fistula in ano and tem痔疮肛门和tem瘘课件

Hemorrhoidectomy FistulainanoandTEM WendieGrunberg 3Loopsofexternalsphincter Subcutaneous C superficial B deep A BloodSupply Therectumandanalcanalaresuppliedbythesuperiorrectalartery thecontinuationoftheinferiormesentericartery withassistancefromthemiddleandinferiorrectalarteries andbythemediansacralartery Thesubmucosalvenousplexusabovethepectinatelinedrainsintothesuperiorrectalveins portalsystem whichmaybecomevaricose resultingininternalhemorrhoidsor piles Thesubmucosalplexusbelowthepectinatelinedrainsintotheinferiorrectalveins whichmaybecomevaricose resultinginexternalhemorrhoidsorpiles Theunionsofthesuperiorwiththemiddleandinferiorrectalveinsareimportantportal systemicanastomoses Innervation Parasympatheticfiberssupplythesmoothmuscle includingtheinternalsphincter Sympatheticfibersaremainlyvasomotor Somaticmotorfiberssupplytheexternalsphincter Sensoryfibersareconcernedwiththereflexcontrolofthesphinctersandwithpain Theanalcanalisverysensitivebelowthepectinateline sothatexternalhemorrhoidsmaybeverypainful Hemrroidectomy Injection Indications Theinjectionofhemorrhoidsisapalliativeprocedure Thepatientisambulatory Itmaybeusedforthebleedinginternalhemorrhoidthatdoesnotprolapse ItisnotapplicabletoexternalhemorrhoidsContraindications reactiveinflammationorthrombosis acutefissure fistulaorperianalabscess severecryptitisorpapillitis andanadvanceddegreeofprolapse Injection Acompletestudyofthecolonandrectumtoruleoutpolypsoramalignancymustbeperformedbeforeinjection Theanorectalareaisbestexaminedwithananoscopewhiletheremainderofthecolonrequireseithercolonoscopyorsigmoidoscopyplusbariumenema Injection PreoperativepreparationsNopreoperativepreparationisnecessaryotherthanadisposablecommercialenemaself administeredbythepatient Injection Procedure Ananoscopeisinserted Thesclerosingsolutionisinjectedabovethehemorrhoidabout3mmbelowthemucosaSlightdistentionofthemucosawillresult butitshouldnotblanch Oneto2mLofsolutionisusuallysufficientforonehemorrhoid Nomorethanthreesitesareinjectedatasingleoperation Injection PostOpcare Stoolsoftenersandsitzbathsarerecommended Ifthepatientcomplainsofpainordiscomfort heorsheistoldtoreturnpromptlyforexaminationtoruleoutpotentiallyseriousinfection Injectionsareusuallyrepeatedatintervalsofaboutaweekuntilallsitesareinjected Keepingachartoftheexactsiteofeachinjectionensuresthatallquadrantsreceiveoneinjection IncisionandRubber BandingofHemorrhoids Indications performedingood riskpatientswithpersistentsymptoms Bleeding protrusion pain pruritus andinfectionarethemorecommonindicationswhenpalliativemedicalmeasureshavefailed Thepresenceofaserioussystemicdisease suchascirrhosisoftheliver oraprobableshortlifeexpectancyfromadvancedageoranyothercauseshouldbeageneralcontraindicationtooperationunlessanalsymptomsaremarked Rubberband Simpleinternalhemorrhoidsthatprolapsemaybetreatedbyrubber bandingAfterinsertionofananoscope theinternalhemorrhoidisgraspedwithanAllis likeclampinsertedthroughthebandinginstrument whichhasbeenpreloadedwithtworubberbands Theareaispinchedtobesureitispain free Astheforcepsorsuctiondrawsthehemorrhoidintotheinstrument itisfired Theconstrictingrubberbandsstrangulatethehemorrhoidandbotharethensilentlypassedafewdayslater Positioning Thepositioningofthepatientdependsonthetypeofanesthesiaused Withspinalanesthesia thepronejackknifepositionaffordsthesurgeonthebestexposure Ifgeneralanesthesiaisused anexaggerateddorsallithotomypositionispreferred withthebuttocksextendingbeyondtheedgeofthetableandthelegsheldinstirrups Procedure Incision Theanalcanalmaybegentlydilatedtoabouttwofingers widthtopermitadequateexposure Asuitableself retainingretractorisinsertedintothecanal andfurtherinspectionismade Agauzespongeisintroducedintotherectum andtheretractoriswithdrawn Thesurgeonmakesgentletractiononthesponge reproducing ineffect thepassageofabolusthroughthecanal Asthespongeiswithdrawn theprolapsinghemorrhoidsmaybeidentifiedandarepickedupwithhemorrhoidclamps Clampsareplacedonalltheprolapsinghemorrhoidsandleftinplaceasmarkersduringtheoperation Procedure Incision AtriangularincisionismadefromtheanalvergetothepectinatelineBytractiononthetwoclampsandcarefulbluntandsharpdissectionwiththescalpel itispossibletodissectoffthetriangularareaofskinandthehemorrhoidaltissuefromtheouteredgeoftheexternalsphinctermuscle Manysmallfibrousbandswillbefoundrunningupwardintothehemorrhoidalmass Theserepresentthecontinuationdownwardofthelongitudinalmuscleandmaybedivided Dissectioniscarriedtotheouteredgeoftheexternalsphincter Theanalskinmustbedividedtoandslightlybeyondthepectinateline Therenowremainmucosaandthedeepveinsenteringthehemorrhoidalmass Thetissueissecuredwithastraightclampandatransfixingsutureisplacedattheapexofthehemorrhoidalmass Thehemorrhoidaltissueisremovedwithaknife andanover and overcontinuoussutureismadeinthemucosa Theclampisremovedandacontinuoussutureapproximatesthemucosa includingthetwoedgesofthepectinateline Asthesutureiscontinuedexternally smallbitesaretakenintheexternalsphinctermuscleThedeepportionoftheskinisclosedbyasubcutaneousapproximationandtheskinedgesareleftopentoprovideforbetterdrainageandpreventpostoperativeedema Allpossiblemucosaltissuemustbepreservedtopreventstenosis However relativelylargeareasofskinmaybesafelyremovedinthetriangularincision Withextensivehemorrhoidsitmaybenecessarytoexciseone halfofthemucosaoftheentirecanalinthisfashion Thetriangularincisionmayextendfromtheanalvergeandreachthepectinateanteriorlyandposteriorly Themucosaisdividedhorizontally takingsmallbitesoftissueinaseriesofhemostatsThismucosalflapissuturedintotheexternalsphincterhorizontallytopreventstenosisAllredundantincisionalskinmarginsshouldbeexcisedtominimizethesubsequentdevelopmentofpotentiallydamagingperianalskintabs PostOpcare Asterileprotectivedressingisappliedtotheanus Petrolatummaybeappliedlocally Thepatientisencouragedtohaveabowelmovementandusuallywilldosobythethirdday Localapplicationofheatisusefulinalleviatingdiscomfort Thepatientmaytakesitzbathsasdesired Weeklyanaldilatationmaybeneededpostoperativelyuntilhealingiscomplete TreatmentofThrombosedHemorrhoids Thrombosedexternalhemorrhoidsmayberemovedinthepatientwhoisambulatory Theanusiscleansed andlocalanesthesiaisadministeredbyinjectionoverthesurfaceandjustbeneaththethrombosedhemorrhoids Anellipticalincisionismadeoverthethrombosedarea andtheclotisremovedbyfingercompressionorbyintroductionofasmallcuretteThisexcisionleavesnoredundantscartissue andfinalhealingoccurswithouttabformation Gentledissectionoftheclotcausesnobleedingitshouldnotbenecessarytosuturethewound Rarely asutureoffineabsorbablesuturemaybenecessary Thepatientmayreturnhomeimmediately DrainageofIschiorectalAbscess IndicationsIschiorectalabscessesaredrainedimmediately Carefulpalpationoftenshowsevidenceoffluctuationnotseenintheperianaltissue Operationisnotdelayeduntilfluctuationisobvious becauseaperirectalabscessmayrupturethroughthelevatormuscleintotheretroperitonealtissue AnesthesiaGeneralanesthesiawithendotrachealintubationmaybeused however regionalanesthesia eitherspinalorepidural issatisfactory PositionThelithotomypositionispreferredfordrainage IncisionandExposure Thecommonlocationsofischiorectalabscesses Abscessesmaybelocatedextraperitoneallyabovethelevatoranimuscle Carefulrectalandsigmoidoscopicexaminationshouldbeperformedtodetectassociatedpathologicprocessesafterthepatienthasbeenanesthetized Anincisionismadeatthemaximumpointoftendernessandplacedeitherparallelorradialtotheanus Iftheabscessliesabovethelevator theincisionisdeepenedradiallytoavoidnervesandbloodvessels Procedure Afterincisionanddrainage thecavityisexploredwiththeindexfingertoensurecompletedrainageandtoascertainthatnoforeignbodyisintheischiorectalspace Aspecimenofthedrainingmaterialisobtainedforbacteriologicstudies Usually thereisnocommunicationwiththerectum Iftheabscessissmall andaclearcommunicationwiththerectumisidentified thetractmaybeexcised Theouteropeningmustbesufficientlylarge forthecommonerroristodrainalargecavitythroughacomparativelysmallincision resultinginthedevelopmentofachronicabscess Closure cavityispackedPostoperativeCareMoistcompressesandsitzbathsreduceinflammationandpromoterapidhealing Postoperativedressingstoassurehealingfromthebottomareasimportantastheoperation Anischiorectalabscessispronetoresultinananalfistula however inabouthalfofthecases therewillbeprimaryhealingwithproperpostoperativecare FistulainAno IndicationsThemajorityofanalfistulaeresultfrominfectionarisinginacrypt extendingintotheperianalmusculature andthenrupturingeitherintotheischiorectalfossaorsuperficialperirectaltissues Operativeobliterationofthefistulaisalwaysindicatedifthepatient sgeneralconditionisgood Fistula Anatomicconsiderations Theexternalsphinctermusclecanbedividedintothreeportions thesubcutaneous superficial anddeepportions ThesubcutaneousportionliesjustbeneaththeskinandbelowtheloweredgeoftheinternalsphincterThesuperficialanddeepportionssurroundthedeeperpartoftheinternalsphincterandcontinueupwardtojoinwiththelevatormuscleThelevatoranisurroundstheanalcanallaterallyandposteriorly butitisabsentanteriorlyThelongitudinalmuscleoftheanusisthecontinuationdownwardofthelongitudinalmuscleofthelargebowelTheinternalsphinctermuscleisabulbousthickeningofthecircularmusclecoatofthelargebowel Anatomy Incontinencewillnotoccurifanyportionoftheexternalsphincterorlevatormuscleremainsintact AnanteriorfistulainvolvingonlythesubcutaneousandsuperficialportionsoftheexternalsphinctermaybeexcisedinoneoperationAnanteriorfistulainvolvingtheentireexternalsphinctercannotbeexcisedinoneoperationwithoutproducingtotalincontinence Posteriorly ifthelevatoranimuscleisleftintact afistulacanbecompletelyexcisedwithfarlessdangeroftotalincontinence MostfistulaeariseintheanalglandsatthebaseofthecryptsofMorgagni therefore theabscessusuallylieswithinthesubstanceoftheinternalsphincterItextravasatesthroughthemuscle tendingtofollowthetissueplanescreatedbythefibromuscularseptaofthelongitudinalmuscle Fistulaerarelyarisefromperforationsoftheanalcanalassociatedwithforeignbodiesorabscesses asintuberculosisorulcerativecolitis TheinternalopeningmaybeabovethepectinatelineandmaytraversetheentiresphincterorportionsofthelevatorItmaybenecessarytooperateinstagesortousethesetontechniquetoavoidincontinence Simpleanalfistulaefollowadirectrouteintheanus Complicatedfistulaefollowamoredeviousroute oftenhorseshoeinshapeandwithnumerousopenings Mostcomplicatedfistuloustractsopenintotheposteriorhalfoftheanus Shouldthefistulahavemultiplesinuses themainexitwillusuallybeposterior eventhoughoneopeningisanteriortothelineasinglefistulousopeninganteriortoX Xusuallyextendsdirectlyintotheanteriorhalfoftheanus Goodsall srule Goodsall sRule Fistulotomy lay opentechnique forverysuperficialfistulawithminimalresultingdamagetosphinctermuscle Alternatively placementofsetonsintotheexistingfistulatractstoallowforadequatedrainageofactivesuppurations Twodifferenttypesofsetons Cuttingseton placedaroundsphincterportioninvolvedinatranssphinctericfistulawithintenttohavethesetonslowlyerodethroughthatsphincterportion Drainingseton single multiple short term long term placedintoexistingfistulatractsolelytoavoidfuturepusaccumulationandallowtracttoclosedownontoseton Adrainingsetonmayalsobeplacedinpreparationforfuturefistulaprocedures eg collagenplugplacement CuttingSeton Procedure 1 Patientpositioning pronejackknifeposition 2 Forelectivecases pudendal perianalnerveblockwith15 20ccoflocalanestheticinadditiontogeneralanesthesiatoimproverelaxationoftheanalsphinctermuscles 3 Insertionofanalretractorandcircumferentialexaminationofdentateline identificationofprimaryopening Ifnotvisible testingwithinjectionofperoxideintosecondaryopening avoidoverflowspill appearanceofbubblingataprimaryopening 4 Carefulprobingoffistulatractwithcurvedsilverprobetakingcaretoavoidcreatingnewtractbyforcefuladvancement Ifinsertionisnoteasy placementofKocherclamptoexternalopeningandcentrifugaltraction ie awayfromanus tostraightenfistulatractwhiletryingtoinsertprobeagain Ifstillnosuccess partialexternalfistulotomytoreassesscoursevsfistuloscopy usingureteroscope Ifprimaryopeningcannotbefounddespiteallattempts removalorwidedrainageofsinus butunfortunatelyhighchanceoffailureandreopeningofafistulalater 5 Fistulatractsuccessfullyprobedassessmentoftheextentofsphincterinvolvement a Fistulotomy verysuperficialtractwithoutrelevantsphincterinvolvement 20 fistulotomyfromsecondarytoprimaryopeningalongtheprobe eg withelectrocautery b Cuttingseton 20 sphincterinvolvedcuttingseton devisionofmucocutaneouslayerbetweentwoopeningswithoutcuttingthroughmuscle caveat nocuttingsetonoverintactskin pullinginasuturetiedtoedgeofgauze scrubbingoutfistulatract withgauzeorbrush pullinginseton eg anelasticvesselloop whichistieddownwiththreesuturessuchthatitjustsitsonthemusclewithoutstrangulatingit c Drainingseton 20 sphincterinvolvedbutsetonplacementonlytocooloffsuppuration preventrecurrentabscesses eg long termsetonsinCrohndisease ormaturefistulawithoutimmediateplantoeliminatefistula but eg laterfistulasurgerywithcollagenplug setonpulledintotractandtiedtoitselfwithoutdivisionofmucocutaneouslayerbetweenprimaryandsecondaryopening AftercareOpenwoundcareuntilcompletehealing fistulotomy skinclosureexceptforseton cutting drainingseton sitzbathsorshowerstwiceperday afterbowelmovements Cuttingseton tighteningofcuttingsetoninmonthlyintervalsuntilithaserodedthroughtheinvolvedsphinctercomplex leavingascarbehind Fistula in Ano EndorectalAdvancementFlap Closureoftheprimaryfistulaopeningbymeansofaplicationofthemusclelayerandanoverlyingadvancementflaptocoverthesiteoftheopeningtoinduceanobliterationofthefistulatractonceitisnotfedanymore Flap 1 Patientpositioning pronejackknifeposition 2 Forelectivecases pudendal perianalnerveblockwith15 20ccofalocalanestheticinadditiontogeneralanesthesiatoimproverelaxationofanalsphinctermuscles 3 Insertionofanalretractorandidentificationofprimaryopening 4 Carefulprobingoffistulatractwithsilverprobe 5 Insertionofanalretractorandreassessmentofthefistula Dependingonlocalanatomy placementofLoneStarretractormayproveadvantageous Flap 6 Limitedexcisionofprimaryopening removalofepithelializedtractwithinmusclelayer widening excisionofsecondaryopening 7 ClosureofmusculardefectwithinterruptedVicrylsutures 8 MarkingofU shapedbroad basedflap basestartingdistaltoprimaryfistulaopening extendinglaterallyandproximally onequartertoone thirdofanteriorcircumference Atraumaticraisingofflap afteradequatemobilization flapshouldcoverdefectwithoutanytension Carefulhemostasis avoidtractionordiffusecauterydamagetoflap 9 Suturingflapinplaceintwolayers deepermuscularlayer Vicryl maturationofmucosalanastomosiswithinterruptedsutures egchromic TransanalEndoscopicMicrosurgery TransanalEndoscopicMicrosurgery Combinationoftechniquesusedforconventionaltransanalexcisionwithlaparoscopictechnologyandinstrumentation endorectalsystemtocreatepneumorectumforoptimalexposureandendoscopicmagnificationforexcellentvisualizationIndicationsandcontraindicationsarethesameasforconventionaltransanalexcision exceptthathigherlesionsupto12 14cmcanbetargeted Verylowlesionsarenotamenableandarebettertreatedwithaconventionaltransanalexcision TEM Indications Polyporotherpathology eg ulcer between3and12 14 cm Noabsolutesizelimit lessthanhemicircumference aslongastissueadequate eg sufficientlypliablefordefectclosure RectalcancerT1N0lesion invadessubmucosa 4cmlargestdiameter lessthanone thirdofcircumference WellormoderatelydifferentiatedhistologyNoevidenceofpoorprognosticindicators eg lymphatic vascularinvasion havingsignificantcomorbiditiesorextensivemetastasisbutlocallyhighlysymptomatic TEM Preparation Fullcolonicevaluationandhistologicdocumentation Rigidsigmoidoscopy determinationoflevelaboveanalvergeandexactlocationoncircumferenceareveryimportantforcorrectpatientpositioningStaging ERUS Bowelcleansing fullbowelcleansing Prophylacticantibiotics TEM Procedure 1 Patientpositioning thelesionhastobedown ie posteriorlesionlithotomy leftlesionleftlateral rightlesionrightlateral anteriorlesionpronejackknifepositionwithlegsspreadapart foraccess