Rectal prolapse 251

Most operations can be performed with the patient in the litho-tomy position. The prone (Latin: pronusbent forward) jack-knifeposition has the advantage of superior visibility and superior accessfor your assistant.

1. Identification and differentiation of the internal and

betweentherectumandanalcanalat lessthan90 (Fig.14.2).

236ferred to as the dentate line (Fig. 14.1): it does not represent thepoint of fusion between the embryonic hindgut and the proctoderm,which occurs at a higher level, between the anal valves and the

also contains the anal intermuscular glands, approximately 12 innumber, arranged around the anal canal. The ducts of these glandspass through the internal sphincter and open into the anal crypts.The anal canal extends from the anorectal junction to the analmarginANATOMY

and is approximately 34 cm long in men and 23 cm long inwomen. The lining epithelium is characterized by the anal valvesmidway along the anal canal. This line of the anal valves is often re-

Spaces

There are three important spaces around the anal canal: the inter-sphincteric space, the ischiorectal fossa and the supralevator space(Fig. 14.1). These spaces are important in the spread of sepsis andin certain operations:n The intersphincteric space liesbetweenthetwosphinctersandcontains

the terminal fibresof the longitudinalmuscleof the large intestine. Itas neoplasms or inflammatory bowel disease should be excluded withcolonoscopy or computed tomography (CT) pneumocolonography.Faecal incontinence 253

Injection of bulking agents 253

INTRODUCTION

The anus is a very precisemechanism it is able to distinguish gaseous,liquid and solid matter with greater sensitivity than the fingers. Thecontrolling sphincter muscles are finely balanced to prevent leakageand urgency and allow us to retain continence. Meticulous attentionto detail and carefully supervised postoperative care are necessary toensure preservationof these extra-ordinary and vital functions. It is alsoessential to have a sound understanding of the anatomy of the area inorder to make a precise diagnosis and perform effective treatment.

Wherever possible, perform a full rectal examination, includinginspection,palpation, sigmoidoscopyandproctoscopy,before carryingoutanyprocedure.Whereappropriate, seriousunderlyingdiseases such14

AnorectumC.J. Vaizey, J.Warusavitarne

CONTENTS

Introduction 236

Anatomy 236

Haemorrhoids 237

Fissure 241

Anal abscess and fistula 242

Fistula 244

Pilonidal disease 247

Hidradenitis suppurativa 247

Anal manifestations of Crohns disease 247

Condylomata acuminata 248

Anal tumours 249

Rectal adenomas 249external sphincters can be difficult. Electrical stimulation,

using an electrical stimulator or electrocautery, causes

twitching of the external sphincter but the internal

sphincter does not respond in this way. Superiorly it is

contiguous with the puborectalis and levator ani muscles,

forming one continuous striated muscle sheet (Fig. 14.1).

The external sphincter is supplied by the pudendal nerve

entering themuscle from its outer aspect posterolaterally,

and the levator ani from branches of the fourth sacral

nerve on its superior aspect.

2. The levator ani and puborectalis muscles are responsible for

holdingtheanalcanal in itscorrectpositioninrelationshipto

the bony pelvis; this is with the top of the anal canal on the

line joining the tip of the coccyx to the inferior aspect of the

symphysis pubis. They also maintain the correct angleDIFFICULTYanorectal junction. In this zone, sometimes called the transitionalzone, there is a mixture of columnar and squamous epithelium.

Sphincters

The anal canal is surrounded by two sphincter muscles. The internalsphincter is the expanded distal portion of the circular muscle of thelarge intestine. It is only about 2 mm thick, composed of smoothmus-cle and is grey/white in colour. The external sphincter lies outside theinternal sphincter with a palpable gutter between them. It is usuallynearly 1 cm thick, composed of striatedmuscle and is brown in colour.

There is usually a pigment change in the skin over the outermargin of the external anal sphincter muscle, with lighter skin out-side and darker skin over the muscle and towards the anal canal. Thisdemarcation is useful when siting the skin incision to operate on theexternal anal sphincter.

?

4Supralevatorspace

Intersphinctericspace

Anal glandand duct

Ischiorectalfossa

Line of analvalves

Fig. 14.1 Diagram to show the essential anatomy of the anal canal.

Fig. 14.2 Sagittal diagram to show the relationship of the distalrectum to the anal canal. The anorectal angle is just less than a right-angle in most people.n The ischiorectal fossa lies lateral to the external sphincter andcontains fat. Abscesses may occur in this site as the result ofhorizontal spread of infection across the external sphincter.

n The supralevator space lies between the levator ani and the rectum.It is also important in the spread of infection.

Prepare

n1 Familiarize yourself with the small range of essential instrumentsfor examination of the patient, such as the proctoscope and therigid sigmoidoscope. In awake patients with anal sphincterspasm, use a small paediatric sigmoidoscope.

n2 Operating proctoscopes of the Eisenhammer, Parks and Sims typeare essential for operations on and within the anal canal.

n3 Use a pair of fine scissors, fine forceps (toothed and non-toothed),a light needle-holder, Emett's forceps and a small no. 15 scalpelblade for intra-anal work. Alternatively, diathermy dissectioncreates a virtually bloodless field.

n4 For fistula surgery have a set of Lockhart-Mummery fistula probes(Fig. 14.3), together with a set of Anel's lacrimal probes.

n5 Most patients require no preparation, or two glycerine supposito-ries, to ensure that the rectum is empty before anal surgery. If forany reason the bowels need to be confined postoperatively, carryout a full bowel preparation to empty the whole large intestine.

n6 Minor operations can be performed under local infiltration anaes-thesia; larger procedures demand regional or general anaesthesia.

n7 For outpatient procedures use the left lateral position, or alterna-tively the knee-elbow position. For anal operations most Britishsurgeons favour the lithotomy position, although the prone jack-knife position (Fig. 14.4) can also be used.n8

H

Ap

c

n

n1

Fig.

Fig.ANORECTUM 1If you prefer to shave the area before starting an anal operation,carry it out in the operating theatre immediately beforehand,where there is good illumination.

AEMORRHOIDS

praise

KEY POINT Primary, secondary or incidental?

Have you excluded pelvic tumours, large-bowel

carcinoma and inflammatory bowel disease?

Haemorrhoids usually do not need treatment if the symptomsare minimal and you have excluded a primary cause.

14.3 A set of four Lockhart-Mummery fistula probes.

14.4 The jack-knife position.

237

It is most conveniently carried out following a full rectal examination

n4

? DIFFICULTY

1. If the procedure produces severe pain it may be because

you applied the band too low onto the sensitive

epithelium of the lower anal canal.

2. Try the effect of analgesics.

3. If they do not control the pain, remove the bands this can

be difficult in the outpatient setting and can require a light

238

14 ANORECTUMif no further investigation is required. Leave the patient in the left lat-eral position.

Action

n1 Pass the full-length proctoscope and withdraw it slowly to iden-tify the anorectal junction the area where the anal canal beginsto close around the instrument.

n2 Place a ball of cotton wool into the lower rectum with Emett'sforceps to keep the walls apart. Since you will not usuallyremove it, warn the patient that it will pass out with the nextmotion.

n3 Identify the position of the right anterior, left lateral and rightposterior haemorrhoids.

n4 Fill a 10-ml Gabriel pattern syringe with 5% phenol in arachis oilwith 0.5% menthol (oily phenol BP).

n5 Through the full-length proctoscope, insert the needle intothe submucosa at the anorectal junction at the identified posi-tions of the haemorrhoids in turn. Inject 35 ml of 5%phenolin arachis oil into the submucosa at each site, to produce a swell-ing with a pearly appearance of the mucosa in which the vesselsare clearly seen. Move the needle slightly during injection toavoid giving an intravascular injection.

n6 Delay removing the needle for a few seconds following theinjection, to lessen the escape of the solution. If necessary,press on the injection site with cotton wool to minimize leakage.

n7 Warn the patient to avoid attempts at defecation for 24 hours.

c KEY POINTS Injection sclerotherapy caution

n Avoid injecting the solution too superficially.

This produces a watery bleb, which may ulcerate and

subsequently cause haemorrhage.

n Avoid injecting the solution too deeply. This produces

an oleogranuloma with subsequent features of an

extrarectal swelling. Too deep anterior injection in male

patients causes perineal pain and sometimes haematuria

from prostatitis. This is a serious problem. Halt the

injection immediately.

n If you suspect that the needle has entered the urinary

tract, administer antibiotics. Do not hesitate to admit thes is an outpatient procedure and does not require any anaesthesia.n2 Small internal haemorrhoids can be treated by injection sclerother-apy. Prolapsing haemorrhoids may be ligated with rubber-bands.Large prolapsing haemorrhoids, which are usually accompaniedby a significant external component, are best treated by haemor-rhoidectomy. The advent of day-case diathermy haemorrhoidect-omy has rendered surgical treatment simpler and more availablethan in the past.

n3 As a rule avoid treating haemorrhoids if the patient also hasCrohn's disease.

INJECTION SCLEROTHERAPY

Thipatient, since septicaemia is common and may be severe.n5 Any number of haemorrhoids can be banded on each occasion;however, the view is often obscured once two bands have beenapplied. Repeat banding where necessary but delay it for68 weeks.

Aftercare

n1 Advise the patient to take a mild analgesic and sit in a hot bath ifthe procedure causes discomfort.suction device can be applied. Cover the hole on the device toactivate the suction and then wait for a few seconds.

The band can then be deployed.n2 There are several different designs of band applicator (Fig. 14.5);the suction bander is relatively expensive, but is convenient andeasy to use.

n3 There are two conceptually different strategies:n Band, or inject, above the haemorrhoid in order to hitch it

back into its normal place. Grasp the redundant mucosaproximal to the haemorrhoid and band that.

n Try to destroy the haemorrhoid itself.

n4 Enquire about anticoagulants pre-procedure. Banding should notbe performed if the patient is on Warfarin or Clopidigrel andsome surgeons prefer to stop Aspirin as well.

NOTE: the bands are usually marked as being latex-free.

Action

n1 Load one band onto the end of the sucker and one onto theapplicator before applying your gloves.

n2 Pass the full-length proctoscope and withdraw it slowly to iden-tify the anorectal junction. Position the end of the proctoscopemidway between the anorectal junction and the dentate line.

n3 The haemorrhoids will fall into view and then the end of theRUBBER-BAND LIGATION

n1 This can also be performed as an outpatient procedure and doesnot require anaesthesia.tion of haemorrhoids.

Fig. 14.5 A simple instrument with which to perform elastic-bandligaanaesthetic and the use of an operating proctoscope.

n2

n3

n1 There are several methods of performing a haemorrhoidectomy.

n2 Give oral metronidazole 400 mg t.d.s. for 5 days, which also sig-

haemorrhoid with the back of a pair of scissors. Now excise

Fig. 14.6 Plan the operation by inserting the Eisenhammer retractor,establish the site and size of the haemorrhoids and identify the skinbridges to preserve them.

Fig. 14.7 In the event that there is an additional haemorrhoid,over and above the usual three, divide the skin bridge above the

ANORECTUM 14Assess

n1 Plan the operation by inserting the Eisenhammer retractor andestablish which haemorrhoids need to be removed; also estimatethe state and size of the skin bridges (Fig. 14.6).

n2 Determine whether:n A three-quadrant haemorrhoidectomy will be sufficientn There is one additional haemorrhoid that needs removal, or

the situation is more complex than this.

n3 If there is one additional haemorrhoid you may:n Leave it and be prepared to return on another occasion if it

proves troublesomeretention of urine.nificantly reduces postoperative pain.

n3 Place the anaesthetized patient in the lithotomy position withsome head-down tilt. Avoid caudal anaesthetic as it may provokeWe shall describe the diathermy technique, which has evolvedout of the ligation and excision technique of Milligan andMorgan.

n2 Haemorrhoidectomy should be a curative procedure. Perform itcarefully and thoroughly.

Prepare

n1 Start lactulose, a non-absorbed disaccharide which produces anosmotic bowel action, 30 ml twice daily 2 days preoperatively.This reduces postoperative pain.c KEY POINT Monitor temperature

n If the patient develops severe fever, admit the

patient for treatment with intravenous antibiotics.

HAEMORRHOIDECTOMY

Appraisedrop off after 510 days and may be accompanied by a smallamount of bleeding.

n4 Warn the patient that secondary haemorrhage occurs in approxi-mately 2% any time up to 3 weeks after the application. Tell thepatient to report to hospital if this is severe, since it may requiretransfusion and operative control of the bleeding.inflammation.

Advise the patient that the haemorrhoid and the band shouldAnalgesics relieve the pain. Give metronidazole tablets200400 mg three times daily, which may help reducePain developing slowly in 12 days may be from ischaemia.n Fillet it out by undermining the skin bridgen Another technique is to divide the skin bridge above the

dentate line, reflect it out of the anus, and trim the

denbactrimany redundant mucosa and stitch the trimmed flap backinto position with 2/0 synthetic absorbable sutures of Vicryl(Fig. 14.7).tate line, reflect it out of the anus, trim the haemorrhoid with thek of a pair of scissors, excise redundant mucosa and stitch themed flap back into position with 2/0 Vicryl.

239

n4 The haemorrhoids may be even more extensive and may becircumferential. In this case:n Perform a standard three-quadrant haemorrhoidectomy and

return on another occasion to deal with any residualhaemorrhoids

n If you are experienced in the technique, consider performingthe circumferential Whitehead haemorrhoidectomy de-scribed in 1882 by the English surgeon Walter Whitehead(18401914). He described the excision of a tubular segmentof the anal canal, withmucosal-cutaneous re-anastomosis. Usepolyglactin 910 (Vicryl). Difficulties include the Whiteheaddeformity mucosal ectropion (Greek: ekout trepein toturn) and late stenosis.

Action

n1 Inject bupivacaine (Marcaine) 0.25% with adrenaline (epineph-rine) 1:200 000 into each skin bridge and into the externalcomponent of each haemorrhoid to be excised.

n2 Wait, and gently massage away excess fluid from the injectionwith a moistened gauze.

n4

sphincter.

n6 Narrow the pedicle as you dissect up towards the apex, otherwiseyou risk encroaching on the skin bridge.

n7 When you have encompassed the internal component of the hae-morrhoid, simply transect the pedicle with diathermy.

n8 Repeat the procedure on the right anterior haemorrhoid and thenthe right posterior haemorrhoid.

n9 Ensure complete haemostasis and check each wound and apex.

c KEY POINT Haemostasis

n Remember that bleeding comes fromwhat remains inside

the patient, not from what has been removed.

n10 Inspect the skin bridges and perform any further procedure asnecessary and as earlier decided in the Assess section (Fig. 14.10).

n11 Do not apply any anal canal dressing.n12 Insert a diclofenac (Voltarol) suppository into the anus.

Aftercare

n1 Allow the patient home after recovery from the anaesthetic.n2 Warn that there is likely to be an early increase in pain 35 days

postoperatively.

n3 Pain can usually be satisfactorily controlled with non-steroidal

240

14 ANORECTUMFig.Eiseallousing cutting diathermy on skin and coagulating diathermy forall other dissection (Fig. 14.9).

c KEY POINT Avoid diathermy burns

n When using cutting diathermy on skin, do not linger in

one area or the skin develops indolent burn marks.plane of the dissection (Fig. 14.8).

Grasp the external component and excise it with electrocautery,n3 Commence with the left lateral haemorrhoid. Place the Eisen-hammer retractor in the anal canal and open it sufficiently toput the internal sphincter under tension. This demonstrates the14.8 Commence with the left lateral haemorrhoid. With thenhammer in the anal canal, the internal sphincter is put on stretchwing easy identification.n5 Now extend the haemorrhoidal dissection up the anal canal,separating the haemorrhoid from the underlying internal

Fig. 14.9 Using electrocautery dissection, excise the external skincomponent and then continue the dissection up the anal canalseparating haemorrhoid from anal sphincter.n4

anti-inflammatory drugs (NSAIDs).

Manage the bowels with lactulose 30 ml orally twice daily untildefecation is comfortable.

The principle is a limited removal of anoderm with immediate sutur-

n2 Exclude excoriation in association with pruritus ani, Crohn'sdisease, primary chancre of syphilis, herpes simplex, leukaemiaand tumours.

n3 Treat superficial fissures with 2% diltiazem ointment (Ano-healTM) or 0.4% glyceryl trinitrate cream (RectogesicTM) twice aday. GTN can cause headaches; diltiazem occasionally causeslocal irritation.

n4 Botulinum toxin injection is an alternative therapy, especiallyuseful in patients who are non-compliant in regularly applyingcreams. Doses of botulinum toxin type A (Botox)may range from2.5 to 50 units and reports have included injections into the in-ternal and external anal sphincter either directly into the fissure or

notomy.

ANORECTUM 14ing. Randomized trials have failed to show any advantage.

Stapled haemorrhoidectomy

Linear staples impinging on skin or the rectum are painful. Circular sta-pling above the dentate line, originally advocated by Longo, has had an5 Some surgeons advocate a reversible chemical sphincterotomywith locally applied 0.2% glyceryl trinitrate (GTN) applied threetimes daily.

n6 Review the patient in the outpatient clinic within 1012 days.

OTHER PROCEDURES

Closed haemorrhoidectomy

Mucocutaneous bridge

Fig. 14.10 Haemorrhoidectomy: it is essential to preserve threemucocutaneous bridges.variable reception from surgeons across the world. A major advantageoverconventionalhaemorrhoidectomyisa reductioninshort-termpost-operativepain.However therecanbemajorcomplications, including fis-tula formation, and tenesmus and faecal urgency are more common.Symptom control and safety are similar for the two treatments but there-treatment rate for recurrent prolapse at 1 year is higher following a sta-pled operation when compared to conventional haemorrhoidectomy.

HALO procedureThis ligation procedure employs Doppler-guided haemorrhoid arteryligation. At best it is a more accurate alternative to haemorrhoidalbanding and may reduce the need for conventional haemorrhoidsurgery in patients who fail rubber-band ligation treatment. It doesnot address the external component of haemorrhoids, which arecommonly the major presenting feature.

FISSURE

Appraise

n1 Most ulcers at the anal margin are simple fissures in ano, possiblyassociated with a sentinel skin tag and/or hypertrophied analpapilla or anal polyp.The position statement for the Association of Coloproctology ofGreat Britain and Ireland includes an algorithm on the treatmentof fissures. Only resistant high-pressure fissures should be treatedwith lateral sphincterotomy, resistant low-pressure fissure may healwith the use of an anal advancement flap.

LATERAL SPHINCTEROTOMY

Appraise

n1 This is very successful, curing more than 95% of patients. It wasintroduced by Eisenhammer in 1951.

n2 To avoid exacerbating the pain, avoid preoperative preparation.n3 The operation can be carried out as a day-case procedure.n4 Warn the patient of a 1 in 20 chance of permanent flatus incon-

tinence and a 1 in 200 chance of faecal leakage.at sites removed from it. Dysport is an alternative preparationwhich requires roughly three times the number of units used withBotox. However, studies suggest that the two formulations arenot bioequivalent, whatever the dose relationship.

n5 Reserve operation for failures, which are more common whenthere is a sentinel tag, an anal polyp, exposure of the internalsphincter or undermining of the edges (Fig. 14.11).

n6 Anal dilatation is no longer an acceptable treatment as it causesunpredictable stretching of the internal and external sphinctersand lower rectum, producing anunacceptable risk of incontinence.

7 The standard procedure is a lateral (partial internal) sphincter-Fig. 14.11 A fissure with a sentinel skin tag, an anal polyp andundermining of the edges of the ulcer.

241

Action

n1 Place the patient in the lithotomy position, with general or regionalanaesthesia.

n2 Pass an Eisenhammer bivalve operating proctoscope. Examinethe fissure to exclude induration suggestive of an underlyingintersphincteric abscess.

n3 Remove hypertrophied anal papillae or a fibrous anal polyp,sending them for histopathological examination. Remove asentinel skin tag.

n4 Rotate the operating proctoscope to demonstrate the left lateralaspect of the anal canal. Palpate the lower border of the internalsphincter muscle. If desired, you may replace the Eisenhammerretractor with a Parks retractor which permits outward traction,making the internal sphincter more obvious.

n5 Make a small incision 1 cm long in line with the lower border ofthe internal sphincter. Insert scissors into the submucosa, gentlyseparating the epithelial lining of the anal canal from the internalsphincter, and also into the intersphincteric space to separate theinternal and external sphincters.

ninternal sphincter muscle up to the level of the top of the fissure

the tissues are inflamed and oedematous, do the minimum to

242

14 ANORECTUM(Fig. 14.12).

c KEY POINTS Limit the sphincteric division

n Do not extend the division of the internal sphincter above

the upper limit of the fissure.

n Never extend it above the line of the anal valves.Fig.forceps for 30 seconds. This markedly reduces haemorrhage.

With one blade of the scissors on each side of it, divide then6 If youmake a hole in the mucosa open it completely to avoid therisk of sepsis.

n7 Clamp the isolated area of the internal sphincter with artery

814.12 Lateral partial internal sphincterotomy.promote resolution of the infection. More tissue can be dividedlater to resolve the condition. Send a specimen of pus to the lab-oratory for culture. The presence of intestinal organisms suggeststhe presence of a fistula.

n5 Avoid preoperative preparation of the bowel as it causes unnec-essary pain.

n6 Place the anaesthetized patient in the lithotomy position andshave the operation area.

PERIANAL ABSCESS

n1 Recognize the abscess as a swelling at the anal margin.n2 Make a radial incision and excise overhanging edges. Allow pus to

drain and send a sample to the laboratory.n9 Press on the area for 23 minutes to stop the bleeding. Thewounds do not normally need to be closed.

n10 Do not apply a dressing unless there is excessive bleeding thatwill be controlled by pressure from it. The dressing exacerbatespostoperative pain.

n11 Apply a perineal pad and pants.

Aftercare

n1 Prescribe a bulk laxative such as sterculia (NormacolTM) 10 mlonce or twice a day.

n2 Bruising under the perianal skin signifies a haematoma, but itrequires no treatment.

ANAL ABSCESS AND FISTULA

Appraise

n1 Most abscesses and fistulas in the anal region arise from a primaryinfection in the anal intersphincteric glands. Furthermore, they rep-resent different phases of the same disease process. An acute-phaseabscess develops when free drainage of pus is prevented by closureof either the internal or external opening of the fistula (or both).

n2 Other causes of sepsis in the perianal region include pilonidal in-fection, hidradenitis suppurativa, Crohn's disease, tuberculosisand intrapelvic sepsis draining downwards across the levator ani.

n3 Once established, an intersphincteric abscess may spread verti-cally downwards to form a perianal abscess or upwards to formeither an intermuscular abscess or supralevator abscess, depend-ing upon which side of the longitudinal muscle spread occurs(Fig. 14.13A). Horizontal spread medially across the internalsphincter may result in drainage into the anal canal, but spreadlaterally across the external sphincter may produce an ischiorectalabscess (Fig. 14.13B). Finally, circumferential spread of infectionmay occur from one intersphincteric space to the other, from oneischiorectal fossa to the other and from one supralevator space tothe other (Fig. 14.13C).

n4 Once an abscess has formed surgical drainage must be instituted;antibiotics have no part to play in the primary management. Asn3 Gently examine the wound to see if there is a fistula.n4 Insert a gauze dressing soaked in normal saline solution and

surrounded by Surgicel. Do not pack the wound tightly.

ular

tor

cter

l sptioC) C

4INTERMUSCULAR ABSCESS

n1 Recognize the abscess as an indurated swelling, sometimes mo-bile within the lower rectal wall.

C

Fig. 14.13 Spread of intersphincteric abscess. (A) Verticaintersphincteric abscess. (B) Horizontal spread from infecischiorectal fossa, upwards into the supralevator space. (Intersphinabscess

PerianalabscessAIntermuscabscess

Supralevaabscessn2 As this is an upward extension of an intersphincteric abscess,manage it similarly, but the upper limit of division of the internalsphincter and/or circular muscle of the rectum is higher.

n3 Control bleeding from the divided edges of the rectal wall.n4 Insert a gauze dressing soaked in normal saline to the upper limit

of the wound. Do not pack the wound tightly.

SUPRALEVATOR ABSCESS

n1 This is recognizable as a fixed indurated swelling palpable abovethe anorectal junction.

n2 Drainage of a supralevator abscess extends upwards to a similarlevel as an intermuscular abscess, except that the whole rectal wallneeds to be divided.

n3 Insert a gauze dressing soaked in normal saline, surrounded bySurgicel, into the anal canal to the upper limit of the wound.Do not pack the wound tightly.

ISCHIORECTAL ABSCESS

n1 Recognize this as a brawny inflamed swelling in the ischiorectalfossa.

n2 An ischiorectal abscess often spreads circumferentially from oneside to the other, so carefully examine the patient underanaesthesia to determine if this has occurred. Recognize theabscess by feeling the induration inferior to the levator animuscle.n3 For the same reason, employ a circumanal incision to establishdrainage. Excise the skin edges to create an adequate openingand send a specimen of pus to the laboratory.c

n

n

n4

Po

n1

n2

n3

n4edially across the internal sphincter into themferential spread.read upwards and downwards from a primaryn mircuic

Supralevatorabscess

Ischiorectalabscess

B

ANORECTUM 1KEY POINTS Gentleness

Be very careful when exploring the cavity with your

finger. You may spread infection, damage the levator ani

or injure the rectum itself.

Never use a probe.

Gently insert a gauze dressing soaked in normal saline sur-rounded by Surgicel to the upper limit of the wound. Do not packthe wound tightly.

stoperative

Remove the dressing on the second postoperative day while thepatient lies in the bath, having been given an intramuscular injec-tion of pethidine 100 mg or papaveretum 715 mg.

Initiate a routine of twice-daily baths, irrigation of the woundand the insertion of a tuck-in gauze dressing soaked in physiolog-ical saline or 1:40 sodium hypochlorite solution.

If the patient has evidence of persistent local or systemic sepsis,administer systemic antibiotics guided by the culture report.Metronidazole is effective against anaerobic organisms.

Assess the patient for the possible presence of a fistula detected atthe time of abscess drainage, or a history of recurrent abscesses, orpalpable induration of the perianal area, anal canal and lowerrectum, or the presence of gut organism in the pus. If so, planto re-examine the patient under anaesthesia and carry out theappropriate treatment.

243

FISTULA

Appraise

n1 A fistula is an abnormal communication between two epithelial-lined surfaces. Therefore, in the context of fistula in ano, thereshould be an external opening on the perianal skin, an internalopening into the anal canal and a track between the two.

n2 There may be no external opening, or it may be healed over. Like-wise, there may be no internal opening as the sepsis arises in the

feel induration in the wall of the anal canal between a fingerin the anal canal and the thumb externally. If there is an upward

n Never force a probe or you may create false passages.

n2 If there is a long subcutaneous track, the probe is directed fromthe external opening towards the anus. Lay it open and removethe granulation tissue with a curette. The upward extensionbetween the sphincters becomes apparent as granulation tissueexudes from the opening.

n3 Divide the internal sphincter as high as the tip of the probe. Againremove granulation tissue by curettage. If no granulation tissueprotrudes from a residual part of the track, and palpation revealsno more induration, do nothing more.

n4 If necessary, totally divide the internal sphincter and the muscleof the lower rectum completely, to lay open the fistula.

5 Create an adequate external wound to allow drainage.

neously some distance from the anus.

244

14 ANORECTUMarea of the intersphincteric gland, which is the primary site of in-fection. It may not drain across the internal sphincter into theanal canal. Finally, the track may follow a very complicated path.

n3 The presence of infection is characterized by the physical sign ofinduration, detected by palpationwith a lubricated, covered finger.

SUPERFICIAL FISTULA

Assess

n1 Place the anaesthetized patient in the lithotomy position. Alwaysperform sigmoidoscopy, looking especially for inflammatorybowel disease.

n2 Palpate the perianal skin, anal canal and lower rectum to detectinduration. This is confined to the distal anal canal and localizedto one area, as superficial fistulas are really fissures covered withskin and lower anal canal epithelium (Fig. 14.14).

Action

n1 Insert a bivalve operating proctoscope and pass a fine probealong the track.

n2 Lay open the fistula using a no. 15 bladed knife or electrocautery.n3 Curette the granulation tissue and send a specimen for

histopathology.

n4 If there is no induration deep to the internal sphincter, fashionthe external skin wound so that it becomes pear-shaped and per-form a lateral sphincterotomy (see above).

n5 Insert a gauze dressing soaked in normal saline solution and sur-rounded by Surgicel to the upper limit of the wound.

INTERSPHINCTERIC FISTULA

n1 An intersphincteric fistula results when the sepsis is inside thestriated muscle of the pelvic floor and the anal canal (Fig. 14.15).Fig. 14.14 A diagram to show a superficial fistula and the pear-shaped wound required to treat it.extension, you feel induration in the rectal wall. Although theinternal opening into the rectum may be above the anorectalring, laying it open is not difficult, as the striated muscle willnot be divided. Remember that there may not be an internalopening.

Action

n1 Insert a bivalve operating proctoscope and pass a fistula probe,such as Lockhart-Mummery's, or Anel's lacrimal probe, alongthe track. This runs parallel to the long axis of the anal canal.

c KEY POINT Gentle manipulationn1 Have the anaesthetized patient in the lithotomy position.Perform sigmoidoscopy in all cases, especially looking for in-flammatory bowel disease.

n2 Palpate carefully for induration. There is often a long subcuta-neous perianal track leading to the external opening. You cannn6

n7sessAsFig. 14.15 Intersphincteric fistula. Note how the track may extendupwards into the rectum above the level of puborectalis and subcuta-Insert a gauze dressing soaked in normal saline solution sur-rounded by Surgicel. Do not pack the wound tightly.

Apply a perineal pad and pants.

n8 Now identify the primary track across the external sphincter. If itis at or below the line of the anal valves, divide the muscle. If it ishigher, as it often is, it may be possible to divide the muscle, but

4Assess

n1 Have the anaesthetized patient in the lithotomy position with thebuttocks well down over the end of the table. Invariably performsigmoidoscopy, especially lookingfor inflammatoryboweldisease.

n2 Palpate carefully for induration. The external opening(s) areusually laterally placed and indurated, but there is not usuallyany induration extending towards the anus subcutaneously in atrans-sphincteric fistula. You may palpate induration within thewall of the anal canal, the site of the primary anal gland infection.Induration is also detected under the levator ani muscles andis often circumferential. Palpate between a finger in the lowerrectum, and thumb on the perianal skin, for a large area of indu-ration. This is especially obvious if circumferential spread hasnot occurred and the contralateral side is normal.

c KEY POINTS Complex presentations

n Remember that there may be no internal opening the

infection has not crossed the internal sphincter.

n If there is an internal opening at the level of the anal

valves, the level at which the primary track crosses then

n

Ac

n1

n2sphincter into theanal canal,whereyou find the internalopeningofthefistula,which isusuallyat the levelof theanalvalves(Fig.14.16).TRANS-SPHINCTERIC FISTULA

n1 In a trans-sphincteric fistula, the primary track passes acrossthe external sphincter from the intersphincteric space to the ischio-rectal fossa. The infectionmay also have drained across the internal

Fig. 14.16 Trans-sphincteric fistula.external sphincter may not be the same it may be lower

or higher (Fig. 14.17).

Infection can spread vertically in the intersphincteric

space and open into the rectum, in addition to spreading

across the external sphincter.

Circumferential spread of infection and other secondary

tracks may also develop.

tion

Pass a bivalve operating proctoscope in order to try and identifythe internal opening.

Pass a Lockhart-Mummery probe into the external opening.It may extend several centimetres and can be felt very close toa finger in the rectum. Do not force the probe, and do not passit into the rectum, as this is never the site of the internal opening.n3 If there is spreadof infection towards themidline posteriorly, directthe probepreviously inserted into the external opening, posteriorlytowards the coccyx. With a scalpel (no. 10 blade) in the groove ofthe probe divide the tissue between the skin and the probe; divideskin and fat only, you should not divide any muscle. Apply tissue-holding forceps to the skin edges and secure any major bleedingpoints. Alternatively, perform the laying open with electrocautery.

n4 Curette away granulation tissue, sending some for histopatholog-ical examination, and look for a forward extension from the siteof the external opening. Lay it open.

n5 Seek any extension of the sepsis to the opposite side by palpation,probing and looking for granulation tissue pouting from an open-ing in the previously curetted track. Use a no. 10 bladed knife orelectrocautery to divide skin and fat to lay open any further tracks.

n6 Insert the bivalve proctoscope again and re-identify the internalopening. It may or may not be possible to pass a probe eitherthrough the internal opening into the previously opened tracksor from the previously opened tracks into the anal canal.

n7 Divide the anal canal epithelium and the internal sphincter to thelevelof the internalopening, ifpresent,withano.15bladedknifeorelectrocautery, thusopeningup the intersphincteric space. If there isno internal opening, open the intersphincteric space in a similarway, to the level of the anal valves. Curette any granulation tissue.

Fig. 14.17 The level at which the primary track crosses theexternal sphincter is not necessarily at the same level as theinternal opening into the anal canal. It may be higher or lower;furthermore, there may be an upward intersphincteric extension.?

1

2ANORECTUM 1determining this requires considerable experience. It is often saferto drain the track by inserting a seton: use a length of fine siliconetubing (1 mm diameter) or no. 1 braided suture material. Mono-filaments such as nylon are often uncomfortable for the patientbecause of the sharp ends beyond the knot.

DIFFICULTY

. Accurate definition of a complex fistula can be difficult.

Do not be tempted to risk causing incontinence by

dividing the external sphincter.

. Insert a loose seton (Latin: setabristle; a ligaturethreaded through the track), and order a magnetic

resonance imaging (MRI) scan to clarify the situation; you

can then plan effective and safe definitive treatment.

245

n9 Once all the septic areas have been drained, fashion thewound so that drainage can continue and the wound canheal from its depths. You almost certainly need to trim the skinand fat.

c KEY POINTS The phases of the procedure

n Drain the secondary tracks.

n Drain the intersphincteric abscess of origin.

n Drain the primary track, either by dividing the muscle or

muscle above all themuscles of continence (Fig. 14.18). As this isa variant of a high trans-sphincteric fistula, manage it on similar

infection from the ischiorectal fossa is also unusual and mayresult from the injudicious use of a probe during operation.

acute appendicitis, Crohn's disease or diverticular disease andnot, therefore, of anal gland origin) by treating the primary

ter giving an intramuscular injection of pethidine 100 mg or

times by giving laxatives. If they do not coincide, arrange bath-ir-

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14 ANORECTUMFig.supdisease (see Chapters 11, 13).n2 Create a defunctioning loop colostomy as a preliminary to clos-ing the opening in the rectum and treat the fistula along the linesindicated above.

n3 Manage a fistula arising from pelvic sepsis (for example fromprinciples.

n This is a very rare form of fistula. When possible refer the patientto a surgeon specializing in this field.

EXTRASPHINCTERIC FISTULA

n1 An extrasphincteric fistula arising from an upward extension ofby inserting a seton.

n10 Insert gauze dressings soaked in normal saline surrounded bySurgicel into the wounds and the anal canal. Do not pack thedressings tightly.

n11 Apply a perineal pad and pants.

SUPRASPHINCTERIC FISTULA

n In a suprasphincteric fistula, the primary track crosses the striated14.18 Suprasphincteric fistula. There may be an associatedralevator abscess.n7 A seton does not complicate the postoperative routine. Allow thewound to heal around it; this may take 3 months. Then, undergeneral anaesthesia, remove the seton and curette its track freeof granulation tissue. Spontaneous healing occurs in approxi-mately 40% of patients. If healing does not occur, lay open theresidual track. The advantage of this staged division of the exter-nal sphincter is that healing occurs around the scaffolding of theexternal sphincter. When it is subsequently divided and this isnot always necessary its ends separate only slightly. This pro-duces a better functional result than if it were divided at theoutset.

Complications

n1 Failure to heal may result from inadequate drainage of the inter-sphincteric abscess, of secondary tracks, or of the primary track.Give the nurses clear instructions and advice about the dressings.Inadequate postoperative dressings allow bridging of the woundedges and pocketing of pus. If there is excessive growth of gran-ulation tissue, cauterize it with silver nitrate or curette it awayunder general anaesthetic.

c KEY POINTS Slow healing?

n Is the patient malnourished or suffering from zinc

deficiency?

n If hairs are growing into the wound, shave the area.

n Have you missed a specific cause for the fistula, such as

Crohns disease?

n2 Secondary haemorrhage may occur from any potentially septic,open wound healing by second intention.rigation-dressing routines as necessary.

n5 If there is voluminous discharge of pus, review the wound inthe operating theatre under general anaesthesia after 1014 days.In patients with large wounds, this may need to be repeated.Lay open any residual tracks and curette away the granulationtissue.

n6 Administer antimicrobial agents such as ciprofloxacin or metro-nidazole for up to 28 days, to assist in the elimination of thesepsis. A pus swab may further guide the choice of antibiotic.n3Encourage the bowel movements to coincide with these dressingpapaveretum 715 mg. Carry out the first dressing in the operat-ing theatre under general anaesthesia if the wound is veryextensive.

n2 Initiate a routine of twice-daily baths, irrigation of the woundand insertion of gauze soaked in physiological saline.

n3 Inspect the wound at regular intervals until healing is complete.n4Postoperative

n1 Remove the dressing on the second or third postoperative day af-Anal incontinence of varying degrees may follow division of thesphincter muscles. If the entire sphincter complex has inadver-tently been divided, consider repairing it once the sepsis has beeneradicated and healing has occurred.

n The use of fibrin glues injected into the track and bioprosthetic

n3 Curette away the granulation tissue and embedded hairs.

2 The perianal area has a bluish discoloration and there may be

4n4 Check with a probe in the base of the wound to detect any sidetracks, and look for any residual granulation tissue that may bepouting from a side track.

n5 Fashion the wound so that there are no overhanging edges.plugs sutured to the track is appealing in that there is no sphincterdestruction and continence is maintained. However, initial en-thusiasm over the short-term external opening healing rateshas been tempered by a lack of evidence of healing of the trackon MRI scanning and high recurrence rates.

PILONIDAL DISEASE

A simple pilonidal sinus detected as a chance finding during routineexamination probably does not require treatment. Operate only if itis painful or infected, producing a pilonidal abscess.

Prepare

Place the anaesthetized patient in the left lateral position with theright buttock strapped to hold it up. Elastic adhesive strapping is ad-equate and adheres better if the skin has been sprayed with com-pound tincture of benzoin. Carefully shave the area.

Action

n1 Determine the extent of sepsis by palpation for induration and byusing probes.

n2 Completely excise the skin of the septic area.n4 Successful fistula surgery depends upon accurate definition of thepathological anatomy, drainage of the intersphincteric abscess oforigin, the primary and secondary tracks, and excellent postoper-ative wound care.

OTHER PROCEDURES

n A loose seton can be very acceptable to the patient even in thelong term, provided that the seton is discrete and comfortable.The use of rubber sloops tied with several silk knots and left dan-gling between the buttocks will cause irritation and soreness.A neat 1 Ethibond thread, with only two knots, secured with3/0 Ethibond to anchor the whiskers can be completely comfort-able, especially with the knots turned into the track.

n A tight seton is designed to cut through the fistula track slowly, inthe hope of reducing the separation of muscle ends. Apply itfirmly but not tightly. Replace it at monthly intervals.

n Specialist colorectal surgeons may create advancement flaps toavoid sphincter division and employ an intersphincteric ap-proach and core-out fistulectomy. The technique is employedparticularly in high trans-sphincteric fistulae, especially when sit-uated anteriorly in women, who have a short anal canal, and issuccessful in around 50% of cases.n6 Secure haemostasis.n7 Dress the wound with gauze soaked in physiological saline solu-

tion and apply pressure to it.Action

n1 Drain the pus from each abscess. They are oftenmultiple andmayintercommunicate.

n2 Curette away all the granulation tissue.n3 Remove all overhanging skin.n4 Allow the defect to heal by second intention.n5 In very severe cases it may be necessary to excise and graft an area

most affected in order to prevent multiple recurrences.

ANAL MANIFESTATIONS OF CROHNSDISEASE

Appraise

n1 These occur in approximately 50% of patients affected withCrohn's disease.OTHER PROCEDURES

n1 Lay open a simple pilonidal sinus and marsupialize (Latin:marsupiumpouch; create a pouch with an open mouth) thewound. This keeps thewoundopenuntil the interior has filled up.

n2 In Bascom's operation each pit is excised with a no. 11 bladedknife. Drain the cavity through a laterally placed incision.

n3 Various rotation flaps can be used, all having the objective ofavoiding a midline suture line.

HIDRADENITIS SUPPURATIVA

Appraise

n1 Hidradenitis (Greek: hidros sweatadengland itis inflam-mation) suppurativa (Latin:pus-forming) is a septic processthat involves the apocrine (Greek: apooffkrinein to sepa-rate; the secretion is a breakdown product of the cell) sweatglands. It occurs in the perineum as well as the axillae.

n2 Recurrent abscess formation often results from inadequate drain-age. There is no communication with the anal canal and the in-fection is superficial. Occasionally, hidradenitis occurs inassociation with Crohn's disease and lithium therapy.

n3 Combine surgical treatment of acute abscesses with continuingdermatological input as topical or systemic antimicrobial agents,retinoids, hormonal therapy and immunosuppressive medica-tions may also help to control the disease.Postoperative

n1 Initiate a twice-daily routine of bath, irrigation and dressing.n2 Keep the wound edges shaved.n3 Cauterize any excess granulation tissue with silver nitrate.n4 Complications include haemorrhage, delayed healing and recur-

rence. If necessary, repeat the operative procedure.

ANORECTUM 1noedematous skin tags. Ulceration, which can be extensive, mayinvolve the perianal skin, anal margin and anal canal. Sepsismay occur in the form of either an abscess or a fistula (Fig. 14.19).

247

nAc

n1

n2

n3

n4

C

Ap

n1

n2 Treat scattered lesions by applying 25% podophyllin in com-pound benzoin tincture. Treatmore extensive lesions by operationusing the technique of scissor excision.

Action

n1 Have the anaesthetized patient placed in the lithotomy or pronejack-knife positions.

n2 Infiltrate a solution of 1:300 000 adrenaline (epinephrine) innormal saline under the epithelium bearing the perianal lesionsto reduce bleeding during excision of the warts and to separatethe individual lesions, thus preserving the maximum amountof normal skin.

n3 Hold the warts with fine-toothed forceps and remove them withpointed scissors.

n4 Remove intra-anal canal warts in the same way after inserting abivalve operating proctoscope. There is often a confluent ringof lesions in the upper anal canal. Totally remove these and thenjoin the mucosa of the lower rectum to that of the anal canalat the dentate line with sutures (Fig. 14.20). In addition to ach-ieving mucosal apposition, this mucosal anastomosis ishaemostatic.

n5 Send the excised lesions, particularly the intra-anal ones, for his-topathological examination.

3. Ulceration1. Bluish hue

disease.

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14KEY POINT Suspect Crohns diseasec4. Sepsis

2. Oedematous tags

Fig. 14.19 Diagram to show the anal manifestations of Crohns ANORECTUMAlways think of the possibility of anal Crohns disease. This

may be the first manifestation of the condition.

tion

Remove a small biopsy specimen of a skin tag, or granulation tis-sue together with a rectal mucosal biopsy for histopathologicalexamination.

Drain any abscess in the usual way, taking care not to divide anymuscle.

For long-term seton drainage of fistulas, again prefer a soft suturematerial such as No. 1 Ethibond. By using 3/0 Ethibond a secureknot can be tied without the need for too many throws thatwould create a bulky knot. Again turn the knot so that it lieswithin the track, leaving only a smooth loop of suture on theoutside.

Fully investigate the patient.

ONDYLOMATA ACUMINATA

praise

Condylomata acuminata (genital warts) result from humanpapillomavirus (HPV) infection of the squamous epithelium.Papilliferous lesions may develop on the perianal skin,within the anal canal and on the genitalia. Exclude otherforms of sexually transmitted disease and attempt to tracecontacts.A

B

CFig. 14.20 (A) Confluent intra-anal canal warts above the dentateline. (B) Thewarts, togetherwith all themucosa, are removed, leavinga section of muscle denuded ofmucosa. (C) The lower rectal mucosa isattached to the dentate line by interrupted absorbable sutures.

n3 There is virtually no indication for local excision in infiltrative

behaviour as there is no invasion of neoplastic cells across the

than 2 cm in diameter.

n1 Totally remove lesions less than 5 mm across by twisting with a

and confined to the lower two-thirds of the rectum (see below).

a higher level.

4squamous carcinoma of the anal canal, which may be treatedconservatively in the majority of cases by primary radiotherapywith chemotherapy. Reserve surgery for residual tumour, compli-cations of therapy or subsequent tumour recurrence.

n4 If surgery is indicated after failed combined modality therapy,then this usually requires abdominoperineal excision of the rec-tum and anal canal (see Chapter 13), widely excising the perianalAppraise

n1 These may be benign or malignant. Condylomata acuminata,keratoacanthoma, apocrine gland tumours, premalignantBowen's disease and Paget's disease are benign.

n2 Excise condylomata acuminata (warts) with scissors as above.n3 Totally excise other tumours. If the defect is not too large allow

the wound to heal by second intention. Close large defects withsplit skin grafts.

n4 Histopathological information is essential in deciding whether ornot any further treatment is required.

n5 Malignant tumours of the anal margin are mainly squamous cellcarcinomas, although basal cell carcinoma can occur. Indurationsuggests malignancy. Small microinvasive carcinomas can beadequately treated by wide local excision, but more advancedcancers require a combination of radiotherapy and chemother-apy (see below).

ANAL CANAL TUMOURS

Appraise

n1 These are almost always malignant and include squamous cellcarcinoma, basaloid carcinoma, adenocarcinoma and malignantmelanoma.

n2 Examine the tumour under anaesthesia and remove a biopsyspecimen.Postoperative

n1 No special measures are needed.n2 Carry out regular examinations to detect further wart formation,

which usually occurs within the first 3 months. Treat scatteredlesions with podophyllin. More extensive recurrences requirefurther inpatient treatment.

ANALTUMOURS

Tumours in this region may be divided into two groups, althoughopinions differ as to the anatomical level of division.

For the purposes of this chapter anal canal tumours arise fromthe dentate line and above. Anal margin tumours arise below thedentate line.

ANAL MARGIN TUMOURSskin, ischiorectal fossa fat and the levator ani muscles near thelateral pelvic wall. Ensure that you have positive histologyafter radiochemotherapy of a squamous carcinoma prior to per-forming an abdominoperineal resection.n4 Those in the lower third of the rectum that are circumferentialmay be suitably excised by a modified Soave operation (seebelow).

n5 Employ anterior resection for sessile non-circumferential tu-mours with the lower border in the upper third of the rectum,and circumferential tumours with the lower border in the uppertwo-thirds of the rectum.

SUBMUCOSAL EXCISION OF SESSILEADENOMA

Appraise

n1 Undertake this technique only if there are nomalignant lesions atn2Submucosally excise those that are sessile, non-circumferentialpair of Patterson biopsy forceps.

n2 Employ diathermy snare excision for those that are pedun-culated.

n3n4 Be sure to remove the whole lesion by performing a total excisionbiopsy, which is diagnostic as well as therapeutic if the lesionproves to be totally benign. Do not perform an incision biopsyas it is not representative of the whole lesion and makes subse-quent submucosal excision difficult.

Actionmuscularis mucosae. A more useful classification is accordingto their clinical appearance; for example, are they pedunculatedor sessile?

n2 Are there any other neoplastic lesions benign or malignant inthe large intestine? In patients with lesions more than 2 cm in di-ameter, there is an incidence of further tumours of 25% (benign18%, malignant 7%). Order a colonoscopy.

c KEY POINT Familial disease?

n Multiple small adenomatous polyps in the rectum suggest

the diagnosis of familial adenomatous polyposis.

n3 Is the lesion totally benign or does it have malignant areas? Thereis a 50% chance of malignant areas in patients with lesions largerRECTAL ADENOMAS

Appraise

n1 Adenomas of the rectummay be classified on a histopathologicalbasis into tubular, tubulovillous and villous. From the clinicalviewpoint these three types of adenoma are similar in their

ANORECTUM 1Undertake this technique provided the tumour does not feelindurated on palpation with the finger or the end of the sigmoid-oscope, suggesting malignant change.

249

Prepare

n1 Order full bowel preparation.n2 Place the patient in the lithotomy position or the jack-knife

position, which is especially suitable for anterior lesions.

Action

n1 Insert a bivalve operating proctoscope and ensure that illumina-tion is adequate. You may find it advisable to wear a headlamp.

n2 Inject 1:300 000 adrenaline (epinephrine) in physiological salineinto the submucosa under the tumour.

c KEY POINT Cause for suspicion

n Benign tumours are entirely mucosal; therefore, if you

find it difficult to create artificial oedema in the

submucosa, suspect malignant invasion (Fig. 14.21).

n3 With sharp scissors or electrocautery incise the mucosa approxi-mately 1 cm from the edge of the tumour and then dissect it freeof the circular muscle of the rectum, which appears as white fibresin the distended submucosal layer (Fig. 14.22).

n4 Seal bleeding points with diathermy.

n5 Stenosis of the rectummay develop if excision was performed fortoo large a lesion.

MODIFIED SOAVE OPERATION

n1 Reserve this operation for large circumferential lesions with theirlower border in the lower third of the rectum and extending intothe upper third.

n2 In principle the entire tumour is excised submucosally by a com-bined abdominal and peranal approach. The rectal musculartube is relined with descending colon, anastomosed throughthe anus to the level of the dentate line (Fig. 14.24) as describedin Chapter 13.

n3 Circumferential lesions extending over only a few centimetrescan be treated by submucosal excision, with plication of themus-cle tube to allow mucosal anastomosis.

n4 This is an unusual operation best reserved for performance in aspecialist centre.

OTHER PROCEDURES

Both transanal endoscopic microsurgery (TEMS) and extended endo-

within it. This will prove difficult if there has been a previous incision

250

14 ANORECTUMbiopsy, or malignancy is present.Fig.mu14.21 1:300 000 adrenaline (epinephrine) in normal saline iscted into the submucosa to elevate the mucosa and the tumourFig.injen5 Allow the wound to heal spontaneously without suturing it. Closeany defect you inadvertently created in the muscle with sutures.

n6 Pin the specimen to a cork board before fixing it, so that thepathologist can determine whether or not there is any malignantinvasion, by taking serial sections (Fig. 14.23).14.22 The mucosa is dissected from the underlying circularscle (white fibres).Postoperative

n1 No special measures need be adopted other than to ensure thatconstipation does not occur.

n2 Haemorrhage is a rare complication.n3 Study the histopathological report. If there are malignant foci,

decide whether or not to proceed to a more radical procedure.

n4 Follow-up the patient to detect any recurrence andmetachronous(sequential but separated by appreciable intervals) lesions.

Fig. 14.23 The specimen with a margin of normal mucosa is pinnedto a cork board prior to fixing to assist the histopathologist.scopic mucosal resection (EMR) can be used to cure superficial mu-cosal tumours of the gastrointestinal tract, regardless of their size, aslong as the tumours are localized and without metastases. They areboth very specialist techniques.

n3 The patient should be catheterized.4 Place the anaesthetized patient in the Lloyd-Davies (lithotomy

4TEMS is a minimally invasive surgical technique that allows thesurgeon to operate on lesions in the mid and upper rectum withan operating microscope inserted into the anus. An operating proc-toscope (a 2 inch wide tube) is placed through the anus and posi-tioned over the lesion. The rectum is filled with carbon dioxide gasso there is room to work. A special microscope is used to look atthe area directly and with a video camera. Long instruments are thenused to grasp, cut and suture.

The application of conventional EMR with snaring was somewhatlimited by the size of the tumour. The Japanese introduced extendedEMR or endoscopic submucosal dissection (ESD) with a new endo-scopic resection technique using sodium hyaluronate and a needleknife resection for en bloc resection of large but superficial gastricneoplasms in 1998. This has been extended to other areas of the gas-trointestinal track including the colon and rectum.

Recentnon-randomized studies suggest thatEMRisequally effectivein removing large rectal adenomas when compared to TEM. Currentclinical practice mainly depends on local expertise in TEM or EMR.Fig. 14.24 Modified Soave operation. Themucosa has been removedfrom the distal rectum by both the abdominal and perineal surgeon.The descending colon is now passed into themuscle tube and suturedat the dentate line.RECTAL PROLAPSE

Appraise

n1 The symptom of prolapse (i.e. tissue slipping through the anus)may result from causes other than complete rectal prolapse.Distinguish haemorrhoids, anal polyps, mucosal prolapse andrectal adenomas. An internally intussuscepted rectum lies inthe lower third of the rectum (the first phase of prolapse),whereas a complete prolapse passes through the anal sphincterand keeps it open: sphincter function is inhibited in both cases.

n2 Treatment consists of control of the prolapse, re-education of thebowel habit and improvement, if necessary, of sphincterfunction.

n3 First control the prolapse. Many operations have been describedto achieve control: in the UK complete rectal prolapse is usuallytreated either by abdominal rectopexy or by perineal mucosalsleeve resection (Delorme's procedure, see below).

n4 An open abdominal rectopexy is currently rarely performed, butfollows the same steps as the laparoscopic operation describedbelow.nTrendelenburg) position.

Action

n1 Make a subumbilical 12-mm incision and enter the peritonealcavity using the Hasson technique. Place a Hasson trocar in theperitoneal cavity. The camera and stack should be on the patient'sleft side. The bed should be tilted to the head down and left lat-eral position to allow the small bowel tomigrate to the upper ab-domen. Measures should be taken to avoid the patient slippingoff the table.

n2 Achieve CO2 pneumoperitoneum to 1215 mm Hg.n3 Place a 12-mm trocar under direct vision in the right iliac fossa.

Insert another 5-mm trocar a hand's breadth above this trocar.Insert a 3rd 5-mm trocar in the left lateral region.

n4 If the small bowel cannot be adequately moved out of the pelvisthe ileal attachments to the lateral abdominal wall should be di-vided to allow the bowel tomove cephalad. Starting at the level ofthe sacral promontory, incise the peritoneum on the medial sidebeside (but not damaging) the superior haemorrhoidal arteryusing an energy device such as the harmonic scalpel. Prior tomak-ing this incision, use a non-traumatic bowel grasping forceps ton5 Abdominal rectopexy is associated with unpredictable postoper-ative constipation, which in somepatients can be severe. There areclaims that concomitant sigmoid resection (resection rectopexy,also known as the Frykman-Goldberg operation) reduces this risk.

n6 After rectopexy only a few patients have sphincter dysfunction se-vere enough to produce significant incontinence. Pelvic floorphysiotherapy, faradism and electrical stimulators give littlelong-term benefit. The problem results from pelvic floor neuro-genic myopathy producing a shortened anal canal with wideningof the anorectal angle. Postanal pelvic floor repair reduces theanorectal angle and lengthens the anal canal, restoring satisfac-tory continence in some patients.

n7 All abdominal pelvic dissection inmale patients has the potentialto cause either erectile or ejaculatory dysfunction. Because of thisit is essential that this complication be mentioned and recordedwhen obtaining informed consent.

n8 The laparoscopic ventral rectopexy is a newer technique whichis particularly beneficial in the presence of a rectocele and enter-ocele as it bolsters the rectovaginal septum. Proponents of theoperation suggest it should be the treatment of choice for allpatients with rectal prolapse.

LAPAROSCOPIC ABDOMINAL RECTOPEXY

Prepare

n1 No bowel preparation is usually required but can be used at thediscretion of the clinician.

n2 Order metronidazole 500 mg intravenously and Augmentin1.2 g intravenously at induction of anaesthesia.

ANORECTUM 1retract the rectum superiorly (assistant through the left sidedport)and cephalad (surgeons left handed grasper pulling the rectosig-moid cephalad). The incision will result in gas entering the plane

251

ofdissection, enabling goodvisualizationof theplane. Theureterslie laterally onboth sides, but always check their position. Thepre-sacral nerves lie just behind the superior haemorrhoidal artery;take care to preserve them. Extend the dissection in the lateral di-rection till the left ureter is identified. As the dissection progressesensure the bow created by the superior haemorrhoidal artery isplaced on tension with the left handed grasper. Now extend theperitoneal incision to the bottom of the prerectal pouch, thenacross the midline between the rectum and vagina or bladder,so that the rectum may be separated from them.

n5 Enter the postrectal space and open it up by dissection, holdingthe rectum forward with your left handed grasper. Exert adequatetension on the rectum to display the areolar tissue. Seal any ves-sels with the energy device.

n6 Now that the anterior and posterior dissection of the rectum iscomplete its only attachments are the two lateral ligaments.It is arguable whether or not these should be divided.

n7 Achieve perfect haemostasis.n8 Using a 3/0 ethibond suture and two needle holders inserted

through the right sided port, place a stitch between the upperparts of the lateral ligaments on the right side and the vertebral

Prepare

til close to the level of the anus. Unless you do this, only half of

252

14 ANORECTUMdisc just distal to the sacral promontory; avoiding the mediansacral artery. These will suspend the rectum while scarring fixesit in place. Two to three such sutures will ensure the rectum staysattached to the promontory. If the surgeon is not skilled inintracorporeal knot tying, a knot pusher can be used after sutureplacement.

n9 Observe whether the sigmoid loop is redundant. If it is, andparticularly if there is a background history of constipation, per-form sigmoid resection with end-to-end anastomosis. Otherwiseit is not worth resecting the sigmoid colon (Fig. 14.25). Toremove the specimen and create the purse-string suture for anvilplacement a 34-cm left iliac fossa incision can be made.Fig. 14.25 Abdominal rectopexy can be done with or withoutsigmoid resection and is now usually achieved simply with a seriesof non-absorbable sutures rather than as previously withsponge or mesh.the prolapse will have been treated.

n5 Re-approximate the mucosal edges using interrupted 2/0 poly-glactin 910 (Vicryl) sutures, which are also used to plicate thedenuded rectal wall. Ensure that each suture takes several bitesof the rectal wall in order to obliterate any potential dead spacen1 Reproduce the prolapse and infiltrate the submucosal planewith saline containing 1:300 000 adrenaline (epinephrine) tofacilitate the dissection and to limit bleeding.

n2 Make a circumferential incision through the mucosa 1 cm prox-imal to the dentate line. Identify the white annular fibres of therectal wall lying deep to the submucosa.

n3 Develop the submucosal plane circumferentially using eitherscissor dissection or electrocautery until you reach the apex ofthe prolapse.

n4 Continue the dissection back up inside the prolapsed rectum un-n1 Order a full bowel preparation.n2 The patient is given general or regional anaesthesia and lies in the

lithotomy position.

Actionn1 Haemorrhage may lead to a pelvic haematoma.n2 Postoperative constipation is unpredictable and can be trouble-

some.

MUCOSAL SLEEVE RESECTION (DELORMEPROCEDURE)

The functional results of this procedure (Fig. 14.26) are good and itis particularly useful if the prolapse is small or incomplete and inhigh-risk patients who are unsuitable for abdominal surgery.n10 A drain is not usually necessary, but if there is a persistentcollection of blood and fluid in the pelvis insert a tube drainfor 24 hours.

n11 Close the laparoscopic port sites.

Postoperative

n1 The patient can be commenced on an enhanced recovery pro-gramme. If no resection is performed start a normal diet as soonas the patient is able to tolerate it. If a resection is performed, startwith free fluids till the patient passes flatus.

n2 Remove the catheter on the first postoperative day.n3 Avoid constipation. Give a mild osmotic laxative to initiate

bowel movement. Subsequently use suppositories such as glycer-ine and bisacodyl.

Complicationsbeneath the mucosa.

n6 The plicated rectal wall returns to the pelvis and lies above thesphincter, preventing further prolapse.

surgical and obstetric trauma) or muscle atrophy.

sols. (E) The completed procedure.

4n2 Operative treatment may be employed for the correction of somecongenital abnormalities, complete rectal prolapse and simpledisruption of the external sphincter (sphincter repair). Severe in-continence may need to be treated with the implantation of anartificial bowel sphincter. Sacral nerve stimulation is an alterna-tive approach which is gaining in popularity.Postoperative

n1 Avoid constipation by using an osmotic laxative.n2 Complications can include haemorrhage, anastomotic break-

down and stricture formation.

FAECAL INCONTINENCE

Appraise

n1 Determine the cause of faecal incontinence. If the analsphincter is normal consider causes such as faecal impactionor irritable bowel syndrome. If the anal sphincter is abnormalconsider the possibility of a congenital abnormality, completerectal prolapse (see above), a lower motor neurone lesion,disruption of the sphincter ring due to trauma (including

Fig. 14.26 Delorme Prodedure. (A) Infiltration with adrenaline-salinethe mucosal sleeve dissection. (D) Insertion of muscle plication sutureA B Cn3 Disruption of the sphincter ring may be suggested by a historyof trauma accidental, obstetric or surgical and diagnosedby detecting a defect in the sphincter ring using endoanalultrasound.

INJECTION OF BULKING AGENTS

n1 The use of polytetrafluoroethylene (Teflon or polytef) was firstreported in the context of a weakened or defective internal analsphincter muscle by Shafik in 1993.

n2 Injection of PTQ (silicone based) implants is now licensed in theUK. Reports on the use of other substances in faecal incontinencehave been limited. Most substances have limited, if any, durabil-ity whether injected submucosally, intramuscularly or into theintersphincteris space.

n3 The use of radiofrequency ablation has been employed as analternative in the USA, but is not currently in use in the UK. It usescircumferential treatments to produce scarring of the anal canal.Prepare

n1 The patient should be put onto laxatives 2 days pre-injection, tocontinue for a week after injection.

n2 An enema can be given preprocedure.n3 If the procedure is to be performed under local anaesthesia, a

local anaesthetic cream can be used prior to injection of theanaesthetic agent.

n4 Antibiotics are given intravenously at the time of the first injec-tion and continued orally for a week after.

Action

n1 There is little agreement on the optimal injection methodology.n2 The patient may be in the prone jack-knife, lithotomy or left

lateral position.

n3 Injections are sometimes given circumferentially in all patientsand sometimes only into a specific site in those with a singleinternal anal sphincter defect.

n4 Trans-sphincteric injectionmay reduce infection when comparedto direct anal canal injection.

n5 The site of the injection may be guided by the index finger toD E

ution. (B) Beginning the mucosal sleeve dissection. (C) Completion ofANORECTUM 1avoid any dispersal of product; however, some centres prefer touse a retractor or ultrasound guidance.

OVERLAPPING SPHINCTER REPAIR

A colostomy is necessary only in complex cases, such as pati-ents with Crohn's disease, rectovaginal fistula or where theinjury is very extensive (e.g. a cloacal defect extending into thevagina).

Prepare

n1 Order a full bowel preparation.n2 The patient is given a general anaesthetic and placed in the supine

position if construction of a loop sigmoid colostomy is required(see Chapter 13). Then place the patient in the lithotomy posi-tion for the sphincter repair.

n3 Pass a urinary catheter. 253

Action

n1 Make an incision following the slight pigment change seenaround the anus. Centre it on the point of injury and extend itthrough 180 (Fig. 14.27).

n2 Dissect out into ischiorectal fat. This means that the anal sphinc-ter now lies between the depths of the wound and the anal canal(Fig. 14.28).

n3 For an anterior, usually obstetric, injury mobilize the anus fromthe vagina. It helps to place two fingers in the vagina and two Allisforceps on the anal margin of the wound. The plane lies fraction-ally posterior to any large veins (because these will be paravaginalveins) (Fig. 14.29).

n4 Split the muscle scar down its length and develop the plainbetween the anal mucosa and the muscle on either side.

n5 After sufficient mobilization you can achieve a muscle overlap ofabout 2 cm, extending the length of the anal canal. Suture with2/0 polydioxanone (PDS) (Fig. 14.30).

n6 When possible, close the wound. Otherwise leave it open to healby second intention (Fig. 14.31).

Postoperative

n1 The patient can eat and drink normally and does not need con-finement of the bowels.

SACRAL NERVE STIMULATION

Fig. 14.27 The incision should follow the slight pigment change seen

Fig. 14.29 Next, dissect close to the anal mucosa. This leaves a bulkof tissue between the lateral ischiorectal plane and the perianalplane that will contain the divided ends of internal and externalsphincter.

Fig. 14.30 After sufficient mobilization a muscle overlap of about2 cm can be achieved, extending the length of the anal canal. Suturewith 2/0 polydioxanone (PDS).

254

14 ANORECTUMaround the anus. It should be centred on the point of injury and willusually extend 180.Fig. 14.28 Dissect out laterally into ischiorectal fat. This means thatthe anal sphincter now lies between the depths of the wound and theanal canal.n1 This is performed in two stages: a temporary testing phase and apermanent implant for those patients who are found to gainbenefit during the testing phase.

responsive.

4n2 There is no need for any bowel preparation.n3 The patient is given a general anaesthetic without muscle relax-

ants and lies in the prone jack-knife position. The anus and thebig toes should be visible.

TEMPORARY TEST WIRE INSERTION

Action

n1 Mark out the bony landmarks for the position of the S3 foramina.They are typically 1 cm cephalad to the crest of the sacrum and1 cm lateral to the midline.

n2 Insert the 20 G, 3.5-inch (9-cm) spinal insulated needles(Medtronic 041828004) into S3 on either side, and findthe best response to stimulation using an external, hand-

Fig. 14.31 When possible, close the wound. It may help to close it inan inverted Y fashion allowing reconstruction of the perineal bodyand lengthening the distance between the posterior fourchette andthe anal canal. Otherwise leave it open to heal by second intention.held neuro-stimulator (Medtronic Model 3625 Screener).The current used for stimulation usually ranges from 0.5 to2 mA at a rate of 20 Hz and a pulse width of 200 seconds.

n3 Response to the stimulus is assessed clinically, looking for deep-ening and flattening of the buttock groove from lifting and drop-ping of the pelvic floor (known as a bellows action) and aflexion of the big toe.

n4 If the response if suboptimal it may be necessary to insert the nee-dles into S2 or S4. Stimulation at the level of S2 usually causes aclamp-like contraction of the anal sphincter with rotation ofthe leg, ankle flexion and calf contraction. S4 is associated witha bellows action and a pulling sensation on the perineum butnot with any toe movement.

n5 Using the foramen of maximal response, thread a temporary per-cutaneous stimulator test lead (Medtronic 3057) down throughthe needle and re-test the adequacy of the stimulation with theexternal stimulator and the wire. If a good response is stillobtained slide the needle out over the wire, being very carefulnot to dislodge the wire. Secure the wire.

Postoperative

n1 When the patient is awake and co-operative, attach the wire to theexternal stimulator (Medtronic Model 3625 Screener).

n5 Plan to use adequate antibiotic cover in the perioperative period.the size of the cuff to be implanted. All parts of the sphincter arecarefully primed with radio-opaque fluid, with the exclusion ofall air bubbles prior to implantation.

n3 A further bikini-line incision a few centimetres long is thenmade on the side chosen for implantation of the pump (this de-Action

n1 Make an incision similar to that for an anterior overlapping repairarcing around the front of the anus.

n2 A tunnel is then created around the outside of the anal sphinctersto accommodate the hydraulic cuff. Sizers can be used to assessARTIFICIAL BOWEL SPHINCTER(THE ACTICON)

The operation to implant the Acticon is relatively simple. However,infection is a major hazard and preoperative preparation should bemeticulous.

Prepare

n1 Order a full bowel preparation.n2 Irrigate the rectum and vagina with Betadine wash-outs.n3 Get the patient to shower in antiseptic.n4 Swab the patient for MRSA (methicillin-resistant Staphylococcus

aureus).Postoperative

The stimulator is externally programmed using telemetry. The currentrequired for stimulation is usually between 0.5 and 2 volts at a fre-quency of 15 pulses/second and a pulse width of 210 microseconds.n2 The stimulus employed for the 3-week temporary test phase isthat which is the maximum comfortably tolerated by the patient,and usually ranges between 0.5 and 3 mA at 15 pulses/secondwith a pulse width of 210 microseconds.

THE PERMANENT IMPLANT

The decision to proceed to permanent implantation is based on thepatient's and the doctor's subjective assessment of a significantimprovement and on a 50% quantitative improvement in episodesof faecal incontinence, either frequency or amount lost.

Action

n1 The initial steps taken to find the correct foramen during the testare repeated. The permanent electrode (Medtronic 3093) is theninserted instead of the wire and this self-secures with barbs. Thisis then tunnelled subcutaneously out to the permanent stimula-tor which is implanted in the buttock.

n2 The stimulator is left turned off until the patient is awake and

ANORECTUM 1pends on whether the patient is right- or left-handed).

n4 The connector tube from the cuff is tunnelled up to the abdom-inal incision; the pump and the preperitoneal reservoir are

255

implanted through the same incision. The pump sits in the labiamajorum in women and in the scrotum in men. All three majorcomponents are connected by fully implanted silicone tubing.

n5 The pump is squeezed to achieve cuff deflation via a temporarytransfer of fluid into the balloon. A push-button device on thepump locks the pump closed until healing has occurred at about6 weeks.

Postoperative

n1 Continence is restored by re-activating the pump with a sharpsqueeze in the clinic setting at about 6 weeks.

n2 Time must be spent with the patient to ensure his full under-standing of the pump mechanism or he may not be able to passstools on discharge.

FURTHER READING

Beck DE, Wexner SD. Fundamentals of Anorectal Surgery. 2nd ed.Philadelphia: Saunders; 1998.

Fielding LP, Goldberg SM. Rob and Smith's Operative Surgery. 5th ed.Oxford: Butterworth-Heinemann; 1993.

Goldberg SM, Gordon PH, Nivatvongs S. Essentials of Anorectal Surgery.Philadelphia: Lippincott; 1980.

Goligher JC. Surgery of the Anus, Rectum and Colon. 5th ed. London:Baillire Tindall; 1984.

Henry MM, SwashM. Coloproctology and the Pelvic Floor. 2nd ed. Oxford:Butterworth-Heinemann; 1992.

Keighley MRB, Williams NS. Surgery of the Anus, Rectum and Colon.2nd ed. London: Saunders; 1999.

Martin M-C, Givel J-C. Surgery of Anorectal Diseases. Berlin: Springer-Verlag; 1990.

Nicholls RJ, Dozois RR. Surgery of the Colon and Rectum. Edinburgh:Churchill Livingstone; 1997.

Phillips RKS. Colorectal Surgery: A Companion to Specialist SurgicalPractice. London: Saunders; 1998.

Sir Alan Parks Symposium Proceedings. Ann R Coll Surg Engl 1983;(Supplement).

Thomson JPS, Nicholls RJ, Williams CB. Colorectal Disease. London:Heinemann Medical Books; 1981.

Todd IP, Fielding LP. Rob and Smith's Operative Surgery: Alimentary Tractand Abdominal 3. Colon, rectum and anus. 4th ed. London:Butterworths; 1983.

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14 ANORECTUM

AnorectumINTRODUCTIONANATOMYSphinctersSpaces

HAEMORRHOIDSAppraiseINJECTION SCLEROTHERAPYAction

RUBBER-BAND LIGATIONActionAftercare

HAEMORRHOIDECTOMYAppraisePrepareAssessActionAftercare

OTHER PROCEDURESClosed haemorrhoidectomyStapled haemorrhoidectomyHALO procedure

FISSUREAppraiseLATERAL SPHINCTEROTOMYAppraiseActionAftercare

ANAL ABSCESS AND FISTULAAppraisePERIANAL ABSCESSINTERMUSCULAR ABSCESSSUPRALEVATOR ABSCESSISCHIORECTAL ABSCESSPostoperative

FISTULAAppraiseSUPERFICIAL FISTULAAssessAction

INTERSPHINCTERIC FISTULAAssessAction

TRANS-SPHINCTERIC FISTULAAssessAction

SUPRASPHINCTERIC FISTULAEXTRASPHINCTERIC FISTULAPostoperativeComplications

OTHER PROCEDURES

PILONIDAL DISEASEPrepareActionPostoperativeOTHER PROCEDURES

HIDRADENITIS SUPPURATIVAAppraiseAction

ANAL MANIFESTATIONS OF CROHN'S DISEASEAppraiseAction

CONDYLOMATA ACUMINATAAppraiseActionPostoperative

ANAL TUMOURSANAL MARGIN TUMOURSAppraise

ANAL CANAL TUMOURSAppraise

RECTAL ADENOMASAppraiseActionSUBMUCOSAL EXCISION OF SESSILE ADENOMAAppraisePrepareActionPostoperative

MODIFIED SOAVE OPERATIONOTHER PROCEDURES

RECTAL PROLAPSEAppraiseLAPAROSCOPIC ABDOMINAL RECTOPEXYPrepareActionPostoperativeComplications

MUCOSAL SLEEVE RESECTION (DELORME PROCEDURE)PrepareActionPostoperative

FAECAL INCONTINENCEAppraise

INJECTION OF BULKING AGENTSPrepareActionOVERLAPPING SPHINCTER REPAIRPrepareActionPostoperative

SACRAL NERVE STIMULATIONTEMPORARY TEST WIRE INSERTIONActionPostoperative

THE PERMANENT IMPLANTActionPostoperative

ARTIFICIAL BOWEL SPHINCTER (THE ACTICON)PrepareActionPostoperative

FURTHER READING