Symposium Hemorrhoidectomy--How I Do It: Semiclosed Technique FreEr. Rviz-Mop,rNo, M.D.* Mexico City, Mexico
bosed hemorrhoids. We definitely are not of the opinion that external thrombosed hemorrhoids should be routinely excised under local anesthesia, as these patients will also have internal hemorrhoids and other associated diseases. We stress the fact that only precise and radical removal of all pathologic anorectal conditions, including, naturally, all hemorrhoidal tissue, is the only correct surgical management. Approximately 30 per cent of our patients had been treated elsewhere previously, by injection or surgery.
THE PURPOSE of this presentation is to describe our semiclosed technique for hemorrhoidectomy and to analyze some results obtained in our last 2,000 consecutive cases. Our youngest patient was 2 years old, and the oldest was 81 years of age. T h e highest incidence occurred in the fourth decade. T h e ratio of males to females was 1.2 to 1. Symptomatology Pain was the main complaint, followed by bleeding, anal discomfort, pruritus and protrusion. Associated minor proctologic diseases included cryptitis, which was most common, followed by papillitis, thrombosis, and fissure. It is interesting that cryptitis was much less common among those patients who had large prolapsing hemorrhoids. All cases in which the associated proctologic diseases were apparently more serious than the hemorrhoidal disease are also considered in this series. Such associated diseases included anal ulcer, fistula, and abscess (non-granulomatous). We differentiate between anal fissure and anal ulcer: T h e former is the initial stage with a small superficial reversible lesion, whereas anal ulcer is the fibrous, deep, large, irreversible, severe lesion. For almost 30 years, it has been our policy to operate immediately in cases of acute, massive, prolapsed, throm-
Operative Technique Anesthesia: Lumbar epidural analgesia between L5 and S1 is administered using 12-18 ml of 1 per cent lidocaine solution with epinephrine. T h e catheter is left in place until the following morning. This anesthesia has been employed in the vast majority of our cases. It is administered by the anesthesiologist with the patient in the prone position, with the advantage that the patient does not have to be moved or his position changed after analgesia has been attained. Headaches are not encountered when the epidural analgesia is applied by a competent anesthesiologist. A spinal saddle block with a 26-gauge needle or general anesthesia was used in only ten of these patients when the preferred method could not be utilized.
* Unidad de Proctologla de la Ciudad de M6xico, Tlacotalpan 51, M~xico 7, D.F., Mfixico.
177 Dis. Col. & Reel. April, 1977
Volume 20 Number 3
] 78
RUIZ-MORENO
Dis. Col. & Reef. April, 1977
FIG. 1 (left). W i t h long R u s s i a n forceps, the u p p e r m o s t level of r e d u n d a n t mucosa, above the h e m o r rhoidal mass, is grasped. L i g h t traction is exerted, a n d a deep p r i m a r y stitch is placed a n d tied b e y o n d it, u s i n g 4-0 or 5-0 Dexon with a half-circle a t r a u m a t i c 5-T needle. FIG. 2(right). A long, n a r r o w tearlike incision with the thin e n d cephalad a n d s t a r t i n g just u n d e r the stitch is executed w i t h a n u m b e r - l l scalpel, c u t t i n g m u c o s a a n d s u b m u c o s a to the m u s c u l a r layer. T h e incision goes a r o u n d the h e m o r rhoidal tissue.
All patients are placed in the prone position with elevation of the pelvis, except some heavily pregnant women and patients who have cardiopulmonary disturbances, for whom the Sims' position is indicated. A non-irritant colored antiseptic sohttion is used on the skin. T h e anal canal and rectum are generously washed with an aqueous 1:5,000 merthiolate solution, which is aspirated. Gauze sponge is not used. Gentle dilatation is performed with a Pratt bivalve speculum. A Fansler operating scope, which I have modified, is introduced with the aid of aqueous jelly lubricant. This instrument, with the patient in the inverted or prone position, gives the surgeon great visibility and depth of the localized operating field; the tissues do not suffer distortion; each hemorrhoidal mass is well localized at the instrument's lateral opening, and the redundant mucosa of the lower rectum is easily distinguished. I believe that in good, substantial, efficient surgical treatment for hemorrhoidal disease the redundant mucosa of the lower rectum must always be excised. With long Russian forceps, the uppermost level of redundant mucosa, above the hem-
orrhoidal mass, is grasped. Slight traction is exerted, and a deep primary stitch is placed and tied beyond it, using 4-0 or 5-0 Dexon with a hatLcircle atraumatic 5 - T needle (Fig. 1). A long, narrow tear-like incision, with the thin end cephalad and starting just under the stitch, is executed with a number-It scalpel, cutting mucosa and submucosa to the muscular layer. T h e incision goes around the hemorrhoidal tissue (Fig. 2). Thus, hemorrhoid and redundant mucosa and submucosa are sharply dissected free from the underlying muscular structures. T h e circular muscle fibers of ~he lower rectum, internal anal sphincter, and subcutaneous external sphincter muscles are identified and left intact (Fig. 3). Another advantage of this procedure, utilizing this special operating scope, is that the anal canal is not distorted; no traction is necessary to draw out the hemorrhoids; therefore, the internal sphincter does not descend to the anal orifice, and the external subcutaneous sphincter does not move outward. A scalpel with a number-15 blade is used to perform a very" superficial sphincterotomy, less than 1 mm deep, of the in-
Volume 20 Number 3
SEMICLOSED T E C H N I Q U E
179
FIG. 3.(above, left). H e m o r r h o i d and r e d u n d a n t mucosa and submucosa are sharply dissected free from the underlying m u s c u l a r structure. T h e circular muscle fibers of the lower rectum, internal anal sphincter, and subcutaneous external sphincter muscles are identified and left intact. Fro. 4(above, right) A scalpel with a number-15 blade is used to perform a very superficial sphincterotomy, less than 1 m m deep, of the internal and external subcutaneous sphincters, as well as a very superficial incision of the circular muscle layer of the lower rectum. T h i s is done at the midline of all h e m o r r h o l d e c t o m y wounds. FIG. 5. (below, le/t). Suture both borders. T h e same Dexon with which the deep p r i m a r y stitch was executed is used to suture together, with interlocked or r u n n i n g sutures, both borders of the incised rectal mucosa down to 2 cm above the pectinate line. Fro. 6 (below, right). From here, this interlocked s u t u r e is continued in the same m a n n e r with a 4-0 or 5-0 Dexon with a 5-T needle, but only each border is taken and is approximated to the middle of the open wound with a r u n n i n g suture so as to diminish the width of the wound.
ternal and external subcutaneous
sphincters,
as w e l l as a v e r y s u p e r f i c i a l i n c i s i o n o f t h e circular muscle This
layer of the lower rectum.
is d o n e a t tile m i d l i n e
orrhoidectomy
wounds
o f all t h e h e m -
(Fig. 4 ) .
However,
Era. 7. T h i s continuous suture is placed without tension. T h e raw surface is thus reduced, leaving a clean, narrow, draining w o u n d as the borders of the w o u n d are approximated. T h e s u t u r e goes a r o u n d the w o u n d and back to the rectal mucosa; it is tied in triple knots.
180
RUIZ-MORENO
this incision is always avoided in women at the anterior midline and also in those men whose sphincters are discovered to be hypotonic when first examined at the office. Gauze sponges are not utilized to wipe the bleeding. Instead, a special non-traumatic suction retractor, which I designed some years ago, is employed. I believe that the surgeon should use every possible device to avoid unnecessary trauma, especially in the raw areas of the anus, which are very sensitive. Suture Both Borders: T h e same Dexon with which the deep primary stitch was executed is used to suture together, with interlocked or running sutures, both borders of the incised rectal mucosa down to 2 cm above the pectinate line (Fig. 5). This suture must be wide and deep, including mucosa, submucosa and muscle, in order to obtain wound integrity. T h e mucosa alone has hardly any suture-holding integrity. T h e needle should penetrate the mucosa and submucosa at least 3 m m from its edge and bite the same depth into the muscle. From here, this interlocked suture is continued in the same manner with 4-0 or 5-0 Dexon with a 5 - T needle, but only each border is taken and is approximated to the middle of the open wound with a running suture so as to diminish the width of the wound (Fig. 6). T h e small needle bites into the muscle layer, and the suture fixes first the mucosal border and submucosa to the internal sphincter muscle and continues to the border of the anal canal which is, in turn, fixed to the underlying muscle. T h e suture is continued to the perianal skin, which is also sutured to the muscle and subcutaneous tissue beneath it. This continuous suture is placed without tension. T h e raw surface is thus reduced, leaving a clean, narrow, draining wound as the borders of the wound are approximated. T h e suture goes around the wound and back to the rectal mucosa; it is tied in
Dis, CoL & Rect, April, 1977
triple knots (Fig. 7). Hemostasis of all bleeding sites is controlled by these stitches, which may be changed to interlocked sutures when deemed necessary. T h e borders of the wound are thus approximated, forming the semiclosed technique. It is our custom to place the anal canal (modified skin) and anal skin sutures immediate to the border to minimize skin loss; this suture must penetrate only superficially into the underlying muscle, as it is well known that skin has much better suture-holding integrity than mucosa. T h e plunger is introduced into the speculum, rotated, and placed where the next hemorrhoidal mass is situated, and the same surgical procedure is carried out. T h e width of the wounds depends on the volume and width of the hemorrhoids; however, the excised hemorrhoidal tissue should not include all the localized hemorrhoid at the operating scope opening; the remaining hemorrhoidal tissue is dissected out from beneath the mucosa and skin, keeping one flap on each side of the wound which will be sutured, as we have pointed out before. From three to six incisions are made. T h r e e may be good-sized excisions; all hemorrhoidal tissue must be excised, including both primary and secondary hemorrhoids. Even the smallest hemorrhoids must be eliminated, with all areas of secondary anorectal disease, such as hypertrophiec[ papillae, fissures, cryptitis, and fistulas. Extreme care must be taken to leave enough mucocutaneous bridges with good circulation between the semiclosed wounds. Sometimes, after the three main hemorrhoids have been excised, a linear incision only is necessary over the secondary small hemorrhoids, but it must cut across to the muscular layer (Fig. 8). T h e depth of the sphincterotomy in these sites is minimal, less than 1 mm; the complete borders of these wounds are sutured separately, in a semiclosed manner, to avoid narrowing the anal canal. Stenosis is an impossible corn-
Volume 20 Number 3
SEMICLOSED T E C H N I Q U E
plication with our operating scope, as it protects the normal diameter of the anal canal and lower rectum, particularly when the surgeon uses good sound judgment as to how much total tissue should be eliminated. We have devised a very thin crypt hook and a magnifying concave mirror, similar to those used by dentists, and make use of them routinely during surgical operations to detect and eliminate crypts that normally would be overlooked and might, in the future, be initial abscess focuses. A small Gelfoam rolled around a thin Penrose drain may be (very seldom) left in the anorectum when there is blood oozing from the wound. Otherwise, only a small strip of gauze is left externally at the anal opening. We have persuaded our anesthesiologists to keep our patients' blood pressures during surgical procedures 5-10 mm Hg above normal. Doing this, we feel safer, and also have the impression that the patients have less possibility of bleeding postoperatively. This type of operation takes longer to perform, an average of an hour, and is more meticulous. We have the impression that this is a very anatomically and physiologically sound procedure: the tissues do not suffer distortion, and are not pulled or transposed away from their normal situation as happens with the different "open methods"; an anatomically and physiologically normal anal canal and lower rectum remain after operation; only the diseased tissues are excised. T h e use of very thin suturing material compels the surgeon to handle the tissues very gently. This cannot be a rough surgical procedure. T h e tissues are not stretched, unnecessary trauma is avoided, and the sutures are not tense. I am sure that all these technical considerations are the reason the complications with this procedure are almost nil. This surgical technique offers a radical cure with the least inconvenience to the patient; pain is greatly diminished (it is surprising to see the great number of pa-
181
FIG. 8. Extreme care m u s t be taken to leave enough mucocutaneous bridges with good circulation between the semiclosed wounds. Sometimes, after the three main h e m o r r h o i d s have been excised, only a linear incision is necessary over the secondary small hemorrhoids, b u t it m u s t cut across to the muscular layer.
tients who definitely do not have any pain whatsoever during their first bowel movement) ; normal healing is accelerated. Postoperative bleeding is quite rare, and never have we needed to treat a bleeding patient by surgery. This type of bleeding stops spontaneously or with the aid of Gelfoam. Since pain depends on the individual's sensitivity and varies according to the patient's psychologic condition, we routinely make it a point to speak to the patient before the operation and emphasize the importance of learning to relax both mentally and physically. T h e patient is told what will be done, what to expect, and is given reassurance by the surgeon, assistants, anesthesiologists, and nurses in order to eliminate anxiety and to obtain his maximum cooperation, particularly since many are under the false impression that hemorrhoidectomy is "extremely" painful. T o prevent pain, 10 ml, containing only 5 mg fentanyl citrate, are administered in a 1,000 ml 5 per cent glucose solution during the first 10-12 postoperative hours at an average rate of 30 drops per administration. Mild analgesics are given orally during the following days when necessary; we never use morphine or meperidine. Very rarely,
182
RUIZ-MORENO
a small dose of 6 ml of 1 per cent lidocaine may be supplied through the lumbar catheter, during the first postoperative hours, and hot packs may be applied to the anal area six to eight hours after operation to make the patient more comfortable. }Ve believe in p a m p e r i n g our patients; they feel better. Mild tranquilizers are prescribed. A normal high-roughage diet is ordered six to eight hours after operation. However, the fluid intake during operation and the following hours is kept low to avoid distention and the necessity for catheterization of the bladder. As a rule, two tablespoons of bulk-forming laxative are given the night of the operation and one to two more the following evening. This will produce a soft, normal bowel movement approximately 36 hours after operation. W h e n a spontaneous bowel movement has not been achieved after breakfast on the second postoperative day, two Dulcolax suppositories are introduced, and ordinarily the bowel movement will appear within an hour. Patients are surprised at the trivial discomfort experienced. Rarely is an enema necessary. T h e laxative is reduced every day until a thick, well-formed spontaneous bowel movement is produced, which is generally on the fourth day. Patients are trained to obtain a daily bowel movement before breakfast. Naturally, all our patients are briefed again the day after operation on their bowel movement, how to relax, and how to make themselves comfortable in the Sitz bath where their first bowel movements will take place. T h e y are instructed to get under the
Dis. Col, & Rect. April, 1977
shower after the bowel movement, where they will cleanse the anal region with mild soap and water, to be followed by a Sitz bath. T h e y are invited to m a k e use of this hot-water therapy as often as desired, but at least four 20-minute hot Sitz baths a day are prescribed. A hot pack with an electric pad is to be placed over the anal region while the patient is in bed. Furthermore, he is instructed to walk at least a quarter of a mile four times a day, beginning the day a{ter the operation. H e is taught to keep his anus constantly clean a n d dry with absorbent tissue paper. By doing this, he will be more comfortable. T h e wounds at the anal canal and lower rectum are cleaned twice a day with a cortisone-analgesic cream on an applicator during the four-day hospital stay by one of the assistants while making rounds. No antibiotics are ever prescribed. Dilatations are never necessary. T h e patient is seen at the office three times a week the first week, twice the second and third weeks, and once the fourth week after operation. H e is invited to return once a m o n t h for two months and then twice a year for those more than 40 years of age or once a )rear for those less than 40 years old. By doing this, we have been able to follow our patients very thoroughly and prove that a soft, almost imperceptible scar exists in a normal, not distorted or retracted anus without skin tags. Incontinence, leakage of flatus or soiling of the underclothes, stricture, or recurrence has not been found; the anorectum has been restored to its normal anatomic condition and physiologic performance.
bosed hemorrhoids. We definitely are not of the opinion that external thrombosed hemorrhoids should be routinely excised under local anesthesia, as these patients will also have internal hemorrhoids and other associated diseases. We stress the fact that only precise and radical removal of all pathologic anorectal conditions, including, naturally, all hemorrhoidal tissue, is the only correct surgical management. Approximately 30 per cent of our patients had been treated elsewhere previously, by injection or surgery.
THE PURPOSE of this presentation is to describe our semiclosed technique for hemorrhoidectomy and to analyze some results obtained in our last 2,000 consecutive cases. Our youngest patient was 2 years old, and the oldest was 81 years of age. T h e highest incidence occurred in the fourth decade. T h e ratio of males to females was 1.2 to 1. Symptomatology Pain was the main complaint, followed by bleeding, anal discomfort, pruritus and protrusion. Associated minor proctologic diseases included cryptitis, which was most common, followed by papillitis, thrombosis, and fissure. It is interesting that cryptitis was much less common among those patients who had large prolapsing hemorrhoids. All cases in which the associated proctologic diseases were apparently more serious than the hemorrhoidal disease are also considered in this series. Such associated diseases included anal ulcer, fistula, and abscess (non-granulomatous). We differentiate between anal fissure and anal ulcer: T h e former is the initial stage with a small superficial reversible lesion, whereas anal ulcer is the fibrous, deep, large, irreversible, severe lesion. For almost 30 years, it has been our policy to operate immediately in cases of acute, massive, prolapsed, throm-
Operative Technique Anesthesia: Lumbar epidural analgesia between L5 and S1 is administered using 12-18 ml of 1 per cent lidocaine solution with epinephrine. T h e catheter is left in place until the following morning. This anesthesia has been employed in the vast majority of our cases. It is administered by the anesthesiologist with the patient in the prone position, with the advantage that the patient does not have to be moved or his position changed after analgesia has been attained. Headaches are not encountered when the epidural analgesia is applied by a competent anesthesiologist. A spinal saddle block with a 26-gauge needle or general anesthesia was used in only ten of these patients when the preferred method could not be utilized.
* Unidad de Proctologla de la Ciudad de M6xico, Tlacotalpan 51, M~xico 7, D.F., Mfixico.
177 Dis. Col. & Reel. April, 1977
Volume 20 Number 3
] 78
RUIZ-MORENO
Dis. Col. & Reef. April, 1977
FIG. 1 (left). W i t h long R u s s i a n forceps, the u p p e r m o s t level of r e d u n d a n t mucosa, above the h e m o r rhoidal mass, is grasped. L i g h t traction is exerted, a n d a deep p r i m a r y stitch is placed a n d tied b e y o n d it, u s i n g 4-0 or 5-0 Dexon with a half-circle a t r a u m a t i c 5-T needle. FIG. 2(right). A long, n a r r o w tearlike incision with the thin e n d cephalad a n d s t a r t i n g just u n d e r the stitch is executed w i t h a n u m b e r - l l scalpel, c u t t i n g m u c o s a a n d s u b m u c o s a to the m u s c u l a r layer. T h e incision goes a r o u n d the h e m o r rhoidal tissue.
All patients are placed in the prone position with elevation of the pelvis, except some heavily pregnant women and patients who have cardiopulmonary disturbances, for whom the Sims' position is indicated. A non-irritant colored antiseptic sohttion is used on the skin. T h e anal canal and rectum are generously washed with an aqueous 1:5,000 merthiolate solution, which is aspirated. Gauze sponge is not used. Gentle dilatation is performed with a Pratt bivalve speculum. A Fansler operating scope, which I have modified, is introduced with the aid of aqueous jelly lubricant. This instrument, with the patient in the inverted or prone position, gives the surgeon great visibility and depth of the localized operating field; the tissues do not suffer distortion; each hemorrhoidal mass is well localized at the instrument's lateral opening, and the redundant mucosa of the lower rectum is easily distinguished. I believe that in good, substantial, efficient surgical treatment for hemorrhoidal disease the redundant mucosa of the lower rectum must always be excised. With long Russian forceps, the uppermost level of redundant mucosa, above the hem-
orrhoidal mass, is grasped. Slight traction is exerted, and a deep primary stitch is placed and tied beyond it, using 4-0 or 5-0 Dexon with a hatLcircle atraumatic 5 - T needle (Fig. 1). A long, narrow tear-like incision, with the thin end cephalad and starting just under the stitch, is executed with a number-It scalpel, cutting mucosa and submucosa to the muscular layer. T h e incision goes around the hemorrhoidal tissue (Fig. 2). Thus, hemorrhoid and redundant mucosa and submucosa are sharply dissected free from the underlying muscular structures. T h e circular muscle fibers of ~he lower rectum, internal anal sphincter, and subcutaneous external sphincter muscles are identified and left intact (Fig. 3). Another advantage of this procedure, utilizing this special operating scope, is that the anal canal is not distorted; no traction is necessary to draw out the hemorrhoids; therefore, the internal sphincter does not descend to the anal orifice, and the external subcutaneous sphincter does not move outward. A scalpel with a number-15 blade is used to perform a very" superficial sphincterotomy, less than 1 mm deep, of the in-
Volume 20 Number 3
SEMICLOSED T E C H N I Q U E
179
FIG. 3.(above, left). H e m o r r h o i d and r e d u n d a n t mucosa and submucosa are sharply dissected free from the underlying m u s c u l a r structure. T h e circular muscle fibers of the lower rectum, internal anal sphincter, and subcutaneous external sphincter muscles are identified and left intact. Fro. 4(above, right) A scalpel with a number-15 blade is used to perform a very superficial sphincterotomy, less than 1 m m deep, of the internal and external subcutaneous sphincters, as well as a very superficial incision of the circular muscle layer of the lower rectum. T h i s is done at the midline of all h e m o r r h o l d e c t o m y wounds. FIG. 5. (below, le/t). Suture both borders. T h e same Dexon with which the deep p r i m a r y stitch was executed is used to suture together, with interlocked or r u n n i n g sutures, both borders of the incised rectal mucosa down to 2 cm above the pectinate line. Fro. 6 (below, right). From here, this interlocked s u t u r e is continued in the same m a n n e r with a 4-0 or 5-0 Dexon with a 5-T needle, but only each border is taken and is approximated to the middle of the open wound with a r u n n i n g suture so as to diminish the width of the wound.
ternal and external subcutaneous
sphincters,
as w e l l as a v e r y s u p e r f i c i a l i n c i s i o n o f t h e circular muscle This
layer of the lower rectum.
is d o n e a t tile m i d l i n e
orrhoidectomy
wounds
o f all t h e h e m -
(Fig. 4 ) .
However,
Era. 7. T h i s continuous suture is placed without tension. T h e raw surface is thus reduced, leaving a clean, narrow, draining w o u n d as the borders of the w o u n d are approximated. T h e s u t u r e goes a r o u n d the w o u n d and back to the rectal mucosa; it is tied in triple knots.
180
RUIZ-MORENO
this incision is always avoided in women at the anterior midline and also in those men whose sphincters are discovered to be hypotonic when first examined at the office. Gauze sponges are not utilized to wipe the bleeding. Instead, a special non-traumatic suction retractor, which I designed some years ago, is employed. I believe that the surgeon should use every possible device to avoid unnecessary trauma, especially in the raw areas of the anus, which are very sensitive. Suture Both Borders: T h e same Dexon with which the deep primary stitch was executed is used to suture together, with interlocked or running sutures, both borders of the incised rectal mucosa down to 2 cm above the pectinate line (Fig. 5). This suture must be wide and deep, including mucosa, submucosa and muscle, in order to obtain wound integrity. T h e mucosa alone has hardly any suture-holding integrity. T h e needle should penetrate the mucosa and submucosa at least 3 m m from its edge and bite the same depth into the muscle. From here, this interlocked suture is continued in the same manner with 4-0 or 5-0 Dexon with a 5 - T needle, but only each border is taken and is approximated to the middle of the open wound with a running suture so as to diminish the width of the wound (Fig. 6). T h e small needle bites into the muscle layer, and the suture fixes first the mucosal border and submucosa to the internal sphincter muscle and continues to the border of the anal canal which is, in turn, fixed to the underlying muscle. T h e suture is continued to the perianal skin, which is also sutured to the muscle and subcutaneous tissue beneath it. This continuous suture is placed without tension. T h e raw surface is thus reduced, leaving a clean, narrow, draining wound as the borders of the wound are approximated. T h e suture goes around the wound and back to the rectal mucosa; it is tied in
Dis, CoL & Rect, April, 1977
triple knots (Fig. 7). Hemostasis of all bleeding sites is controlled by these stitches, which may be changed to interlocked sutures when deemed necessary. T h e borders of the wound are thus approximated, forming the semiclosed technique. It is our custom to place the anal canal (modified skin) and anal skin sutures immediate to the border to minimize skin loss; this suture must penetrate only superficially into the underlying muscle, as it is well known that skin has much better suture-holding integrity than mucosa. T h e plunger is introduced into the speculum, rotated, and placed where the next hemorrhoidal mass is situated, and the same surgical procedure is carried out. T h e width of the wounds depends on the volume and width of the hemorrhoids; however, the excised hemorrhoidal tissue should not include all the localized hemorrhoid at the operating scope opening; the remaining hemorrhoidal tissue is dissected out from beneath the mucosa and skin, keeping one flap on each side of the wound which will be sutured, as we have pointed out before. From three to six incisions are made. T h r e e may be good-sized excisions; all hemorrhoidal tissue must be excised, including both primary and secondary hemorrhoids. Even the smallest hemorrhoids must be eliminated, with all areas of secondary anorectal disease, such as hypertrophiec[ papillae, fissures, cryptitis, and fistulas. Extreme care must be taken to leave enough mucocutaneous bridges with good circulation between the semiclosed wounds. Sometimes, after the three main hemorrhoids have been excised, a linear incision only is necessary over the secondary small hemorrhoids, but it must cut across to the muscular layer (Fig. 8). T h e depth of the sphincterotomy in these sites is minimal, less than 1 mm; the complete borders of these wounds are sutured separately, in a semiclosed manner, to avoid narrowing the anal canal. Stenosis is an impossible corn-
Volume 20 Number 3
SEMICLOSED T E C H N I Q U E
plication with our operating scope, as it protects the normal diameter of the anal canal and lower rectum, particularly when the surgeon uses good sound judgment as to how much total tissue should be eliminated. We have devised a very thin crypt hook and a magnifying concave mirror, similar to those used by dentists, and make use of them routinely during surgical operations to detect and eliminate crypts that normally would be overlooked and might, in the future, be initial abscess focuses. A small Gelfoam rolled around a thin Penrose drain may be (very seldom) left in the anorectum when there is blood oozing from the wound. Otherwise, only a small strip of gauze is left externally at the anal opening. We have persuaded our anesthesiologists to keep our patients' blood pressures during surgical procedures 5-10 mm Hg above normal. Doing this, we feel safer, and also have the impression that the patients have less possibility of bleeding postoperatively. This type of operation takes longer to perform, an average of an hour, and is more meticulous. We have the impression that this is a very anatomically and physiologically sound procedure: the tissues do not suffer distortion, and are not pulled or transposed away from their normal situation as happens with the different "open methods"; an anatomically and physiologically normal anal canal and lower rectum remain after operation; only the diseased tissues are excised. T h e use of very thin suturing material compels the surgeon to handle the tissues very gently. This cannot be a rough surgical procedure. T h e tissues are not stretched, unnecessary trauma is avoided, and the sutures are not tense. I am sure that all these technical considerations are the reason the complications with this procedure are almost nil. This surgical technique offers a radical cure with the least inconvenience to the patient; pain is greatly diminished (it is surprising to see the great number of pa-
181
FIG. 8. Extreme care m u s t be taken to leave enough mucocutaneous bridges with good circulation between the semiclosed wounds. Sometimes, after the three main h e m o r r h o i d s have been excised, only a linear incision is necessary over the secondary small hemorrhoids, b u t it m u s t cut across to the muscular layer.
tients who definitely do not have any pain whatsoever during their first bowel movement) ; normal healing is accelerated. Postoperative bleeding is quite rare, and never have we needed to treat a bleeding patient by surgery. This type of bleeding stops spontaneously or with the aid of Gelfoam. Since pain depends on the individual's sensitivity and varies according to the patient's psychologic condition, we routinely make it a point to speak to the patient before the operation and emphasize the importance of learning to relax both mentally and physically. T h e patient is told what will be done, what to expect, and is given reassurance by the surgeon, assistants, anesthesiologists, and nurses in order to eliminate anxiety and to obtain his maximum cooperation, particularly since many are under the false impression that hemorrhoidectomy is "extremely" painful. T o prevent pain, 10 ml, containing only 5 mg fentanyl citrate, are administered in a 1,000 ml 5 per cent glucose solution during the first 10-12 postoperative hours at an average rate of 30 drops per administration. Mild analgesics are given orally during the following days when necessary; we never use morphine or meperidine. Very rarely,
182
RUIZ-MORENO
a small dose of 6 ml of 1 per cent lidocaine may be supplied through the lumbar catheter, during the first postoperative hours, and hot packs may be applied to the anal area six to eight hours after operation to make the patient more comfortable. }Ve believe in p a m p e r i n g our patients; they feel better. Mild tranquilizers are prescribed. A normal high-roughage diet is ordered six to eight hours after operation. However, the fluid intake during operation and the following hours is kept low to avoid distention and the necessity for catheterization of the bladder. As a rule, two tablespoons of bulk-forming laxative are given the night of the operation and one to two more the following evening. This will produce a soft, normal bowel movement approximately 36 hours after operation. W h e n a spontaneous bowel movement has not been achieved after breakfast on the second postoperative day, two Dulcolax suppositories are introduced, and ordinarily the bowel movement will appear within an hour. Patients are surprised at the trivial discomfort experienced. Rarely is an enema necessary. T h e laxative is reduced every day until a thick, well-formed spontaneous bowel movement is produced, which is generally on the fourth day. Patients are trained to obtain a daily bowel movement before breakfast. Naturally, all our patients are briefed again the day after operation on their bowel movement, how to relax, and how to make themselves comfortable in the Sitz bath where their first bowel movements will take place. T h e y are instructed to get under the
Dis. Col, & Rect. April, 1977
shower after the bowel movement, where they will cleanse the anal region with mild soap and water, to be followed by a Sitz bath. T h e y are invited to m a k e use of this hot-water therapy as often as desired, but at least four 20-minute hot Sitz baths a day are prescribed. A hot pack with an electric pad is to be placed over the anal region while the patient is in bed. Furthermore, he is instructed to walk at least a quarter of a mile four times a day, beginning the day a{ter the operation. H e is taught to keep his anus constantly clean a n d dry with absorbent tissue paper. By doing this, he will be more comfortable. T h e wounds at the anal canal and lower rectum are cleaned twice a day with a cortisone-analgesic cream on an applicator during the four-day hospital stay by one of the assistants while making rounds. No antibiotics are ever prescribed. Dilatations are never necessary. T h e patient is seen at the office three times a week the first week, twice the second and third weeks, and once the fourth week after operation. H e is invited to return once a m o n t h for two months and then twice a year for those more than 40 years of age or once a )rear for those less than 40 years old. By doing this, we have been able to follow our patients very thoroughly and prove that a soft, almost imperceptible scar exists in a normal, not distorted or retracted anus without skin tags. Incontinence, leakage of flatus or soiling of the underclothes, stricture, or recurrence has not been found; the anorectum has been restored to its normal anatomic condition and physiologic performance.
