Perianal Surgery Flashcards
Haemorrhoids pathophysiology
Disrupted and dilated anal cushions
• Gravity, straining → engorgement and enlargement of
anal cushions
• Hard stool disrupts connective tissue around
cushions.
• Haemorrhoids arise above dentate line - not painful
Presentation of haemorrhoids
• Fresh painless PR bleeding - Bright red - On paper or stool • Pruritis • Lump in perianal area • Severe pain = thrombosis
Haemorrhoid Investigation
- Full abdo exam
- Inspect perianal area: masses, recent bleeding
- DRE: can’t palpate piles unless thrombosed
- Rigid sig to identify higher rectal pathology
- Proctoscopy
- Anaemia - FBC and a coagulation screen
Mx of haemorrhoids
Conservative:
• ↑ fibre and fluid intake
• Stop straining
Medical: • Topical - Anusol: hydrocortisone + lidocaine - Analgesics • Laxatives: lactulose or fybogel
Interventional: • Injection with sclerosant • Banding → thrombosis and separation • Cryotherapy • Infra-red coagulation
Surgical:
Haemorrhoidal artery ligation
Haemorrhoidectomy - Excision of piles + ligation of vascular pedicles
• Discharge with laxatives post-op
Side effects of haemorrhoidectomy
Bleeding, infection and stenosis
Mx of thrombosed piles
- Analgesia
- Ice-packs
- Stool softeners
- Topical lignocaine jelly
- Pain usually resolves in 2-3wks
- Haemorrhoidectomy is not usually necessary
Anal fissure
Tear of squamous epithelial lining in lower anal canal
Causes of anal fissure
• Hard stool
- Assoc. with constipation
• Rarer causes, often → multiple ± lateral fissures
- Crohn’s
- Herpes
- Anal Ca
- Trauma
Presentation of anal fissure
• Intense anal pain especially on defecation
• Fresh rectal bleeding
- On paper
• pruritis
Examination:
• PR often impossible
• Groin LNs suggest complicating factor: e.g. HIV
Management of anal fissure
Conservative:
• Soaks in warm bath
• Toileting advice
• Dietary advice: ↑ fibre and fluids
Medical: • Laxatives: lactulose + fybogel • Topical: - Lignocaine - GTN ointment - Diltiazem cream CCB
• EUA + botulinum toxin injection
Surgical: Lateral partial sphincterotomy
• Pre-op anorectal US and manometry
If recurrent, chronic anal fissure
EUA is done
Complications of sphincterotomy
- Minor faecal/flatus incontinence (= GTN)
- Perianal abscess
Pilonidal Sinus
Ingrown hair causes foreign body reaction → formation of abscess
Anal Carcinoma
Squamous cell carcinoma (80%)
• Spread
- Above dentate line → internal iliac nodes
- Below dentate line → inguinal nodes
Rectal prolapse
Protrusion of rectal tissue through the anal canal
Mx of rectal prolapse
Partial Prolapse:
• Phenol injection
• Rubber band ligation
• Surgery: Delorme’s Procedure
Complete Prolapse
• Conservative
- Pelvic floor exercises
- Stool softeners
• Surgery
- Abdominal Approach: Rectopexy
- Lap or open
- Mobilised rectum fixed to sacrum with mesh
- Perineal Approach: Delorme’s Procedure
Delorme’s Procedure
Resect mucosa and suture the two mucosal boundaries
Classification of haemorrhoids
1st Degree: Remain in the rectum
2nd Degree: Prolapse through the anus on defecation but spontaneously reduce
3rd Degree: Prolapse through the anus on defecation but require digital reduction
4th Degree: Remain persistently prolapsed
Risk factors of haemorrhoids
Chronic constipation
Increasing age
Raised intra-abdominal pressure:
- pregnancy
- chronic cough
- ascites
Complications of haemorrhoids
Thrombosis
Ulceration or gangrene (secondary to thrombosis)
Skin tags
Perianal sepsis.
What is the first line management for symptomatic 2nd degree haemorrhoids?
Haemorrhoidal artery ligation
anorectal abscesses mx
Incision and drainage
Protoscopy once drained to check for fistula
Risk factors for anal fissures
Constipation
Dehydration
Inflammatory bowel disease
Chronic diarrhoea
Investigations of anal fissures
DRE - may need examination under anaesthesia
Proctoscopy
