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

Подождите немного. Документ загружается.

778 Section X • Rectum

STEP 3: OPERATIVE STEPS

1. INCISION

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

2. DISSECTION

◆ Insert a probe through the external opening of the ﬁ stula and gently advance the probe to

identify the ﬁ stulous tract (Figure 70-2).

◆ With the probe in place, use a scalpel or electrocautery to incise skin overlying the ﬁ stulous

tract (Figure 70-3).

◆ Most anal ﬁ stulas arise from an anal crypt at the pectinate line; continue incision and expo-

sure of ﬁ stulous tract to origin at anal crypt.

◆ Use electrocautery or curettage to cauterize and remove inﬂ ammatory tissue along the ﬁ stu-

lous tract (Figure 70-4).

◆ Many anal ﬁ stulas extend internally to circumscribe the external and very rarely the internal

sphincters. To complete the ﬁ stulotomy, the sphincter muscle can be cut, but the sphincter

muscle can be transected in only one place without precipitating incontinence.

CHAPTER 70 • Incision of Fistula-in-Ano 779

Probe

Mike de la Flor

FIGURE 70 –2

Electrocautery

FIGURE 70 –3

FIGURE 70 –4

780 Section X • Rectum

3. CLOSING

◆ For multiple, complex ﬁ stula-in-ano, place a 2-0 silk suture through those ﬁ stulous tracts

that circumscribe an anal sphincter yet cannot be incised. Tie the ends of this suture

together loosely to create a seton. With time the seton will incite sufﬁ cient granulation and

ﬁ brosis that the ﬁ stulous tract can be incised at a second operation or allowed to erode

through the ﬁ stulous tract.

STEP 4: POSTOPERATIVE CARE

◆ Sitz baths

◆ Stool softeners

◆ Repeat doses of mineral oil given orally

STEP 5: PEARLS AND PITFALLS

◆ It is sometimes difﬁ cult to assert with conﬁ dence the path of the ﬁ stula-in-ano. Goodsall’s

rule relates that if the external opening is anterior to an imaginary line drawn across the

midpoint of the anus and less than 3 cm from the anus, the ﬁ stula usually runs directly into

the anal canal. If the external opening is anterior to but greater than 3 cm from the anus,

then the ﬁ stulous tract may curve posteriorly to the posterior midline. If the external open-

ing is posterior to this line, the tract will usually curve to the posterior midline.

SELECTED REFERENCE

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations, 5th ed. New York, Macmillan, 1983, p 420.

782

STEP 1: SURGICAL ANATOMY

◆ Although the widespread adoption of mesh to repair hernias may lead the inexperienced

and reckless to presume otherwise, a comprehensive understanding of the anatomy of the

inguinal region is of paramount importance in inguinal hernia repairs.

◆ See Figures 71-1 and 71-2 for surface and superﬁ cial anatomic structures. The typical loca-

tion of each of the three inguinal hernia types is shown in Figure 71-2.

CHAPTER

Hernia Repair: General

Principles—Tension-Free

versus Tension

Thomas D. Kimbrough

CHAPTER 71 • Hernia Repair: General Principles—Tension-Free versus Tension 783

Femoral artery

Femoral vein

Ilioinguinal nerve

Spermatic

cord

External

inguinal ring

Indirect hernia

Direct hernia

Femoral hernia

Iliohypogastric nerve

Semilunar line

Anterior superior

iliac spine

Site of deep

inguinal ring

Site of superficial

inguinal ring

Pubic tubercle

FIGURE 71 –1

FIGURE 71 –2

784 Section XI • Hernias

◆ Figure 71-3 is a parasagittal representation of the various layers at a point midway in the

right inguinal canal.

Cooper’s ligament

Skin

Pectineus muscle and fascia

External oblique aponeurosis

Spermatic cord and

cremaster muscle

Inguinal ligament

Superior ramus of pubis

Transversus abdominis

aponeurosis arch

Transversalis fascia

Peritoneum

Plane of section (A)

FIGURE 71 –3

CHAPTER 71 • Hernia Repair: General Principles—Tension-Free versus Tension 785

◆ Figure 71-4 is a view from the inner surface of the abdominal wall—that is, from the

preperitoneal space looking out.

FIGURE 71 –4

Epigastric vessels

Rectus muscles

Conjoined tendon

Cooper's ligament

Obturator vessels

Obturator nerve

Vas deferens

Anterior crus of

internal ring

Iliopubic tract

Internal spermatic

vessels

Psoas muscles

External iliac vessels

Normal Anatomic View

786 Section XI • Hernias

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The actual incidence of dangerous complications of untreated hernias is quite low, and the

mortal risk from these complications, when they do occur, is similarly low.

◆ The few deaths that result from hernia repair are far more likely to be due to complications of

comorbidities than operative complications, so any evaluation of a candidate for repair should

include careful attention to other medical problems. Appropriate evaluation and referral for

evaluation and treatment of other signiﬁ cant medical problems should take precedence over a

recommendation for operative repair in elective cases.

◆ On the other hand, the probable natural course of an untreated inguinal hernia over time is

an increase in size and symptoms, so it is not unreasonable to offer repair to a young indi-

vidual with no other medical problems.

◆ The classic recommendation to evaluate and treat those conditions that might chronically

increase intra-abdominal pressure, including chronic cough, constipation, and difﬁ culty with

urination, ﬁ ts under the previous admonition to evaluate comorbidities and does not other-

wise bear special consideration.

◆ In the ﬁ nal analysis, the recommendation for a hernia repair requires of the surgeon a care-

ful balance and consideration of the natural history of untreated hernias, their symptoms

and complications, the patient’s age and comorbidities, and the presence of symptoms and

their immediate and anticipated effect on quality of life.

TENSION VERSUS TENSION-FREE

◆ A basic precept of surgery is that wounds closed under tension are less likely to heal well

than those closed with little or no tension.

◆ All of the classic tissue repairs require the approximation of tissues that do not exist in that

state naturally and thereby to one degree or another create tension on wound closures.

◆ Recognition of this has led to the use of mesh to bridge hernia defects and reinforce what has

been increasingly recognized as an often attenuated, hernia-prone portion of the abdominal

wall, even in those areas away from the actual hernia defect at the time of operation.

◆ The purported advantages of the tension-free repairs obtained with mesh include the

following:

◆ Mesh repairs have lower recurrence rates than tissue repairs.

◆ Postoperative pain is less, and recovery to full activity is faster.

◆ Long-term morbidity is the same as with tissue repairs.

◆ Although there are case reports of complications arising from the mesh itself, these are

sufﬁ ciently rare to not preclude its use.

CHAPTER 71 • Hernia Repair: General Principles—Tension-Free versus Tension 787

◆ The ideal material for tension-free repair has not been identiﬁ ed, and further research holds

the promise of developing materials, whether chemical or biologic, that will decrease even

further those problems associated with use of mesh.

◆ There are arguably some cases in which mesh should or cannot be used. For this reason,

surgeons should be familiar with classic tissue repairs, although one has to recognize that

the exposure of surgeons in training to these repairs will be quite limited in most cases.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The steps outlined here will be those used in the classic anterior approach to the inguinal

canal, which is satisfactory for the performance of most mesh and tissue repairs.

◆ Figure 71-5 illustrates two possible skin incisions for approaching the inguinal region. Inci-

sion A lies in the lower inguinal skin fold. Incision B directly exposes the external ring.

Anterior superior

iliac spine

Pubic tubercle

FIGURE 71 –5

788 Section XI • Hernias

◆ Before the incision is made, 0.25% bupivacaine with epinephrine should be injected medial

to the anterior superior iliac spine and deep to the external oblique aponeurosis. Approxi-

mate areas of injection are marked with an “X” on Figure 71-5. An additional 10 mL should

be injected at the site of the incision.

◆ The skin incision should be carried through the superﬁ cial subcutaneous fat, Scarpa’s fascia,

and the deep subcutaneous fat until the easily recognized oblique ﬁ bers of the external

oblique aponeurosis are identiﬁ ed.

2. DISSECTION

◆ The surgeon should then ﬁ nd the external inguinal ring, obtaining exposure as illustrated in

Figure 71-6. Such exposure can be achieved with hand-held retractors or, as shown, with

self-retaining ones.

◆ As shown in Figure 71-6, the aponeurosis of the external oblique should be divided in the

line of its ﬁ bers through the external inguinal ring. Some advocate the use of a knife for the

initial incision through the aponeurosis. I prefer scissors because they are less likely to

injure underlying structures.

◆ Using a combination of blunt and sharp dissection, the external oblique aponeurosis should

be freed superiorly and laterally from the underlying internal oblique muscle and fascia.

Inferiorly and laterally, the cord structures should be swept off the undersurface of the

external oblique aponeurosis down to the shelving edge of the inguinal ligament.

◆ The next step is longitudinal division of the ﬁ bers of the cremaster muscle that invests the

structures of the spermatic cord as shown in Figure 71-7. Care should be taken to divide

the cremaster away from the ilioinguinal nerve.