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Hemorrhoidectomy, Fistula in ano and TEM

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1 Hemorrhoidectomy, Fistula in ano and TEM
Wendie Grunberg


3 3 Loops of external sphincter
Subcutaneous (C), superficial (B), deep (A)


5 Blood Supply. The rectum and anal canal are supplied by the superior rectal artery (the continuation of the inferior mesenteric artery), with assistance from the middle and inferior rectal arteries, and by the median sacral artery. The submucosal venous plexus above the pectinate line drains into the superior rectal veins (portal system), which may become varicose, resulting in internal hemorrhoids or "piles." The submucosal plexus below the pectinate line drains into the inferior rectal veins, which may become varicose, resulting in external hemorrhoids or piles. The unions of the superior with the middle and inferior rectal veins are important portal-systemic anastomoses.

6 Innervation Parasympathetic fibers supply the smooth muscle, including the internal sphincter. Sympathetic fibers are mainly vasomotor. Somatic motor fibers supply the external sphincter. Sensory fibers are concerned with the reflex control of the sphincters and with pain. The anal canal is very sensitive below the pectinate line, so that external hemorrhoids may be very painful.

7 Hemrroidectomy- Injection
Indications: The injection of hemorrhoids is a palliative procedure. The patient is ambulatory. It may be used for the bleeding internal hemorrhoid that does not prolapse. It is not applicable to external hemorrhoids Contraindications: reactive inflammation or thrombosis, acute fissure, fistula or perianal abscess, severe cryptitis or papillitis, and an advanced degree of prolapse

8 Injection A complete study of the colon and rectum to rule out polyps or a malignancy must be performed before injection. The anorectal area is best examined with an anoscope while the remainder of the colon requires either colonoscopy or sigmoidoscopy plus barium enema.

9 Injection Preoperative preparations
No preoperative preparation is necessary other than a disposable commercial enema self-administered by the patient.


11 Injection- Procedure An anoscope is inserted.
The sclerosing solution is injected above the hemorrhoid about 3 mm below the mucosa Slight distention of the mucosa will result, but it should not blanch. One to 2 mL of solution is usually sufficient for one hemorrhoid. No more than three sites are injected at a single operation.

12 Injection- Post Op care
Stool softeners and sitz baths are recommended. (If the patient complains of pain or discomfort, he or she is told to return promptly for examination to rule out potentially serious infection. Injections are usually repeated at intervals of about a week until all sites are injected. Keeping a chart of the exact site of each injection ensures that all quadrants receive one injection)

13 Incision and Rubber-Banding of Hemorrhoids - Indications
performed in good-risk patients with persistent symptoms. Bleeding, protrusion, pain, pruritus, and infection are the more common indications when palliative medical measures have failed. The presence of a serious systemic disease, such as cirrhosis of the liver, or a probable short life expectancy from advanced age or any other cause should be a general contraindication to operation unless anal symptoms are marked

14 Rubberband Simple internal hemorrhoids that prolapse may be treated by rubber-banding After insertion of an anoscope, the internal hemorrhoid is grasped with an Allis-like clamp inserted through the banding instrument, which has been preloaded with two rubber bands. The area is pinched to be sure it is pain-free. As the forceps or suction draws the hemorrhoid into the instrument, it is fired. The constricting rubber bands strangulate the hemorrhoid and both are then silently passed a few days later


16 Positioning- The positioning of the patient depends on the type of anesthesia used. With spinal anesthesia, the prone jackknife position affords the surgeon the best exposure. If general anesthesia is used, an exaggerated dorsal lithotomy position is preferred, with the buttocks extending beyond the edge of the table and the legs held in stirrups.

17 Procedure- Incision The anal canal may be gently dilated to about two fingers' width to permit adequate exposure. A suitable self-retaining retractor is inserted into the canal, and further inspection is made. A gauze sponge is introduced into the rectum, and the retractor is withdrawn. The surgeon makes gentle traction on the sponge, reproducing, in effect, the passage of a bolus through the canal. As the sponge is withdrawn, the prolapsing hemorrhoids may be identified and are picked up with hemorrhoid clamps. Clamps are placed on all the prolapsing hemorrhoids and left in place as markers during the operation.

18 Procedure- Incision A triangular incision is made from the anal verge to the pectinate line By traction on the two clamps and careful blunt and sharp dissection with the scalpel, it is possible to dissect off the triangular area of skin and the hemorrhoidal tissue from the outer edge of the external sphincter muscle. Many small fibrous bands will be found running upward into the hemorrhoidal mass. These represent the continuation downward of the longitudinal muscle and may be divided


20 Dissection is carried to the outer edge of the external sphincter.
The anal skin must be divided to and slightly beyond the pectinate line. There now remain mucosa and the deep veins entering the hemorrhoidal mass. The tissue is secured with a straight clamp and a transfixing suture is placed at the apex of the hemorrhoidal mass

21 The hemorrhoidal tissue is removed with a knife, and an over-and-over continuous suture is made in the mucosa. The clamp is removed and a continuous suture approximates the mucosa, including the two edges of the pectinate line. As the suture is continued externally, small bites are taken in the external sphincter muscle The deep portion of the skin is closed by a subcutaneous approximation and the skin edges are left open to provide for better drainage and prevent postoperative edema.


23 All possible mucosal tissue must be preserved to prevent stenosis
All possible mucosal tissue must be preserved to prevent stenosis. However, relatively large areas of skin may be safely removed in the triangular incision. With extensive hemorrhoids it may be necessary to excise one-half of the mucosa of the entire canal in this fashion. The triangular incision may extend from the anal verge and reach the pectinate anteriorly and posteriorly. The mucosa is divided horizontally, taking small bites of tissue in a series of hemostats This mucosal flap is sutured into the external sphincter horizontally to prevent stenosis All redundant incisional skin margins should be excised to minimize the subsequent development of potentially damaging perianal skin tabs.

24 Post Op care A sterile protective dressing is applied to the anus. Petrolatum may be applied locally. The patient is encouraged to have a bowel movement and usually will do so by the third day. Local application of heat is useful in alleviating discomfort. The patient may take sitz baths as desired. Weekly anal dilatation may be needed postoperatively until healing is complete.

25 Treatment of Thrombosed Hemorrhoids
Thrombosed external hemorrhoids may be removed in the patient who is ambulatory. The anus is cleansed, and local anesthesia is administered by injection over the surface and just beneath the thrombosed hemorrhoids. An elliptical incision is made over the thrombosed area, and the clot is removed by finger compression or by introduction of a small curette This excision leaves no redundant scar tissue, and final healing occurs without tab formation. Gentle dissection of the clot causes no bleeding it should not be necessary to suture the wound. Rarely, a suture of fine absorbable suture may be necessary. The patient may return home immediately.


27 Drainage of Ischiorectal Abscess
Indications Ischiorectal abscesses are drained immediately. Careful palpation often shows evidence of fluctuation not seen in the perianal tissue. Operation is not delayed until fluctuation is obvious, because a perirectal abscess may rupture through the levator muscle into the retroperitoneal tissue

28 Anesthesia General anesthesia with endotracheal intubation may be used; however, regional anesthesia, either spinal or epidural, is satisfactory. Position The lithotomy position is preferred for drainage.


30 Incision and Exposure The common locations of ischiorectal abscesses.
Abscesses may be located extraperitoneally above the levator ani muscle. Careful rectal and sigmoidoscopic examination should be performed to detect associated pathologic processes after the patient has been anesthetized. An incision is made at the maximum point of tenderness and placed either parallel or radial to the anus. If the abscess lies above the levator, the incision is deepened radially to avoid nerves and blood vessels.

31 Procedure After incision and drainage, the cavity is explored with the index finger to ensure complete drainage and to ascertain that no foreign body is in the ischiorectal space. A specimen of the draining material is obtained for bacteriologic studies. Usually, there is no communication with the rectum. If the abscess is small, and a clear communication with the rectum is identified, the tract may be excised. The outer opening must be sufficiently large, for the common error is to drain a large cavity through a comparatively small incision, resulting in the development of a chronic abscess

32 Closure- cavity is packed Postoperative Care
Moist compresses and sitz baths reduce inflammation and promote rapid healing. Postoperative dressings to assure healing from the bottom are as important as the operation. An ischiorectal abscess is prone to result in an anal fistula; however, in about half of the cases, there will be primary healing with proper postoperative care.


34 Fistula in Ano Indications
The majority of anal fistulae result from infection arising in a crypt, extending into the perianal musculature, and then rupturing either into the ischiorectal fossa or superficial perirectal tissues. Operative obliteration of the fistula is always indicated if the patient's general condition is good

35 Fistula- Anatomic considerations
The external sphincter muscle can be divided into three portions: the subcutaneous, superficial, and deep portions. The subcutaneous portion lies just beneath the skin and below the lower edge of the internal sphincter The superficial and deep portions surround the deeper part of the internal sphincter and continue upward to join with the levator muscle The levator ani surrounds the anal canal laterally and posteriorly, but it is absent anteriorly The longitudinal muscle of the anus is the continuation downward of the longitudinal muscle of the large bowel The internal sphincter muscle is a bulbous thickening of the circular muscle coat of the large bowel.


37 Anatomy Incontinence will not occur if any portion of the external sphincter or levator muscle remains intact.

38 An anterior fistula involving only the subcutaneous and superficial portions of the external sphincter may be excised in one operation An anterior fistula involving the entire external sphincter cannot be excised in one operation without producing total incontinence. Posteriorly, if the levator ani muscle is left intact, a fistula can be completely excised with far less danger of total incontinence.

39 Most fistulae arise in the anal glands at the base of the crypts of Morgagni; therefore, the abscess usually lies within the substance of the internal sphincter It extravasates through the muscle, tending to follow the tissue planes created by the fibromuscular septa of the longitudinal muscle. Fistulae rarely arise from perforations of the anal canal associated with foreign bodies or abscesses, as in tuberculosis or ulcerative colitis. The internal opening may be above the pectinate line and may traverse the entire sphincter or portions of the levator It may be necessary to operate in stages or to use the seton technique to avoid incontinence.


41 Simple anal fistulae follow a direct route in the anus.
Complicated fistulae follow a more devious route, often horseshoe in shape and with numerous openings. Most complicated fistulous tracts open into the posterior half of the anus. Should the fistula have multiple sinuses, the main exit will usually be posterior, even though one opening is anterior to the line a single fistulous opening anterior to X–X usually extends directly into the anterior half of the anus (Goodsall's rule).

42 Goodsall’s Rule

43 Fistulotomy (lay-open technique) for very superficial fistula with minimal resulting damage to sphincter muscle. Alternatively, placement of setons into the existing fistula tracts to allow for adequate drainage of active suppurations. Two different types of setons: Cutting seton: placed around sphincter portion involved in a transsphincteric fistula with intent to have the seton slowly erode through that sphincter portion. Draining seton (single, multiple, short-term/long-term): placed into existing fistula tract solely to avoid future pus accumulation and allow tract to close down onto seton. A draining seton may also be placed in preparation for future fistula procedures, eg, collagen plug placement.

44 Cutting Seton

45 Procedure 1. Patient positioning: prone jackknife position.
2. For elective cases: pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve relaxation of the anal sphincter muscles. 3. Insertion of anal retractor and circumferential examination of dentate line: identification of primary opening? If not visible: testing with injection of peroxide into secondary opening (avoid overflow spill) appearance of bubbling at a primary opening?

46 4. Careful probing of fistula tract with curved silver probe taking care to avoid creating new tract by forceful advancement. If insertion is not easy: placement of Kocher clamp to external opening and centrifugal traction (ie, away from anus) to straighten fistula tract while trying to insert probe again. If still no success: partial external fistulotomy to reassess course vs fistuloscopy (using ureteroscope). If primary opening cannot be found despite all attempts: removal or wide drainage of sinus, but unfortunately high chance of failure and reopening of a fistula later. 5. Fistula tract successfully probed assessment of the extent of sphincter involvement:

47 a. Fistulotomy: very superficial tract without relevant sphincter involvement (< 20%) fistulotomy from secondary to primary opening along the probe (eg, with electrocautery).

48 b. Cutting seton: > 20% sphincter involved cutting seton: devision of mucocutaneous layer between two openings without cutting through muscle (caveat: no cutting seton over intact skin), pulling in a suture tied to edge of gauze, scrubbing out fistula tract (with gauze or brush) pulling in seton (eg, an elastic vessel loop), which is tied down with three sutures such that it just sits on the muscle without strangulating it. c. Draining seton: > 20% sphincter involved but seton placement only to cool off suppuration, prevent recurrent abscesses (eg, long-term setons in Crohn disease), or mature fistula without immediate plan to eliminate fistula (but, eg, later fistula surgery with collagen plug): seton pulled into tract and tied to itself without division of mucocutaneous layer between primary and secondary opening.

49 Aftercare Open wound care until complete healing (fistulotomy), skin closure except for seton (cutting/draining seton): sitz baths or showers twice per day, after bowel movements. Cutting seton: tightening of cutting seton in monthly intervals until it has eroded through the involved sphincter complex (leaving a scar behind):

50 Fistula-in-Ano—Endorectal Advancement Flap
Closure of the primary fistula opening by means of a plication of the muscle layer and an overlying advancement flap to cover the site of the opening to induce an obliteration of the fistula tract once it is not fed anymore

51 Flap 1. Patient positioning: prone jackknife position.
2. For elective cases: pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general anesthesia to improve relaxation of anal sphincter muscles. 3. Insertion of anal retractor and identification of primary opening. 4. Careful probing of fistula tract with silver probe. 5. Insertion of anal retractor and reassessment of the fistula. Depending on local anatomy, placement of Lone Star retractor may prove advantageous.

52 Flap 6. Limited excision of primary opening, removal of epithelialized tract within muscle layer, widening/excision of secondary opening. 7. Closure of muscular defect with interrupted Vicryl sutures. 8. Marking of U-shaped broad-based flap, base starting distal to primary fistula opening, extending laterally and proximally (one quarter to one- third of anterior circumference). Atraumatic raising of flap: after adequate mobilization, flap should cover defect without any tension. Careful hemostasis; avoid traction or diffuse cautery damage to flap. 9. Suturing flap in place in two layers: deeper muscular layer (Vicryl), maturation of mucosal anastomosis with interrupted sutures (eg chromic).



55 Transanal Endoscopic Microsurgery

56 Transanal Endoscopic Microsurgery
Combination of techniques used for conventional transanal excision with laparoscopic technology and instrumentation: endorectal system to create pneumorectum for optimal exposure and endoscopic magnification for excellent visualization Indications and contraindications are the same as for conventional transanal excision, except that higher lesions up to 12–14 cm can be targeted. Very low lesions are not amenable and are better treated with a conventional transanal excision.

57 TEM- Indications Rectal cancer
T1N0 lesion (invades submucosa). < 4 cm largest diameter (less than one-third of circumference) Well or moderately differentiated histology No evidence of poor prognostic indicators, eg, lymphatic/vascular invasion. having significant comorbidities or extensive metastasis but locally highly symptomatic Polyp or other pathology (eg, ulcer) between 3 and 12(14) cm: No absolute size limit (less than hemicircumference) as long as tissue adequate, eg, sufficiently pliable for defect closure.

58 TEM- Preparation Full colonic evaluation and histologic documentation.
Rigid sigmoidoscopy: determination of level above anal verge and exact location on circumference are very important for correct patient positioning Staging: ERUS. Bowel cleansing: full bowel cleansing. Prophylactic antibiotics

59 TEM- Procedure 1. Patient positioning: the lesion has to be down!
ie, posterior lesion lithotomy; left lesion left lateral; right lesion right lateral; anterior lesion prone jackknife position with legs spread apart (for access).

60 TEM- Procedure 2. Pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general anesthesia to improve relaxation of anal sphincter muscles. 3. Insertion of 4-cm operating rectoscope/obturator and fixation to supporting arm, insertion of main body with sealing working and gas ports, stereotactic telescope with connection to video system. 4. Exposure of lesion.

61 TEM 5. Using combination instruments (coagulation/suction) and graspers, a dotted line (high-frequency knife, electrocautery) is marked around target lesion: 1-cm margin. 6. Incision of mucosa right at lower edge and full-thickness incision into perirectal fat (caveat: anterior lesions!).

62 TEM 7. Circumferential dissection and mobilization: avoid traumatizing and fragmentation of specimen. 8. Maintenance of good hemostasis throughout procedure. 9. Continuation until marked area completely excised maintain specimen orientation.

63 TEM 10. Placement and needle fixation of specimen onto cork/wax board and absolute orientation as left, right, proximal, distal; inspection of macroscopic margin, permanent fixation (frozen section only if area of uncertainty). 11. Irrigation with dilute povidone-iodine solution.

64 12. Defect closure with absorbable full-thickness suture (facilitated by use of preknotted suture and endoscopic suturing device, placement of suture clip at end of suture line). 13. Removal of instruments

65 TEM- Aftercare Regular diet as tolerated 6 hours post anesthesia. Maintenance of soft stools (fibers, stool softener, etc). Assessment of final pathology possible need for adjuvant treatment vs oncologic resection. Follow-up (in addition to routine cancer follow-up): ERUS every 3 months (1st year), every 6 months (2nd year), yearly thereafter.

66 TEM- complications Bleeding (surgeon-dependent).
Infection, abscess/fistula formation. Anastomotic dehiscence (caveat: even without leak there will be extensive retroperitoneal air). Stricture formation. Formation of rectovaginal fistula need for colostomy. Recurrent pathology (cancer, polyp, etc).

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