Transcript Stapled Hemorrhoidectomy

Proctology
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Hemorrhoids
Anal - Fissure
Fistula - Ani
Constipation (Obst. Defacation Syndroms)
Incontinence
Tumors (Benign & Malignant)
Infections (Viral, Bacterial, Fungi, Chemical,
Allergic, Others)
Yehiel Ziv, MD, Assaf-Harofe Med. Ctr.
Chairman, The Isreal Society of Colon & Rectal Surgeons
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Levator ani muscle
anal columns
Int. anal sphincter
Anal canal
Ext. anal sphincter
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rectum
Int. anal sphincter
deep part
superficial part
Levator ani muscle
Anal canal
subcutaneus part
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anal column
tributaries of superior rectal
vein
conjoint longitudinal
muscle
ANAL SINUS
anal valve
pecten
external anal sphincter
intermuscular groove
[white line of Hilton]
internal anal sphincetr
tributaries of inferior rectal vein
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Levator ani muscle
Ano-rectal line
anal gland
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levator ani muscle
external anal sphincer
ischioanal fossa
internal anal sphincter
conjoint longitudinal muscle
fibrous septum of ischioanal
fossa
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Hemorrhoids
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Hemorrhoids
• Normal components (sub-mucosal vascular
tissue) of human anatomy
• External (Inf. Hem. Plexus, Somatic Nerve)
• Internal (Sup. Hem. Plexus, Above DL, Senseless)
• Mixed
• 2 – Right Side, Anterior & Posterior
• 1 – Left Side
• M = F, Peak = 45-65y
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Hemorrhoids
• Pathogenesis :
- Increased age
- Ch. diarrhea or constipation
- Increased Intra - Abdominal Pressure
(prolonged sitting, pregnancy etc.)
• Hypothesis:
Hypertrophy or
Increased Muscle Tone
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Hemorrhoids
• Internal Hem. Classification
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1st deg
2nd deg
3rd deg
4th deg
: project into lumen & bleed.
: protrude – spont. reduction
: protrude – manual reduction
: irreducibly prolapsed.
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Hemorrhoids
• Diagnosis
• Medical History
• Physical Examination
Inspection
Digital Exam.
Rectoscopy
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Hemorrhoids
• Symptoms :
– Ext, Hem.
• Pain, bleed, swelling
– Int, Hem.
• Bleed, swelling, soilage, itching,
pain, discharge, protrusion.
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Hemorrhoids
• Medical Treatment :
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Sitz baths,
Diet,
Hygiene,
Stool modifiers,
Topical creams, Suppositories.
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Hemorrhoids
• Minimally Invasive Treatment :
• Int, Hemorrhoids (Grade 2-3)
• RBL
• IRC
• Sclerotherapy
• Cryo
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Hemorrhoids
• Surgical Treatment :
• Ext, Hem.
• Thrombectomy (Emergency)
• Excision
(Failed Med. Treat.)
• Int, Hem.
• Excision or Resection with Anopexy or DHL
(Failed Med. or Invasive Treat. 4th degree,
Association with other anal disease)
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Hemorrhoids
Surgical Treatment :
• Anal Dilatation (rarely used)
• Excision:
- Open (Milligen-Morgan)
- Closed (Fergusson)
- Semiclosed
• Resection with Anopexy (Longo Proc.)
• Trans Anal Ligation of Hem. Arteries
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Hemorrhoids
• Surgical Options :
• Scissors & Scalp
• Ligasure
• Harmonic Scalpel
• Laser
• Stapler
• DHL
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Hemorrhoids
• Surgical Treatment :
• Complications :
– Incontinence, Stenosis,
– Bleeding, Urinary Retention
– Infection (absc., fistula) > Sepsis
– Persistent Hemorrhoids
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Hemorrhoids
• Incarcerated Hemorrhoids
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Treat Medically !!!
(Rest, Magnesium Sulphate 30%,
Suppsitories, Stool-softeners)
Avoids
Complications Rate
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Hemorrhoids
Hemorrhoids in Pregnancy
• Treat Medically or Minimally Invasive
• Failure
Surgery
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Anal Fissure
• Vertical tear in squamous epihelial
lining of the anal canal between the
anal verge and the dentate line
• Location :
Post – 85%, Ant - 10%, Lat – 5%
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Anal Fissure
• Acute
– No secondary changes
• Chronic
– > 30d
– Symptoms > 50%
– Secondary changes
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Anal Fissure
• Secondary changes:
– Sentinel tag (sometimes w fistula)
– Hypertrophied anal papilla
– Indurated edges
– Exposed Int. Sphincter fibers
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Anal Fissure
• Etioligy :
- Trauma
- Spec. underlying Disease :
Chlamidia, Gonorrhea, Herpes,
Syphillis, Aids, TB, Neoplasia,
Crohn, Ulcerative Colitis.
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Anal Fissure
• Pathogenesis :
- Repeated trauma
- Raised Mean Rest. Pressure
- Spasm, ischemia
“Stress fractures of the anal canal“
- Underlying disease
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Anal Fissure
• Symptoms :
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Pain, bleeding, discharge,
swelling, itching.
Diagnosis :
- Inspection, palpation
- Anoscopy/rectoscopy (not recom.)
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Anal Fissure
• Treatment
• Acute AF
– Medical : Diet, Bulk laxatives,
Sitz baths, Topical creams.
• Chronic AF
– Medical, Surgery
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Anal Fissure
• Medical Treat. of Chronic AF
- Diet, Bulk lax., Sitz baths, Creams.
“Chemical” Sphincterotomy
- NTG, ISDN - NO transmitor
- Nifedipine
- Ca Channel Blocker
- Botolinum A - ACE Inhibitor
- Alpha-1 adrenoceptor blockade
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Anal Fissure
• Surgical Treat. of Ch AF
- Open / Closed LIS
- Anal Dilatation (only in special cases)
- Fissurectomy
- Advancement Flap (from inside or outside)
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Anal Fissure
• Surgical Treat. of Recurrent Ch AF
- Open / Closed LIS (other side, after TRUS)
- Anal Dilatation (only in special cases)
- Fissurectomy
- Advancement Flap (from inside or outside)
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Anal Fissure
• Complications
– Incontinence
Conservative, Surgery
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Dilatation, Surgery
Stenosis
Hemorrhage
Infection,
Urin. Reten.
Hemostasis
Ab, Drainage
Cateterization
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Anal Fistula
Pathogenesis :
• Infected Anal Glands
(open to Dentate Line)
• Ductal Obstruction lead to ;
Stasis, Infection, Abscess.
50% develop Fistula
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Anal Fistula
Signs & Symptoms :
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Pain, Pruritus, Bleeding, Discharge.
Pressure (evacution, cough, sitting)
Swelling
Fever
Ano-rectal Pain & High Temp.
= Abscess, until proven otherwise !
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Anal Fistula
Diagnosis:
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History & Physical Examination
Digital Examination
Ano/Rectoscopy
EUA
Fistulography
TRUS
CT-Fistulography
MRI (Ext., Coil)
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Anal Fistula
• Park’s Classification:
– Trans - Sphincteric
– Inter - Sphincteric
– Supra - Sphincteric
– Extra - Sphincteric
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Anal Fistula
• Other Classification:
– Simple Vs Compound (horseshoe)
– Low, Middle, High (Anal Canal)
– Small, Large (Int. opening)
• Special Fistulas
Recto - Vaginal Fistula,
Associated with Underlying Disease
(TB, IBD, Irradiation, Infections)
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Anal Fistula
• Asymptomatic Fistulas
Require No Therapy !!!
• Medical Treatment May Cure
Simple Mild Symptomatic Fistulas
(sitz-baths, antibiotics)
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Anal Fistula
• Surgical Treatment :
Fistulotomy or Fistulectomy
Fibrin Glue
Anal Plage
Seton Placement (Loose, Tight)
RAF (Mucosal or Full Thickness)
Colostomy
Anterior resection
Patches (Omentum, Muscles)
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‫‪ODS‬‬
‫‪Obstructive Defacation Syndroms‬‬
‫מצב שבו החולה אינו מסוגל להתרוקן באופן רגיל ונאלץ‬
‫להשתמש במשלשלים‪ ,‬חוקנים או אמצעים אחרים‪.‬‬
‫– כאבים בזמן יציאה‬
‫– צורך במאמץ חריג על מנת להתרוקן‬
‫– ישיבה ממושכת בשירותים‬
‫– מרווחים ארוכים בין היציאות ‪ 5-10‬ימים‬
‫– אי נוחות באזור חייץ הנקבים בזמן עמידה‬
‫– תחושה מתמדת של חוסר התרוקנות = ‪Tenesmus‬‬
‫= ‪Incomplete Evac‬‬
‫– התרוקנות לא רציפה‬
‫= ‪Incontinence‬‬
‫– הפרעות בשליטה‬
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‫אבחנה של ‪ODS‬‬
‫הופעה קבועה ביותר מרבע היציאות ב‪ 12-‬השבועות האחרונים‬
‫של‪:‬‬
‫– מאמץ מוגבר ביותר ביציאה‬
‫– צואה קשה וגושית‬
‫– הרגשה של חוסר התרוקנות‬
‫– הרגשה של הפרעה או חסימה ביציאה‬
‫– שימוש ביד לצורך יציאה‪ -‬לחץ וגינאלי‪ ,‬רקטלי‪ ,‬לחץ על‬
‫חיץ הנקבים‬
‫– פחות משלוש יציאות לשבוע‬
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‫הברור הקליני‬
‫לפני הניתוח על החולה לעבור סדרה של בדיקות אשר‬
‫יגדירו האם הוא מתאים ליפול שמרני או ניתוח‬
‫• דפקוגרפיה‬
‫• מנומטריה‬
‫• בדיקת ‪ EMG‬אלקטרומיוגרפיה‬
‫• בדיקת זמן מעבר ‪TTI‬‬
‫• בדיקת ‪TRUS‬‬
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ODS ‫גורמים ל‬
Rectocele
Enterocele
Intussusceptions (rectal
invagination)
Genital Prolapse
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Thank You !
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