RECTUM / ANUS

Question 1

Chronic Pilonidal

Answer 1

• prone, tape buttocks open
• remove all hair in operative field

Chronic: Karydakis procedure
o (avoids midline wound, lower recurrence)
o semilateral excision of an ellipse of skin over the sinuses from one side of midline down to the post sacral fascia
o the ellipse should include the primary opening, and all the sinuses en bloc
o one side of the wound is then undermined, and closure is undertaken off the midline gluteal cleft.

Question 2

Recurrent perirectal fistula procedure

Answer 2

Internal advancement flap

LIFT procedure – between internal and external fistula

Question 3

Rubber band ligation (RBL)

Answer 3

is suitable for Grades II and III hemorrhoids. This office procedure is performed in the Sims or prone jackknife position, using either a McGivney/Barron hemorrhoid ligator or a vacuum-assisted device (Figure 4). It is better to treat each hemorrhoidal complex individually to prevent postprocedural pain and undesirable protrusion. Placement of the band at least 5 mm cephalad to the dentate line reduces the incidence of postprocedural pain. Appropriately placed bans occasionally result in minor postprocedural discomfort for up to 24 hours, which is easily controlled by acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs).

Severe pain immediately after the procedure usually indicates placement too close to the dentate line and is treated with cutting the band using a specifically designed cutting hook.

band a maximum two pedicles, especially during the first encounter. If more than three sessions are required to control symptoms, hemorrhoidopexy or hemorrhoidectomy should be offered.

Question 4

Procedures used in the control of bleeding anorectal varices in portal hypertension patient

Answer 4

direct suture ligation;
stapled anopexy;

SHUNTS!

transjugular portosystemic shunt;

mesocaval,
mesorenal,
and
sigmoid to ovarian vein shunts.

Question 5

Closed hemorrhoidectomy (Ferguson hemorrhoidectomy)

Answer 5

for internal hemorroids

prone jackknife (preferred) or lithotomy position under local, regional, or general anesthesia, with the gluteal folds retracted with tape.

Antibiotics are not administered routinely!

A Hill-Ferguson retractor is placed in the anal canal and the hemorrhoid grasped at the perianal skin, the mucocutaneous junction, and the apex of the hemorrhoid.

Dilute epinephrine solution is injected to reduce bleeding during dissection and to spare the superficial external sphincter.

(scalpel/electrocautery) is made from the perianal skin into the anal canal and tapered toward the apex of the hemorrhoid. It is important to dissect superficial to the fibers of the internal sphincter, which is readily recognized due to its white muscle fibers.

The apex of the hemorrhoid is clamped and suture ligated with 2-0 absorbable suture and the wound closed with accurate mucosa to mucosa approximation.

The mucosa is fixed to the underlying sphincter muscle to recreate a new dentate line. The suture line continues into the perianal skin.

The tail of the apical suture is left long for identification of the pedicle in case of postoperative hemorrhage.

Dibucaine-impregnated Gelfoam is placed in the anal canal.

Patients are discharged the same day with narcotic and NSAID pain medications, Sitz baths, and stool softeners and are seen 10 days after surgery.

They are instructed to keep dry gauze in between the buttocks and change it two or three times a day.

The advantage of this technique is faster healing, but it also has the disadvantage of occasional wound infection and fistula formation.

The success rate of this technique in the long-term follow-up period exceeds 90%.
Figure 7 Ferguson hemorrhoidectomy (closed hemorrhoidectomy).