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CHAPTER 65 • Miles Abdominoperineal Resection with Total Mesorectal Excision 757

Closing levator ani muscle with

running sutures

Drains in place

FIGURE 65 –11

FIGURE 65 –12

Omentum

FIGURE 65 –13

758 Section IX • Colon

STEP 4: POSTOPERATIVE CARE

◆ Clear liquids are started on postoperative day 1, and diet is advanced as tolerated.

◆ Postoperative antibiotics are not necessary.

◆ A urinary catheter is left in place for 3 to 5 days to decrease the risk of urinary retention

after pelvic dissection.

STEP 5: PEARLS AND PITFALLS

◆ Obstructing rectal cancer may require a two-stage operation: a diverting descending colos-

tomy, preoperative chemoradiation treatment, and a Miles abdominoperineal resection.

◆ Large anal or distal rectal lesions will require wider perineal resection and may require a

rectus abdominis myocutaneous ﬂ ap to close the perineal wound. Patients who received

preoperative chemoradiation treatment should also be considered for perineal reconstruc-

tion with a myocutaneous ﬂ ap. Alternatively, the perineal defect can be left open and cov-

ered with a wound V.A.C. to allow healing by secondary intention.

SELECTED REFERENCES

1. Havenga K, Grossmann I, DeRuiter M, Wiggers T: Deﬁ nition of total mesorectal excision, including the

perineal phase: Technical considerations. Dig Dis 2007;25:44-50.

2. Fry RD, Mahmoud N, Maron D, et al: Colon and rectum. In Townsend CM (ed): Sabiston Textbook of

Surgery, 18th ed. Philadelphia, Elsevier Saunders, 2008, pp 1348-1432.

760

STEP 1: SURGICAL ANATOMY

◆ Internal hemorrhoids arise proximal to the pectinate line and are insensate. These can be

banded. External hemorrhoids arise distal to the pectinate line and are sensitive to touch.

These are best treated with excision (Figure 66-1).

◆ Indications are as follows:

◆ Rectal bleeding attributed to the hemorrhoid

◆ Persistent anal pain and pruritus

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ A cleansing enema and oral mineral oil should be given several hours before the procedure.

◆ Ensure any bleeding tendencies are corrected.

◆ Anesthesia: spinal or general

◆ Position: prone; jackknife

◆ Operative preparation includes the following:

◆ Before the hemorrhoidectomy, proctoscopy is advisable to exclude any rectal disease.

◆ Ensure that genitals are not compressed by prone positioning.

◆ Place a Foley catheter in the midgut.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Adherent tape is placed along the medial aspect of the buttocks then retracted laterally.

CHAPTER

Hemorrhoidectomy

Dennis C. Gore

CHAPTER 66 • Hemorrhoidectomy 761

2. DISSECTION

◆ Place anal retractor opposite the hemorrhoid.

◆ Grasp hemorrhoid with Babcock clamp and retract.

◆ Place 2-0 Vicryl suture at the internal base of the hemorrhoid and ligate, thereby occluding

venous backﬂ ow; leave a long segment of suture (Figure 66-2).

Internal hemorrhoid

External anal

sphincter muscle

Pectinate line

External hemorrhoid

FIGURE 66–1

762 Section X • Rectum

◆ Use scalpel, Metzenbaum scissors, or electrocautery to excise the hemorrhoid, starting just

external to the suture ligature (Figure 66-3).

◆ Use electrocautery or 4-0 Vicryl sutures to obtain hemostasis.

Hemorrhoid

Pedicle ligated, then

hemorrhoid excised

Mike de la Flor

FIGURE 66–2

FIGURE 66–3

CHAPTER 66 • Hemorrhoidectomy 763

3. CLOSING

◆ With the remaining 2-0 Vicryl suture, reapproximate the wound edges in a running fashion,

thus closing the hemorrhoidectomy wound. A running, locking suture can be used if

needed for improved hemostasis (Figures 66-4 and 66-5).

External anal sphincter muscle

FIGURE 66–4

FIGURE 66–5

764 Section X • Rectum

STEP 4: POSTOPERATIVE CARE

◆ Sitz baths

◆ Repeat oral mineral oil

STEP 5: PEARLS AND PITFALLS

◆ Excise no more than three hemorrhoids at one operative setting. Removal of excessive anal

tissue may lead to stricture.

◆ Ensure in cases of rectal bleeding that other sources of gastrointestinal bleeding, such as

colon cancer and diverticular disease, are excluded before the hemorrhoidectomy.

◆ Hepatic cirrhosis and other bleeding disorders should be addressed and thoroughly

corrected, or the planned procedure should be aborted.

SELECTED REFERENCE

1. Zollinger R Jr, Zollinger R: Atlas of Surgical Operations, 5th ed. New York, Macmillan, 1983, p 416.

765

STEP 1: SURGICAL ANATOMY

◆ See previous chapters for anatomy of the anus.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indication: abscesses requiring emergent drainage

◆ Position: prone, jackknife

◆ Anesthesia: spinal or general

◆ Operative preparation includes the following:

◆ Administer antibiotics before procedure.

◆ Ensure that genitals are not compressed by prone positioning.

◆ Proctoscopy is advisable to exclude any rectal disease such as Crohn’s disease.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Adherent tape is placed along the medial buttocks then retracted laterally.

CHAPTER

Drainage of Perirectal Abscess

Dennis C. Gore

766 Section X • Rectum

◆ Use scalpel or electrocautery to incise over the most prominent point of the abscess

(Figure 67-1).

2. DISSECTION

◆ Using manual inspection, ensure the abscess is completely drained.

◆ Irrigate abscess cavity copiously.

◆ Use electrocautery judiciously to ensure hemostasis.

◆ If hemostasis remains a concern, then the abscess cavity can be packed with moist gauze.

Abscess lanced

FIGURE 67 –1

CHAPTER 67 • Drainage of Perirectal Abscess 767

3. CLOSING

◆ None

STEP 4: POSTOPERATIVE CARE

◆ Mineral oil is given orally when feasible.

◆ Sitz bath

STEP 5: PEARLS AND PITFALLS

◆ Many abscesses are associated with anal ﬁ stulae. Fistulotomy may reduce abscess recurrence.

SELECTED REFERENCES

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations. New York, Macmillan, 1983, p 418.

2. Schwartz SI, Shires GT, Spencer FC, et al: Principles of Surgery, 5th ed. New York, McGraw-Hill, 1989,

p 1305.