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HAEMORRHOIDECTOMY
GRADE 3 (VERY DIFFICULT)
A PANTOGEN OPERATION SCRIPT
MICHAEL EDWARDS
NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON
THIS SCRIPT COVERS:
ELECTIVE HAEMORRHOIDECTOMY FOR PROLAPSING PILES
ACUTE HAEMORRHOIDECTOMY FOR STRANGULATED PILES
HAEMORRHOIDECTOMY FOR RECURRENT PILES
HAEMORRHOIDECTOMY FOR MUCOSAL PROLAPSE
LAY OUT OF OPERATION SECTIONS AND STEPS
The operation is divided into SECTIONS.
The SECTIONS are displayed in sequence in the following paragraphs.
Each SECTION is divided into an unlimited number of very small STEPS.
Each STEP contains an unlimited amount of supporting information (PANTINOS)
SECTION 1.00 PRELIMINARIES
STEP 1.01 CHECK YOU HAVE THE CORRECT PATIENT
STEP 1.02 CHECK YOU HAVE THE CORRECT SIDE.
3 CHECK PROPER INVESTIGATIONS INCLUDING A SIGMOIDOSCOPY.
4 CHECK PREVIOUS SURGERY OR TRAUMA TO THE PERINEUM OR ANAL
CANAL. ( IE RISK OF INCONTINENCE AFTER THE
HAEMORRHOIDECTOMY)
5 CHECK FOR HIP PROBLEMS. (IE AVOID LITHOTOMY POSITION)
6 CHECK THERE IS NO OTHER PROCEDURE TO DO.
7 CHECK THERE IS A DIATHERMY PAD.
8 CHECK THE PERIANAL SKIN IS SHAVED.
9 ANAESTHESIA GENERAL /SPINAL /EPIDURAL
10 POSITION
LITHOTOMY
Use Lloyd Davis stirrups if the hips are
stiff or unstable or there has been previous
hip surgery.
Check the coccyx overhangs the end
of the operating table to get access to the
anal canal.
Hold the scrotum upwards out of the
operating area in a sling of 4 inch
elastoplast.
11 DO SIGMOIDOSCOPY if not already done.
12 STANCE
Sit on a stool facing the patient's perineum.
Have one assistant on your left and the
scrub nurse on your right.
13 PREPARE THE SKIN
From the perineum to the coccyx and from
one mid thigh to the other.
Use two swabs on sticks with 0.5%
Chlorhexidine in 70% propanol, followed by
one to dry off.
Make sure there is no pooling of the
antiseptic, particularly in the vagina.
14 TOWEL UP
Using leggings, a towel under the buttocks and an
anterior towel.
Fix the towels with towel clips into the
skin.
15 PERFORM A MILD SPHINCTER STRETCH if the anal canal is less
than 2 cms. in diameter.
Use 4 fingers inserted 5 cm. so that you can
feel the ring-like internal sphincter.
Stretch the sphincter muscle in an antero-
posterior direction so that the SIDES of the
sphincter stretch.
This will prevent the posterior anal skin
splitting to form a fissure.
16 IDENTIFY THE PILES
Classical piles are 3 bluish 2cm. swellings
bulging out of the anal canal in the 3, 7,
and 11 o'clock positions as you look at the
patient.
They are covered with mucosa and skin.
Sometimes one or piles are missing.
All the anal lining bulges out if the piles
are strangulated or if there is a mucosal
prolapse.
Sometimes skin tags predominate.
You are aiming to remove swellings at the
3, 7, and 11 o'clock positions if present,
while preserving intact bridges of skin and
mucosa between these sites.
Choosing the right tissue to remove requires
a little thought.
17 CLIP THE 3 O'CLOCK SKIN TAG with an artery forceps.
18 EXPOSE THE INTERNAL PILE by pulling radially on the
forceps.
The internal pile is a dark blue vein,
covered with thin mucosa.
19 CLIP THE 3 O'CLOCK INTERNAL PILE with another artery
forceps.
20 RETRACT THE WHOLE PILE radially by pulling on both
forceps.
21 HOLD THE PILE RADIALLY by clipping the two forceps to the
drapes with a towel clip.
22 REPEAT FOR THE 7 O'CLOCK PILE (if present)
BY GOING BACK TO STEP 17 (CLIP THE SKIN TAG)
23 REPEAT FOR THE 11 O'CLOCK PILE (if present)
BY GOING BACK TO STEP 17 (CLIP THE SKIN TAG)
24 DISSECTING THE PILES
You are aiming to incise an ellipse of
skin and mucosa at the site of each pile,
while you preserve skin bridges between the
ellipses.
Then you will be excising each pile without
damaging the internal sphincter.
Start with the lowest pile to keep the
operating field free from blood.
25 DISSECT OUT THE 7 O'CLOCK PILE - READ ON
If absent, DISSECT OUT THE 3 O'CLOCK PILE
- READ ON
If absent, DISSECT OUT THE 11 O'CLOCK PILE
- READ ON
26 RELEASE THE 2 ARTERY FORCEPS from the drapes.
27 RETRACT THE PILE centrally by pulling on the 2 artery
forceps to see the skin side of the pile.
28 SNIP THE BASE OF THE SKIN TAG in the line of the
circumference of the anal canal using round
ended scissors to start the ellipse.
Make the scissor cut 1cm. long normally.
Avoid excising non-piles skin, because it is
unnecessary and very painful afterwards.
29 EXTEND THE INCISION using scissors by immediately
turning into the mucosa of the anal canal
for 2cm.
For a MUCOSAL PROLAPSE, extend the incision
5cm. to remove enough mucosa.
30 GO BACK TO THE OTHER END OF THE PILE INCISION
31 EXTENT THAT END OF THE INCISION into the mucosa to meet
first mucosal incision, and so complete the
ellipse.
32 DISSECT THE PILE off the internal sphincter muscle with
firm gauze dissection.
Show up the fibres of the sphincter muscle
by stretching the pile over a finger
pressing from the mucosal side of the pile.
The internal sphincter muscles fibres are
light brown, fleshy strands running
circumferentially in the subcutaneous
tissues lateral to the pedicle of the pile.
They are often thinned out where they cover
the pile.
It is essential that these fibres are
clearly seen, and are swept laterally to
prevent incontinence after the operation.
You should end up with only the mucosa of
the pile together with its nutrient artery
stretched over your finger.
You can ignore minor bleeding vessels in the
internal sphincter.
The external sphincter will not be found in
this dissection since it lies laterally.
With spinal, caudal, or epidural anaesthesia
the internal sphincter may well relax more
than during a general anaesthetic and willd
be more lateral.
Nevertheless, be absolutely certain that you
have removed all the sphincter fibres from
the pedicle of the skin tag and pile before
transfixing the pedicle.
33 EXCISING THE PILES
34 TRANSFIX THE PEDICLE of the pile with an O silk
transfixion stitch (Ethicon W223).
Tie the knot with a triple knot.
Clip the loose ends of the stitch 5 cms.
from the knot.
Cut the more distal ends.
35 DISSECT OUT THE 3 O'CLOCK PILE
if present GO BACK TO STEP 26 (RELEASE THE 2
ARTERY FORCEPS)
if absent READ ON
36 DISSECT OUT THE 11 O'CLOCK PILE
if present GO BACK TO STEP 26 (RELEASE THE 2
ARTERY FORCEPS)
if absent READ ON
37 REVIEW PROGRESS
You should now have:
3 excision sites
3 intact skin bridges
3 transfixed pedicles
3 sets of ends of silk held by artery
forceps
38 INSPECT EACH EXCISION SITE for bleeding and diathermy as
necessary to obtain haemastasis.
Minor oozing will stop by itself.
39 CUT THE LOOSE ENDS of the transfixion stitches 2 cms.
away from the knot for ease of access if the
patient requires re-exploration for any
bleeding.
40 DRESS THE WOUNDS with a 5cm. square of Paraffin gauze on
each excision site.
41 COVER THE ANUS with 10 gauze swabs held on with elastic
pants.
42 CHECK THERE IS NO OTHER PROCEDURE TO DO
43 FINAL TOUCHES
44 CHECK THE HIPS ARE UNFLEXED CAREFULLY AND IN UNISON
45 WRITE LEGIBLE OPERATION DETAILS
46 FILL IN THE SURGICAL AUDIT FORM
47 PRESCRIBE CALCIUM HEPARIN 5000 UNITS BD subcutaneously
until the patient leaves hospital if he/she
is over 40 years.
48 DICTATE AN OPERATION LETTER TO THE GENERAL PRACTITIONER
49 EQUIPMENT LIST
GENERAL SET +
1 PROCTOSCOPE
1 BLUNT CURVED SCISSOR
50 MATERIALS LIST
SUTURES :- W 334
3 PIECES JELONET
DRESSING GAUZE-WOOL
NETELAST KNICKERS
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Michael Edwards
Email michaeledwardsOK@aol.com
