specifically, some techniques require a much more heavily weighted description of preoperative and/or postoperative parameters rather than intraoperative variables. The matching of illustrations and videos has also been tailored to suit the needs of each chapter. Because of the quantity of material, the book is divided into two volumes: one that includes the abdominal and one that includes anorectal procedures. While many textbooks vie for the attention of surgeons in training and surgeons in practice, the Mastery series, edited by Dr. Josef Fischer, has established itself as the resource for expert management of each theme. Therefore, this book was deliberately crafted to augment rather than to replace several other excellent recently published textbooks. It is our hope that these volumes be used in that context so that the reader can learn the fundamentals and basics using many other excellent source materials and then rely upon the Mastery of Colorectal Surgery books for more clarity in terms of review of very specific procedures. In that same manner, these books perform a ready preoperative resource before embarking upon individual procedures. We wish to thank Josef Fischer with having entrusted us with this latest of his literary offspring. The project took a considerable amount of time and effort and we certainly thank him for his patience. In addition, we thank our respective staff in Weston and in Saint Louis, especially Liz Nordike, Heather Dean, Dr. Fabio Potenti, and Debbie Holton for their extensive efforts as well as Nicole Demoski at Wolters Kluwer. We wish to express our sincerest and deepest gratitude to each and every contributor for their time, attention, expertise, and commitment to the project. Without our individual chapter authors, this work would not exist. We know that each of them has many significant competing obligations for their limited time and thank them for having participated to such an important degree in this project. Last, our appreciation goes to our families for their love and support as it is always time away from them that allows us to produce these type of books. In particular, appreciation goes to Linda Fleshman and to Wesley and Trevor Wexner.

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Contents

Contributors vii Foreword xi Preface xiii

----PART 1: 1

HEMORRHOIDECTOMY

Ferguson 1 Anthony J. Senagore

2

Liga8ure™ 5 Giovanni Milito and Federica Cadeddu

3

Harmonic Scalpel® 15 Dav:id N. Armstrong and Kurt G. Dav:is

4

Procedure for Prolapse and Hemorrhoids (PPH; Stapled Hemorrhoidopexy) 25 Oliver Schwandner

---

PART ll: ANAL FISTULA 5

Flaps (Excision and Closure, Mucosal, Skin) 39 M. Solomon and C. Wright

6

Fistulotomy and Fistulectomy 51 H. Kessler and T. Weidinger

7

Anal Fistula Plug

71

Bruce W. Robb and Marc A. Singer

8

Ligation of the lntersphincteric Fistula Tract (LIFT) 79 Husein Moloo, Joshua I. S. Bleier, and Stanley M . Goldberg

---

PART III: RECTOVAGINAL FISTULA 9

Transperineal Approach 85 C. Neal Ellis

10

Transanal Repair 91 Ann C. Lowry XV

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Contents

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PART IV: OPERATIONS FOR FECAL INCONTINENCE 11

Overlapping Repair 107 Brooke Gurland and Tracy Hull

12

Dynamic Graciloplasty 115 Cornelius Baeten and S. Breukink

13

Artificial Bowel Sphincter 123 Paul-Antoine Lehur and Steven Wexner

14

Sacral Nerve Stimulation 135 Klaus E. Matzel

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PART V: PERINEAL PROLAPSE REPAIR 15

Delorme 149 Abdel Rahman A. Omer and Ian K.H. Scot

16

Altemeier 155 Dana R. Sands

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PART VI: SPHINCTEROTOMY-LATERAL 17

Open Lateral Internal Sphincterotomy 163 S. Alva and Bertram Chinn

18

Sphincter-Sparing Surgical Alternatives in Chronic Anal Fissure 171 Andrew P. Zbar

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PART VII: PRESACRAL TUMORS 19

Technical Considerations in the Surgical Management of Presacral Thmors 179 Najjia Mahmoud and Robert Fry

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PART VID: LOCAL EXCISION OF RECTAL CARCINOMA 20

Standard Transanal 193 Steven R. Hunt

21

Transanal Endoscopic Microsurgery 199 Theodore john Saclarides

Contents

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PART IX: RECTOCELE 22

Transvaginal 213 G. Willy Davila

23

Transanal 223 Sthela M. Murad-Regadas and Rodrigo A . Pinto

24.

Transperineal 227 Guillermo Rosato and Pablo E. Piccinini

25

Repair with Mesh 233 Clifford Simmang and Nell Maloney

26

STARR 237 David jayne and Antonio Longo

2'7

Transtar 245 David jayne and Antonio Longo

28

TRREMS Procedure-Transanal Repair of Rectocele and Full Rectal Mucosectomy with One Circular Stapler 251 Sergio P. Regadas

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PART X: MUSCLE FLAPS

29

Gluteus Maxim.us Transposition

255

Jason W. Allen and Herand Abcarian

30

Gracilis Muscle Flaps 261 Oded Zmora and Fabio M. Potenti

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PART XI: ANAL AND PILONIDAL FLAPS

31

House, Diamond, V-Y 277 james W. Fleshman and Ira J. Kodner

32 33

Endorectal Advancement Flap 283 Maher A. Abbas and Matthew f. Sherman Sleeve Advancement 295 David]. Maron

34

House Flap Anoplasty for Bowen's Disease 301 Jorge A . Lagares-Garcia and Paul R. Sturrock

35

Cleft Lift Procedure for Pilonidal Disease 311 Kim C. Lu and Daniel 0. Herzig

Index 317

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1

Ferguson Anthony J. Senagore

ｾ＠

INDICATIONS/CONTRAINDICATIONS

The most frequent symptoms leading to surgical intervention for hemorrhoidal suffers are bleeding, protrusion, and anorectal discomfort and pain. 1. Bleeding typically bright red blood on the toilet paper or dripping into commode. 2. Occasionally massive bleeding with very large internal hemorrhoids. 3. Hemorrhoidal prolapse usually with bowel movements that may spontaneously

reduce, require manual reduction, or be irreducible depending on stage. 4. Severe, constant pain is usually related to acute thromboses of internal or external

hemorrhoids and associated with a palpable perianal mass. Examination of the patient with hematochezia requires inspection of the perianal area including anoscopy and either rigid proctoscopy or flexible sigmoidoscopy. Colonoscopy can be undertaken based on patient's history, age, or suspicious symptomatology. The author prefers examination in the modified Sims' position (left lateral decubitus with knees drawn toward the chest and the lower legs extended). This position approach allows relative patient comfort, while allowing the clinician to perform all components of the anorectal examination. 1. A careful digital examination of the anal canal and distal rectum and prostate 2. Anoscopy to clearly inspect the hemorrhoidal tissue and anal canal with assessment

of size, degree of prolapse, and any fragility or bleeding 3. Proctoscopy or flexible sigmoidoscopy to exclude neoplasia or inflammation 4. Assessment of the three standard columns (right anterior, right posterior, and left

lateral)

Y

PREOPERATIVE PLANNING

The decision to proceed to excisional hemorrhoidectomy requires a mutual decision by the physician and patient that medical and nonexcisional options have either failed or are inappropriate. Surgery is typically employed when the primary symptom is

1

2

Part I

Hemorrhoidectomy

significant, intractable hemorrhoidal prolapse, or alternatively large external skin tags that impair anal hygiene. Preoperative preparation is generally minimal as the patient population is generally healthy and the procedure is typically ambulatory. If the patient is on therapeutic anticoagulation, this should be managed in conjunction with the managing physician to control the risk of hemorrhage postoperatively 1. The procedures are usually performed in the operating theater following preopera-

tive sodium phosphate enemas to clear the distal rectum of stooL 2. The modified Sims' position is the preferred position by the author for all excisional procedures except for procedure for prolapsing hemorrhoid (PPH) that is optimally performed in lithotomy position. 3. Anesthetic selection is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is highly effective and short acting. 4. Avoid spinal anesthesia due to risk of urinary retention. 5. Restrict intraoperative fluids. 6. Administer preemptive analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) in operating room.

SELECTION OF EXCISIONAL TOOL Surgery Options for excisional hemorrhoidectomy include the following techniques: Milligan-Morgan hemorrhoidectomy 1. This technique resects the entire enlarged internal hemorrhoid complex; in conjunction with ligation of the arterial pedicle correctly performed the intervening anoderm is preserved, while the distal anoderm and external skin are left open to heal by secondary intention. Ferguson closed hemorrhoidectomy 2. Proposed as an alternative to the Milligan-Morgan technique with similar experience and efficacy. The technique employs an hourglass-shaped excision of the entire internal/ external hemorrhoidal complex centered at the mid portion of the anoderm with preservation of the intervening anoderm. Unlike the Milligan-Morgan, the rectal mucosa, anoderm, and perianal skin are closed primarily with an absorbable suture. Whitehead hemorrhoidectomy 3. This technique employs a circumferential excision of the enlarged hemorrhoids with relocation of the prolapsed dentate line to its normal anatomic location in the anal canal. The procedure is effective but given the complexity and the high risk of mucosal ectropion and anal stricture it has largely been abandoned. Procedure for prolapsing hemorrhoids 4. The technique involves transanal placement of a circular purse-string suture placed 1-2 em rostral to the hemorrhoidal pedicle. A specially designed anoscope is used to reduce the hemorrhoids and protect the anoderm during the procedure. A 31-mm stapler is placed transanally to perform a circumferential excision of rectal mucosa just rostral to the hemorrhoidal columns. The purse-string suture is tied securely around the rod of the stapler and then threaded back through the barrel of the device to draw the rectal mucosa into the barrel and allow for repositioning of both the anoderm and hemorrhoidal columns prior to closing and firing the device. 'I!ansanal hemorrhoidal dearterialization 5. This is a technique that involves Doppler-guided hemorrhoidal artery ligation, or transanal hemorrhoidal dearterialization (THD). While not truly an excisional technique, the guided reduction in arterial blood flow coupled with a suture fixation of the mucosa to correct the mucosal prolapse. A specifically designed proctoscope

Chapter 1 Ferguson

with an attached Doppler transducer is inserted to allow identification of the feeding hemorrhoidal artery and via a small window the rectal mucosa 2-3 em above the dentate line is transfixed so that the signal is ablated. A suture mucosopexy is almost always required to lift, pexy, and ultimately ablate the hemorrhoidal complex. The combination of dearterialization, replacement of the hemorrhoidal tissue, and tissue destruction work in concert to correct the hemorrhoidal symptoms.

Instrumentation far Exciaianal Hemorrhoidectomy The claasic instrument of performance of an excisional hemorrhoidectomy has been a scalpel or scissors. This approach is highly effective and of low cost compared to other devices. A variety of energy devices have been used with varying claims of superior speed, reduced bleeding, and less pain. The data remain highly debated and the authors' preference is to use. These instruments: 1. Nd-Yag laser-Although capable of excising hemorrhoidal tissue, the device waa

found to be slower, more costly, and actually delayed healing of the wound leading to increased pain. 2. Monopolar electrocautery-The device is an effective excisional tool capable of improved hemostasis compared to scalpel. It can allow transection of the hemorrhoidal pedicle without suture ligation, at the expense of greater tissue trauma because of lateral thermal spread. 3. LigaSure-A bipolar cautery device capable of simultaneous tissue division and blood vessel coagulation. It has been compared to other e:xcisional tools and has been associated with faster operative times and allows for a sutureless technique. 4. Harmonic Scalpel-The device employs a rapidly reciprocating blade to generate heat for coagulation and tissue transection. The device is relatively expensive and has not demonstrated significant clinical advantages to offset that cost, primarily because of the aasociated thermal tissue injury.

POSTOPERATIVE MANAGEMENT Pain remains the most challenging component of postoperative care following excisional hemorrhoidectomy, especially from the patient's perspective. The optimal analgesic regimen should begin with the accurate in6.ltration ofbupivacaine into the wounds and perianal skin although its use has been variably successful in long-term pain reduction. NSADJ, especially ketorolac, has been very efficacious in managing post-hemorrhoidectomy pain. The patient can then be transitioned to a less expensive oral NSAID for ambulatory analgesia in combination with oral narcotic supplements. The administration of narcotics either by patch or subcutaneous pump has been advocated for posthemorrhoidectomy pain; however, these delivery systems are risky in the ambulatory setting respiratory depression. Urinary retention is another frequent post-hemorrhoidectomy (1-52%) complication. Agents such as parasympathomimetics or a-adrenergic blocking agents may be beneficial. However, the use of sitz baths for comfort and the limitations of perioperative fluid administration to 250 ml may be a more effective approach. Early postoperative bleeding (