Procedures for Benign Anorectal Disease

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CHAPTER 17 Procedures for Benign Anorectal Disease

Hooman Noorchashm, David J. Maron

HEMORRHOIDS

Case Study

A 45-year-old multiparous female presents to a general surgeon’s office complaining of intermittent painless bright red blood per rectum during bowel movements. She also notes anal discharge and perianal pruritis. She reports a long-standing history of constipation. Anoscopy is performed and shows redundant anorectal mucosa in the right anterolateral and right posterolateral positions.

BACKGROUND

Hemorrhoids are cushions of fibromuscular tissue that line the anal canal. Three main bundles of hemorrhoidal tissue are located at the right anterolateral, right posterolateral, and left lateral positions and play a role in anal continence. As it is used clinically, the term hemorrhoid connotes the pathologic engorgement of a cushion of hemorrhoidal tissue. Constipation, prolonged straining, and pregnancy may contribute to hemorrhoid development.

Hemorrhoids are broadly categorized as external or internal. External hemorrhoids develop distal to the dentate line and are associated with pain when they thrombose. Internal hemorrhoids develop proximal to the dentate line and are typically painless. Common presentations of internal hemorrhoids include bleeding and prolapse with defecation. The following classification system is used to describe internal hemorrhoids: (1) first-degree hemorrhoids are nonprolapsed, (2) second-degree hemorrhoids prolapse and spontaneously reduce, (3) third-degree hemorrhoids prolapse and must be digitally reduced, and (4) fourth-degree hemorrhoids are irreducible.

The dentate line is the junction between the columnar epithelium of the upper anal canal and the squamous epithelium of the lower anal canal, also known as the anoderm.

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.
II. Thrombosed External Hemorrhoids: Acute thrombosis of an external hemorrhoid may be associated with severe pain. Patients who present early after thrombosis (<72 hours) may benefit from incision and clot enucleation.

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.

COLORECTAL CANCER MUST ALWAYS BE EXCLUDED AS A SOURCE OF BLEEDING PER RECTUM.

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.

Has your patient undergone colonoscopy?

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

Rubber band ligation can be performed in the office setting and is frequently used for the treatment of first-, second-, and some third-degree hemorrhoids. Traditional open and closed hemorrhoidectomy procedures are technically similar and lead to comparable outcomes. As its name implies, the closed technique involves closure of the defect created by hemorrhoid excision and is the approach most frequently used in the United States. Stapled hemorrhoidopexy is an increasingly popular alternative that may be associated with less postoperative pain than traditional hemorrhoidectomy.

I. Preoperative Considerations

A. Bowel preparation is administered preoperatively.
B. Antibiotics to cover gram-negative and anaerobic bacteria are administered preoperatively.
C. Rubber band ligation is often performed without anesthesia in the office setting. Hemorrhoidectomy and stapled hemorrhoidopexy may be performed under general or spinal anesthesia.

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:

1. A speculum is inserted into the anal canal and the hemorrhoidal bundles are identified.
2. With a band applicator, two rubber bands are applied to each hemorrhoidal cluster above the dentate line (Fig. 17-1).

image

Figure 17-1 Rubber band ligation of hemorrhoids. Rubber bands are loaded onto the applicator, which is introduced into the anal canal. The hemorrhoidal bundles are suctioned into the applicator and bands are applied.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 17th ed. Philadelphia, Saunders, 2004.)

APPLICATION OF RUBBER BANDS BELOW THE DENTATE LINE IS ASSOCIATED WITH SEVERE PAIN BECAUSE THE ANODERM DISTAL TO THE DENTATE LINE IS INNERVATED BY SOMATIC PAIN FIBERS.

B. Closed hemorrhoidectomy:

1. A retractor is inserted into the anal canal, and the hemorrhoidal bundles are identified.
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.
4. After excision, defects are closed with absorbable suture (Fig. 17-2).

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).

image

Figure 17-2 Closed hemorrhoidectomy. A and B, The hemorrhoidal bundle is exposed and excised via an elliptical incision. Care is taken to preserve the underlying sphincter muscles. C, After excision, the defect is closed.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 17th ed. Philadelphia, Saunders, 2004.)

image

Figure 17-3 Stapled hemorrhoidopexy. A suture is placed through the mucosa and submucosa (A), which are drawn into the stapling device (B). The stapler is fired to excise a ring of hemorrhoidal tissue (C).

(From Cameron J: Current Surgical Therapy, 8th ed. Philadelphia, Mosby, 2004.)

POSTOPERATIVE COURSE

Hemorrhoidectomy is typically performed as an outpatient procedure. Patients may experience substantial postoperative pain and should be prescribed analgesic agents and stool softeners. Use of a doughnut cushion may improve comfort when sitting.

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.
IV. Stricture formation after hemorrhoidectomy has been associated with circumferential excision of anoderm. Preservation of intervening islands of anoderm between excised bundles may lessen the risk of stricture formation.

ANORECTAL ABSCESS

Case Study

A 35-year-old male presents to a surgeon’s office complaining of perianal pain and purulent discharge for the last 2 days. His symptoms preclude him from sitting or walking comfortably. One month earlier, the patient underwent incision and drainage of a perirectal abscess and began a course of oral antibiotics.

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.

image

Figure 17-4

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