Fistulotomy

FISTULOTOMY

Goodsall's  rule Fig. 19.8 is often helpful in decending for  the

direction of the tract.

In  fistulas anterior to an imaginary transverse  line  bisecting

the  anus, usually the tract proceeds from opening in a  straight

line to the primary opening in anal canal.

In fistulas posterior to the line usually arise from an  internal

opeing in the posterior midline.

Treatment  is  surgical and consists of unroofing  all  fistulas,

destroying the primary opening and establishing adequate drainage

as in anal fissures.

POST-OPERATIVE MANAGEMENT

Wound  should be kept open post-operatively to  promote  drainage

and allow healing from the depth of the incision.

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ANO RECTAL ABCESSES

 ANORECTAL ABSCESSES AND FISTULAS

These are serious manifestations of anal infection.

*  Infected material collects in the anal crypts and invades  the

   glands.

*  A  superficial  invasion  of  tissue  adjacent  to  the  crypt

   produces a simple perianal abscess.

*  Infection,  however,  may penetrate the  sphincters  into  the

   ischiorectal fossa giving rise to ischio-rectal abscess.

*  Submucosa  or intramural abscess may open internally and  heal

   spontaneously.

*  However, if they open externally in the perianal region,  they

   lead to formation of a fistulous tract (Fistula-in-ano).

DRAINAGE OF ABSCESS

Simple incision will not provide drainage.  Cruciate incision  of

the abscess is preferred.

Digital exploration of the cavity to break up trabaeculations  is

required.   Drainage  of the cavity and frequent  dressings  give

good results.

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CHRONIC Fissure in Ano

CHRONIC ANAL FISSURE

Ulcer  becomes fibrotic and firm on palpation, enlarged  fibrotic

edematous skin tag at the anal margin.

Anal dilation is required in these cases.

OPERATION TECHNIQUE

Fissurectomy  is  an alternative line of treatment  and  involves

removal of all the infected tissues of the anal fissure, drainage

is required by frequent sitz baths for proper wound healing.

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Anal Fissure

ANAL FISSURE

This  is  the most painful anorectal condition.  It  occurs  most

commonly  in  the posterior quadrant at the anal verge due  to  a

linear  tear  of  an anal valve.  It makes a  posterior  (ear  is

common, in females anterior tears are seen more often.

The cause is unknown but it is suspected that constipation  plays

a role.

The  pain of anal fissure results primarily from sphincter  spasm

which is stimulated by the exposed nerve endings in the  infected

ulcer  bed.   Severe  pain and tenderness  often  render  PR  and

proctoscopy examination difficulty.

TREATMENT

CONSERVATIVE MANAGEMENT

Conservative  Management  is required in superficial  fissure  of

recent  origin  (acute fissure), local application of 2.5  or  5%

xylocaine ointment, before bowel movements.

*  Sitz  baths  two  or three times  daily.   Laxative  or  stool

   softener.

*  Injections  of a local anaesthetic agent with a  gloved  index

   finger of the left hand on the anal canal after application of

   5% xylocaine jelly to the fissure.

*  The  needle is passed behind the lining of anal canal  to  the

   level of the fissure and local anaesthetic in oil is injected.

*  This provides immediate relief of pain.

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Hemorrhoids Internal

INTERNAL HAEMORRHOIDS

Internal haemorrhoids involve the haemorrhoidal veins proximal to

the anorectal line and are covered by rectal mucosa.

These   cause   more  troublesome  symptoms   of   bleeding   and

protrussion.

In the early state (stage 1) they appear as a group of small 

veins.  They may bleed during the passage of hard stool or  undue

straining.

Later  the haemorrhoidal masses increase in size.  Rectal  mucosa

overlying  the  varices  becomes stretched  until  the  redundant

mucosa allows protusion of the internal haemorrhoids outside  the

anal orifice, retracts sponontaenously (stage II).

Often  manual  anal  replacement  of  the  protruding  tissue  is

necessary (Stage III).

Pain is not a prminent symptom.  When protrusion of the  internal

haemorrhoids  into  the  anal canal or beyond  the  anal  orifice

produces  sphincter  spasm,  severe pain may  result  leading  to

persistent protruision (Stage IV).

Painful muscle spasm occurs particularly when examination reveals

protruding  Hermorrhoids.  On PR(per rectal),  examination  piles

may be seen at 3,7 or 11 O' clock positions.

TREATMENT

Asymptomatic   haemorrhoids   require  no   treatment.    Careful

cleansing and softening the feces may relieve the patient.

Troublesome  bleeding may be controlled by injection  therapy  or

sclerotherapy.  Injections are given into one qudarant at a  time

and  at  intervals  of one week using  a  gabriol  syringe.   The

injections is given above the pile (Fig. 19.5)

HAEMORRHODECTOMY

Pain, bleeding or protrusion are indications for haemorrhodectomy

(Fig. 19.6).  The skin tags and pile mass are held and isolated by

V shaped skin anal mucosal incised the pedicle is ligated.

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