Hemorrhoidectomy

Hemorrhoidectomy

Objective

In case of piles:

•   Excision of the veins of the anus

•   And associated overlying skin and mucous membrane.

Position

Supine (Lithotomy).

Anesthesia

General.

Procedure

1.  Skin tag held with hemostat and pulled down.

2.  Proximal portions of the hemorrhoidal complex are identified.

3.  Skin and mucous layers cut and suture ligated.

4.  Hemorrhoid is excised by scalpel or scissors.

5.  All primary piles dealt with similarly.

Instruments

•   Rectal set

•   Proctoscope

•   Lubricant

•   Large rubber tube.

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Pre Sacral Rectopexy

Presacral Rectopexy

Objective

In case of:

•   Rectal prolapse

•   Mobilizing the rectum within the abdomen (and pelvis)

•   Fixing it to the presacral fascia and periosteum

•   Encircling band of material such as Teflon, Marlex or Mersilene mesh

Position

Supine.

Anesthesia

General.

Procedure

1.  Vertical or transverse incision.

2.  Rectum is dissected from its supporting tissue attachments.

3.  A mesh of Marlex (or Mersilene, Teflon, etc) is sutured to the presacral periosteum, taking care to avoid the local venous plexus.

4.  Mesh is placed around the bowel to anchor it to the sacrum without restricting the rectum too tightly.

5.  Abdomen is closed in layers.

Instruments

•   General set

•   Deep instrument set

•   Gastrointestinal set

•   Harrington’s retractor (Fig. 9.26)

•   Self-retaining retractor (e.g. Balfour) (Fig. 8.9B)

•   Mesh or banding materials

•   Hemoclip appliers.

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Thiersh procedure Rectum

Thiersch Procedure

Objective

In case of rectal prolapse:

•   A circumferential device or mesh around rectum to restrict downward movement of rectum.

Position

Supine (Lithotomy) or jacknife.

Anesthesia

General.

Procedure

1.  Two incision, 1 cm each are made opposite one another around the anus.

2.  Curved hemostat is passed deep in the perianal tissues external to the sphincter (avoiding the vagina), encircling the sphincter, and exiting the opposite incision.

3.  The prosthetic material is passed through the tunnel created by the clamp.

4.  Repeated for the other side (prosthesis completely encircles the anal canal).

5.  The prosthetic ends are sutured.

6.  The wounds are closed.

Instruments

•   Rectal set

•   Rectal retractors, including Sims, Hill-Fergusson and Sawyer (Fig. 9.17)

•   Prosthesis.

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Hepatic Resection

Hepatic Resection

Objective

In case of tumor to remove:

•   Small wedge biopsy

•   Local excision of tumors

•   A major lobectomy.

Position

Supine.

Anesthesia

General.

Procedure

1.  Abdominal or thoracic abdominal incisions.

2.  If a thoracoabdominal incision, the abdominal portion is incised first.

3.  Hepatic artery, portal vein, major biliary ducts are controlled by vascular forceps.

4.  The liver parenchyma ligate major vascular and biliary channels.

5.  Careful technique is necessary when approaching the posterior surface where the hepatic veins enter the inferior vena cava.

6.  After hemostatsis and the bile ducts are ligated the exposed pnarenchyma covered by greater omentum.

7.  The area is drained.

8.  The abdomen is closed in layers.

Instruments

•   General set

•   Deep instruments set

•   Gastrointestinal set

•   Biliary tract set

•   Thoracotomy set (for thoracoabdominal approach)

•   Hemoclip appliers (various sizes and lengths) (Fig. 17.25)

•   A CUSA may be required (Chapter 2 Fig. 2.7).

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Drainage Liver Abcess

Drainage of Abscess (ES) in
the Region of the Liver

Objective

To provide exit for purulent material within a confined space in or around the liver.

Position

Supine or lateral.

Anesthesia

General.

Procedure

1.  An incision posteriorly along the twelfth rib extraperitoneally.

2.  Or anteriorly, either extraperitoneally or transperitoneally.

3.  The abscess is identified and cultures are taken.

4.  The abscess is evacuated and may be irrigated with an antibiotic solution.

5.  Drains are placed.

6.  The wound is closed in layers.

Instruments

•   General set

•   Deep instruments set

•   Biliary tract set

•   Harrington retractor (Fig. 9.26).

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