Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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768

STEP 1: SURGICAL ANATOMY

◆ See previous chapters for anatomy of the anus.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indication: anal ﬁ ssure

◆ Preoperative planning: a cleansing enema and oral mineral oil should be given several hours

before procedure.

◆ Position: prone, jackknife

◆ Anesthesia: spinal or general

◆ Operative preparation includes the following:

◆ Administer antibiotics before procedure.

◆ Proctoscopy is advisable to exclude any rectal disease.

◆ Ensure that genitals are not compressed by prone positioning.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Use two strips of strong adhesive tape placed 8 to 10 cm from midline, then retracted later-

ally and down and secured to the lower operating table. This tape placement allows retrac-

tion of the buttocks laterally.

CHAPTER

Lateral Sphincterotomy

Dennis C. Gore

CHAPTER 68 • Lateral Sphincterotomy 769

2. DISSECTION

◆ Place anal retractor to expose lateral wall of anus (Figure 68-1).

◆ Use scalpel or electrocautery to make a small incision from just distal to the anal verge

laterally (Figure 68-2).

Fissure

FIGURE 68 –1

Incision distal to anal verge

FIGURE 68 –2

770 Section X • Rectum

◆ Insert either scalpel or electrocautery through incision and cut the external sphincter longi-

tudinally (Figure 68-3).

Longitudinal incision through

external sphincter

FIGURE 68 –3

CHAPTER 68 • Lateral Sphincterotomy 771

3. CLOSING

◆ 3-0 Vicryl interrupted suture (optional)

STEP 4: POSTOPERATIVE CARE

◆ Sitz bath

◆ Stool softeners

STEP 5: PEARLS AND PITFALLS

◆ Consider biopsy of ﬁ ssure to exclude cancer or inﬂ ammatory bowel etiologies, especially if

ﬁ ssure is in a position other than posterior midline or if the patient is elderly.

SELECTED REFERENCE

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

1989, p 1303.

772

STEP 1: SURGICAL ANATOMY

◆ Figure 69-1 shows the posterior lower back with pilonidal cyst.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indication: pilonidal cyst

◆ Anesthesia: general, spinal, or extensive local

◆ Position: prone, jackknife

◆ Operative planning: Ensure genitals are not compressed by prone positioning.

CHAPTER

Pilonidal Cyst Curettage

Dennis C. Gore

Pilonidal cyst

Sinus tract

FIGURE 69 –1

CHAPTER 69 • Pilonidal Cyst Curettage 773

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Use two strips of strong adhesive tape placed 8 to 10 cm from midline retracted laterally,

then down and secured to the lower operating table. This tape placement allows retraction

of the buttocks laterally.

2. DISSECTION

◆ Place probe into the pilonidal opening and advance into sinus tracts (Figure 69-2).

◆ With probe in place, use electrocautery to incise open sinus tracts (Figure 69-3).

Probe

Electrocautery

FIGURE 69 –2

FIGURE 69 –3

774 Section X • Rectum

◆ Use electrocautery or curettage to cauterize and remove inﬂ ammatory tissue and any foreign

materials (usually hair) all along the pilonidal cyst and the accompanying sinus tracts

(Figure 69-4).

FIGURE 69 –4

CHAPTER 69 • Pilonidal Cyst Curettage 775

3. CLOSING

◆ None

STEP 4: POSTOPERATIVE CARE

◆ Wound dressing with moist gauze

STEP 5: PEARLS AND PITFALLS

◆ Pilonidal sinus tracts may extend into surrounding spaces at multiple ﬁ nger-like projections.

◆ Search diligently for all tracts.

SELECTED REFERENCE

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations, 5th ed. New York, Macmillan, 1983, p 422.

776

STEP 1: SURGICAL ANATOMY

See Figure 70-1.

◆ Indication: anal ﬁ stula

◆ Anus

◆ Most anal ﬁ stulas originate from the crypts of Morgagni and extend with varying depth

to the perianal opening.

◆ Goodsall’s rule describes the relationship of the external opening to the internal origin of

the ﬁ stula.

◆ If the external opening is anterior and 3 cm or less from the anus, then the ﬁ stula tract

courses directly toward the anus (see Figure 70-1).

◆ If the external opening is anterior and 3 cm or more from the anus, then the ﬁ stula

tract may curve to enter at the posterior midline.

◆ If the external opening is posterior to the anus, then the ﬁ stula tract will curve to enter

at the posterior midline.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Preoperative planning: A cleansing enema and oral mineral oil should be given several

hours before the procedure.

◆ Position: prone, jackknife

◆ Anesthesia: general or spinal

◆ Operative position preparation includes the following:

◆ Ensure that genitals are not compressed by prone positioning.

◆ Proctoscopy is advisable to exclude rectal disease.

◆ Administer antibiotics before the procedure.

CHAPTER

Incision of Fistula-in-Ano

Dennis C. Gore

CHAPTER 70 • Incision of Fistula-in-Ano 777

Exterior opening,

posterior to anus

External opening, anterior

and <3 cm from anus

Anus

Goodsall's Rule

External opening, anterior

and >3 cm from anus

FIGURE 70 –1