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1、Hemorrhoidectomy, Fistula in ano and TEM,Wendie Grunberg,3 Loops of external sphincter,Subcutaneous (C), superficial (B), deep (A),Blood Supply.,The rectum and anal canal are supplied by the superior rectal artery (the continuation of the inferior mesenteric artery), with assistance from the middle
2、and inferior rectal arteries, and by the median sacral artery. The submucosal venous plexus above the pectinate line drains into the superior rectal veins (portal system), which may become varicose, resulting in internal hemorrhoids or “piles.“ The submucosal plexus below the pectinate line drains i
3、nto the inferior rectal veins, which may become varicose, resulting in external hemorrhoids or piles. The unions of the superior with the middle and inferior rectal veins are important portal-systemic anastomoses.,Innervation,Parasympathetic fibers supply the smooth muscle, including the internal sp
4、hincter. Sympathetic fibers are mainly vasomotor. Somatic motor fibers supply the external sphincter. Sensory fibers are concerned with the reflex control of the sphincters and with pain. The anal canal is very sensitive below the pectinate line, so that external hemorrhoids may be very painful.,Hem
5、rroidectomy- Injection,Indications: The injection of hemorrhoids is a palliative procedure. The patient is ambulatory. It may be used for the bleeding internal hemorrhoid that does not prolapse. It is not applicable to external hemorrhoids Contraindications: reactive inflammation or thrombosis, acut
6、e fissure, fistula or perianal abscess, severe cryptitis or papillitis, and an advanced degree of prolapse,Injection,A complete study of the colon and rectum to rule out polyps or a malignancy must be performed before injection. The anorectal area is best examined with an anoscope while the remainde
7、r of the colon requires either colonoscopy or sigmoidoscopy plus barium enema.,Injection,Preoperative preparations No preoperative preparation is necessary other than a disposable commercial enema self-administered by the patient.,Injection- Procedure,An anoscope is inserted. The sclerosing solution
8、 is injected above the hemorrhoid about 3 mm below the mucosa Slight distention of the mucosa will result, but it should not blanch. One to 2 mL of solution is usually sufficient for one hemorrhoid. No more than three sites are injected at a single operation.,Injection- Post Op care,Stool softeners
9、and sitz baths are recommended. (If the patient complains of pain or discomfort, he or she is told to return promptly for examination to rule out potentially serious infection. Injections are usually repeated at intervals of about a week until all sites are injected. Keeping a chart of the exact sit
10、e of each injection ensures that all quadrants receive one injection),Incision and Rubber-Banding of Hemorrhoids - Indications,performed in good-risk patients with persistent symptoms. Bleeding, protrusion, pain, pruritus, and infection are the more common indications when palliative medical measure
11、s have failed. The presence of a serious systemic disease, such as cirrhosis of the liver, or a probable short life expectancy from advanced age or any other cause should be a general contraindication to operation unless anal symptoms are marked,Rubberband,Simple internal hemorrhoids that prolapse m
12、ay be treated by rubber-banding After insertion of an anoscope, the internal hemorrhoid is grasped with an Allis-like clamp inserted through the banding instrument, which has been preloaded with two rubber bands. The area is pinched to be sure it is pain-free. As the forceps or suction draws the hem
13、orrhoid into the instrument, it is fired. The constricting rubber bands strangulate the hemorrhoid and both are then silently passed a few days later,Positioning-,The positioning of the patient depends on the type of anesthesia used. With spinal anesthesia, the prone jackknife position affords the s
14、urgeon the best exposure. If general anesthesia is used, an exaggerated dorsal lithotomy position is preferred, with the buttocks extending beyond the edge of the table and the legs held in stirrups.,Procedure- Incision,The anal canal may be gently dilated to about two fingers width to permit adequa
15、te exposure.A suitable self-retaining retractor is inserted into the canal, and further inspection is made. A gauze sponge is introduced into the rectum, and the retractor is withdrawn. The surgeon makes gentle traction on the sponge, reproducing, in effect, the passage of a bolus through the canal.
16、 As the sponge is withdrawn, the prolapsing hemorrhoids may be identified and are picked up with hemorrhoid clamps. Clamps are placed on all the prolapsing hemorrhoids and left in place as markers during the operation.,Procedure- Incision,A triangular incision is made from the anal verge to the pect
17、inate line By traction on the two clamps and careful blunt and sharp dissection with the scalpel, it is possible to dissect off the triangular area of skin and the hemorrhoidal tissue from the outer edge of the external sphincter muscle.Many small fibrous bands will be found running upward into the hemorrhoidal mass. These represent the continuation downward of the longitudinal muscle and may be divided,
