AUTOSUTURE SURGICAL STAPLING
INSTRUMENTS
costs In Australia the autosuture stapling instruments tested cost between $750.00 and $1,100.00. The disposable loading units vary in cost between approximately $30.00 and $80.00, depending on the instrument. '
OVERALLEVALUATIONAND COMMENT These well-designed instruments certainly achieve a neat, precise, and haemostatic staple line. It is obvious that competence and confidence with the instruments w i l l increase. R a p i d i t y of performance of procedures will also improve,
POLGLASE ET ALll
although it is apparent even with this early evaluation that there is certainly a time advantage in performing a number of procedures. ACKNOWLEDGEMENTS The authors wish to thank Messrs J. Standing and J. Alcock for technical assistance. REFERENCES GOLIGHER,J. C.. MORRIS, C., MCADAM,W. A. F., DEDOMBAL, F.T. and JOHNSTON, D. (1970), Brit. J. Surg., 75: 817. RAVITCH.MARKM. and STEICHEN, FELICIENM., (1972).Ann. Surg. 175: 615.
THE TECHNIQUE OF ADVANCEMENT FLAP HAEMORRHOIDECTOMY SAMUELSAKKER
Ryde Hospital, Sydney Surgery is still the mainstay of treatment for large, prolapsing haemorrhoids.The teaching of Sir Alan Parks,and more recently the work of W.H.F. Thompson, have shown that degeneration of the supportive tissue of the anal canal and the subsequent sliding of the anal lining, was the greatest contributingfactor in the development Of haemorrhoids. The method of treatment described follows Sir Alan Parks'sprinciples of conservationof the anal canal mucosa and skin. This is then used to reline the anal canal after careful dissection and excision of the external and internal haemorrhoids. It therefore returns this prolapsed, sensitive epithelium to its original Site. Wound healing is rapid and anal stenosis is avoided.
DESPITE the present vogue for conservative management, surgery is still the mainstay of treatment for large, prolapsing haemorrhoids. The advancement flap haemorrhoidectomy offers an excellent solution to a problem which no amount of bran, injection, rubber band ligation, stretching or percutaneous lateral internal sphincterotomy will control. In patients with large, prolapsing internal and external haemorrhoids, the traditional opertion of Milligan et alii (1937) often denudes the anus of a large area of anal mucosa and skin, which plays an important part in the maintenance of continence (Duthie and Gairns, 1960). The remaining wounds take time to heal by secondary intention and reepithelialization. The anal canal is thus relined with scar tissue, which is often friable, insensitive, and prone to stricturing. Sir Alan Parks (1956) described a surgical method, applying and evolving principles first 'Surgeon Reprints Samuel Sakker. 3 Rowe Street, Eastwood,
116
N S W . 2122
stated by J. L. Petit (1774). The soundness of those principles has been confirmed by the work of Thompson (1975) who, in his anatomical and clinical studies, came to the conclusion that the degeneration of the supportive tissue of the anal canal lining and its subsequent sliding downwards was the greatest contributing factor in the development of haemorrhoids. This supports Sir Alan Park's teaching. The advancement flap haemorrhoidectorny is therefore based on the principles of: (it conservation of sensitive anal rnucosal lining; (ii) anatomical dissection of the haemorrhoids; and (iii) high ligation. The conservation of the sensitive mucosa and skin allowsthe relining of theanal canal with pliable, durable, and sensitive epithelium, which plays an important part in the maintenance of anal continence (Duthie an.d Gairns, 1960). This also reduces the extent of the granulating area and therefore promotes faster healing with a minimum of scar tissue, thus avoiding stricture formation. The covering of bared pain fibres within the wound may AUST N.Z. J. SURG VOL. 49 - No. 1, FEBRUARY, 1979
ADVANCEMENT FLAP HAEMORRHOIDECTOMY
SAKKER
High ligation reduces and diminishes pain, as the ligation is carried out within the less sensitive visceral part of the anal canal. The high incidence of stricture noticed in the past has been obviated with conservation of the anal canal lining and its advancement into the anus. This may have also been aided by the postoperative regime to ensure the passage of a firm stool. The technique of advancement flap haemorrhoidectomy is a further evolution of the submucosal haemorrhoidectomy as described by Parks (1956). However, there is little, if any, resemblance to its original description. I
FIGURE 1 A linear ‘V’ incision is made, conserving a triangular flap of anal mucosa and skin with its base on the anal verge.
play some part in the reduction of postoperative pain. Careful anatomical dissection removes both the external as well as the internal haemorrhoids and preserves the internal sphincter. The dissection may easily stray into the internal sphincter, particularly if considerable traction is used. A large wedge of internal sphincter may be thus unknowlingly incorporated in the pedicle tie and excised (Parks, 1956).
TECHNIQUE All patients undergo a sigmoidoscopy and many have an X-ray air contrast enema prior to their admission to hospital. Anaesthesia.E p i d u r a l anaesthesia i s s t r o n g l y recommended, as it reduces pelvic venous pressureand allows a clear operative field. Whichever the anaesthetic, coughing and straining must be avoided. Posture.- The patient is placed in the lithotomyposition with a head-down tilt. The light is focused axially into theanal canal. /nstrumenfs.The Parks anal speculum is essential, preferably of the ratchet type. If a choice of blades is available, then the smaller ones are more useful. Other basic instruments are Metzenbaum’s scissors, Officer’s dissecting forceps, and tungsten-jawed needle holders. Procedure.- A haemmorrhoid is infiltrated submucosally in the internal and external compartments with a solution of
FIGURE2: (left) traction on the haemorrhoid distorts the anatomy. Dissection into the internal sphincter with itssubsequent incorporation in the pedicle is easy. Particular care must therefore be taken to dissect along the correct plane as indicated by the interrupted line. (From A.G. ParksTheTreatment of Haemorrhoids, in C. Roband R. Smith (eds.). Operativesurgery (2nd ed.. London: Butterworth & Co Ltd, 1969)); (right) the internal haemorrhoids are dissected from the internal sphincter.
AUST. N.Z. J. SURG.VOL. 49
- No. 1, FEBRUARY. 1979
117
ADVANCEMENT FLAP HAEMORRHOIDECTOMY
i
SAKKER (Figure 2. right). Bleeding up to this point may be worrisome, but almost always stops when the haemorrhoid pedicle is ligated. Further haemostasis is achieved with diathermy or ligation of bleeding points with 00 catgut. This is repeated with each remaining haemorrhoid. The flaps are then trimmed of any residual veins, mobilized, and advanced into the anal canal and sutured up to the pedicle with 00 chromicized catgut (Figure 3). This leaves a linear V-shaped wound. An alternative incision may be used if the haemorrhoids are particularly large and considerable prolapse is present. A 1inear"Y" incision is then madein theanal mucosaandskin (Figure 4 left), with the fork of the Y encompassing the internal haemorrhoid and the stem of the Y placed towards the anus.
\
FIGURE 3. The flap of anal mucosa and skin is advanced into the anal canal, relining the area bared by the excision of the internal haemorrhoid. (Permission to reproduce figure is gratefully acknowledged) Xylocaine 1% and POR 8 Sandoz (ornipressin) i n the proportion of 30 mi to 1 ml. A 1inear"V" incision is made in the anal mucosa and skin with the point towards the rectum (Figure 1). This conserves a triangular flap of anal rnucosa and skin on its dissection from the external complex of haernorrhoids. The external haemorrhoids are then dissected from the internal sphincter, and dissection of the internal haemorrhoids IS commenced by dividing the mucosal suspensory ligament. The close adherence of the anal canal to the internal sphincter at this point of insertion of the mucosal suspensory ligament (Parks, 1956) makes it easy to distort the anatomy b y traction on the haemorrhoid Care must therefore be exercised toavoid straying into the internal sphincter muscle (Figure 2, left). The internal haemorrhoid is then dissected from the internal sphincter, transfixed. and ligated with 0 chromocized catgut
The external and internal haemorrhoids are then dissected from beneath the skin flaps and off the internal sphincter as described above. This conserves two triangular flaps of anal mucosa and skin (Figure 4, right). The flaps are then trimmed. advanced into !he anal canal, and sutured to the pedicle with 00 chromicized catgut. This converts the Y-shaped wound into a "T" with the bar of the T in the rectum and the stem formed by the longitudinal edges of the flaps (Figure 5). Dressings.- Milton 1 in 80 swabs are used both to support the base of the flaps and to soak up any serum and blood that might be lost. Pads and dressings are held in place by a T binder.
POSTOPERATIVE REGIME The patient is allowed to remain undisturbed for 36 hours. Dressings are only changed if a bowel action occurs. Analgesia, both oral and parenteral, is given as required. After 36 hours the patient hasa twice-daily bath followed by 1 in 80 Milton lay-on dressings. The patients are encouraged to open fheir bowels early, and aperients are used initially to producea soft stool. Ten rnillilitres of Agarol each night forthe first three nights has been found to be the most effective agent. This is followed by a high residue, hydrophilic aperient such as Norrnacol, 5 ml each
FIGURE 4: (left) a linear "Y" incision as an alternative for very large prolapsed haemorrhoids; (right) the haemorrhoid dissected from the internal sphincter, conserving two triangular flaps of anal mucosa and skin.
118
IS
AUST N.Z. J. SURG.VOL 49 - No 1, FEBRUARY, 1979
ADVANCEMENT FLAP HAEMORRHOIDECTOMY
SAKKER
FIGURE5 A purse-string suture of 00 chrornicized catgut, incorporating the apices of the two skin flaps, is placed around the pedicle This advances the flaps into the anal canal Several Interrupted sutures are placed on each side of the purse-string converting the wound into a "T" shape The stem of the T IS left unsuture
night, to produce a formed action It takes approximately three to four days for the bowels to achieve some order, and the patient is kept in hospital until this is satisfactory, about seven days The patients are subsequently encouraged to supplement their diet with bran AND CONCLUSIONS SUMMARY This operation has been carried out on 132 patients with good results The anal wounds were usually healed at the time of the patients'discharge from hospital The patients were reviewed three weeks after the operation, and about 75% were then ready to return to work The author believes that the advancement flap haemorrhoidectomy follows sound scientific
AUST N.Z. J. SURGVOL 49
-
No 1, FEBRUARY, 1979
principles, utilizes a sophisticated surgical technique, and is an advance on the standard Milligan-Morgan operation. ACKNOWLEDGEMENTS I thank Sir Alan Parks for his teaching and encouragement. I also thank Mr John Colins, Medical Artist, and Mr Reginald Money, of the Photographic Department of Sydney Hospital, for the excellent illustrations. I am particularly appreciative of my secretary, Mrs A. Farrawell, for preparing the manuscript. REFERENCES H. L and GAIRNS, F W . (1960). E r l f . J. Sufg. 47- 585. E. T C , MORGAN, C N , JONES L E and OFFICER, R. (1937), Lancef, 2. 1119 PARKS.A . G. (1956). Brit J. Surg., 63. 337. PETIT, J L (1774). cited by A G Parks THOMPSON, W H F (1975). E r l t J. Sufg.. 62: 642' DUTHIE.
MILLIGAN,
119
INSTRUMENTS
costs In Australia the autosuture stapling instruments tested cost between $750.00 and $1,100.00. The disposable loading units vary in cost between approximately $30.00 and $80.00, depending on the instrument. '
OVERALLEVALUATIONAND COMMENT These well-designed instruments certainly achieve a neat, precise, and haemostatic staple line. It is obvious that competence and confidence with the instruments w i l l increase. R a p i d i t y of performance of procedures will also improve,
POLGLASE ET ALll
although it is apparent even with this early evaluation that there is certainly a time advantage in performing a number of procedures. ACKNOWLEDGEMENTS The authors wish to thank Messrs J. Standing and J. Alcock for technical assistance. REFERENCES GOLIGHER,J. C.. MORRIS, C., MCADAM,W. A. F., DEDOMBAL, F.T. and JOHNSTON, D. (1970), Brit. J. Surg., 75: 817. RAVITCH.MARKM. and STEICHEN, FELICIENM., (1972).Ann. Surg. 175: 615.
THE TECHNIQUE OF ADVANCEMENT FLAP HAEMORRHOIDECTOMY SAMUELSAKKER
Ryde Hospital, Sydney Surgery is still the mainstay of treatment for large, prolapsing haemorrhoids.The teaching of Sir Alan Parks,and more recently the work of W.H.F. Thompson, have shown that degeneration of the supportive tissue of the anal canal and the subsequent sliding of the anal lining, was the greatest contributingfactor in the development Of haemorrhoids. The method of treatment described follows Sir Alan Parks'sprinciples of conservationof the anal canal mucosa and skin. This is then used to reline the anal canal after careful dissection and excision of the external and internal haemorrhoids. It therefore returns this prolapsed, sensitive epithelium to its original Site. Wound healing is rapid and anal stenosis is avoided.
DESPITE the present vogue for conservative management, surgery is still the mainstay of treatment for large, prolapsing haemorrhoids. The advancement flap haemorrhoidectomy offers an excellent solution to a problem which no amount of bran, injection, rubber band ligation, stretching or percutaneous lateral internal sphincterotomy will control. In patients with large, prolapsing internal and external haemorrhoids, the traditional opertion of Milligan et alii (1937) often denudes the anus of a large area of anal mucosa and skin, which plays an important part in the maintenance of continence (Duthie and Gairns, 1960). The remaining wounds take time to heal by secondary intention and reepithelialization. The anal canal is thus relined with scar tissue, which is often friable, insensitive, and prone to stricturing. Sir Alan Parks (1956) described a surgical method, applying and evolving principles first 'Surgeon Reprints Samuel Sakker. 3 Rowe Street, Eastwood,
116
N S W . 2122
stated by J. L. Petit (1774). The soundness of those principles has been confirmed by the work of Thompson (1975) who, in his anatomical and clinical studies, came to the conclusion that the degeneration of the supportive tissue of the anal canal lining and its subsequent sliding downwards was the greatest contributing factor in the development of haemorrhoids. This supports Sir Alan Park's teaching. The advancement flap haemorrhoidectorny is therefore based on the principles of: (it conservation of sensitive anal rnucosal lining; (ii) anatomical dissection of the haemorrhoids; and (iii) high ligation. The conservation of the sensitive mucosa and skin allowsthe relining of theanal canal with pliable, durable, and sensitive epithelium, which plays an important part in the maintenance of anal continence (Duthie an.d Gairns, 1960). This also reduces the extent of the granulating area and therefore promotes faster healing with a minimum of scar tissue, thus avoiding stricture formation. The covering of bared pain fibres within the wound may AUST N.Z. J. SURG VOL. 49 - No. 1, FEBRUARY, 1979
ADVANCEMENT FLAP HAEMORRHOIDECTOMY
SAKKER
High ligation reduces and diminishes pain, as the ligation is carried out within the less sensitive visceral part of the anal canal. The high incidence of stricture noticed in the past has been obviated with conservation of the anal canal lining and its advancement into the anus. This may have also been aided by the postoperative regime to ensure the passage of a firm stool. The technique of advancement flap haemorrhoidectomy is a further evolution of the submucosal haemorrhoidectomy as described by Parks (1956). However, there is little, if any, resemblance to its original description. I
FIGURE 1 A linear ‘V’ incision is made, conserving a triangular flap of anal mucosa and skin with its base on the anal verge.
play some part in the reduction of postoperative pain. Careful anatomical dissection removes both the external as well as the internal haemorrhoids and preserves the internal sphincter. The dissection may easily stray into the internal sphincter, particularly if considerable traction is used. A large wedge of internal sphincter may be thus unknowlingly incorporated in the pedicle tie and excised (Parks, 1956).
TECHNIQUE All patients undergo a sigmoidoscopy and many have an X-ray air contrast enema prior to their admission to hospital. Anaesthesia.E p i d u r a l anaesthesia i s s t r o n g l y recommended, as it reduces pelvic venous pressureand allows a clear operative field. Whichever the anaesthetic, coughing and straining must be avoided. Posture.- The patient is placed in the lithotomyposition with a head-down tilt. The light is focused axially into theanal canal. /nstrumenfs.The Parks anal speculum is essential, preferably of the ratchet type. If a choice of blades is available, then the smaller ones are more useful. Other basic instruments are Metzenbaum’s scissors, Officer’s dissecting forceps, and tungsten-jawed needle holders. Procedure.- A haemmorrhoid is infiltrated submucosally in the internal and external compartments with a solution of
FIGURE2: (left) traction on the haemorrhoid distorts the anatomy. Dissection into the internal sphincter with itssubsequent incorporation in the pedicle is easy. Particular care must therefore be taken to dissect along the correct plane as indicated by the interrupted line. (From A.G. ParksTheTreatment of Haemorrhoids, in C. Roband R. Smith (eds.). Operativesurgery (2nd ed.. London: Butterworth & Co Ltd, 1969)); (right) the internal haemorrhoids are dissected from the internal sphincter.
AUST. N.Z. J. SURG.VOL. 49
- No. 1, FEBRUARY. 1979
117
ADVANCEMENT FLAP HAEMORRHOIDECTOMY
i
SAKKER (Figure 2. right). Bleeding up to this point may be worrisome, but almost always stops when the haemorrhoid pedicle is ligated. Further haemostasis is achieved with diathermy or ligation of bleeding points with 00 catgut. This is repeated with each remaining haemorrhoid. The flaps are then trimmed of any residual veins, mobilized, and advanced into the anal canal and sutured up to the pedicle with 00 chromicized catgut (Figure 3). This leaves a linear V-shaped wound. An alternative incision may be used if the haemorrhoids are particularly large and considerable prolapse is present. A 1inear"Y" incision is then madein theanal mucosaandskin (Figure 4 left), with the fork of the Y encompassing the internal haemorrhoid and the stem of the Y placed towards the anus.
\
FIGURE 3. The flap of anal mucosa and skin is advanced into the anal canal, relining the area bared by the excision of the internal haemorrhoid. (Permission to reproduce figure is gratefully acknowledged) Xylocaine 1% and POR 8 Sandoz (ornipressin) i n the proportion of 30 mi to 1 ml. A 1inear"V" incision is made in the anal mucosa and skin with the point towards the rectum (Figure 1). This conserves a triangular flap of anal rnucosa and skin on its dissection from the external complex of haernorrhoids. The external haemorrhoids are then dissected from the internal sphincter, and dissection of the internal haemorrhoids IS commenced by dividing the mucosal suspensory ligament. The close adherence of the anal canal to the internal sphincter at this point of insertion of the mucosal suspensory ligament (Parks, 1956) makes it easy to distort the anatomy b y traction on the haemorrhoid Care must therefore be exercised toavoid straying into the internal sphincter muscle (Figure 2, left). The internal haemorrhoid is then dissected from the internal sphincter, transfixed. and ligated with 0 chromocized catgut
The external and internal haemorrhoids are then dissected from beneath the skin flaps and off the internal sphincter as described above. This conserves two triangular flaps of anal mucosa and skin (Figure 4, right). The flaps are then trimmed. advanced into !he anal canal, and sutured to the pedicle with 00 chromicized catgut. This converts the Y-shaped wound into a "T" with the bar of the T in the rectum and the stem formed by the longitudinal edges of the flaps (Figure 5). Dressings.- Milton 1 in 80 swabs are used both to support the base of the flaps and to soak up any serum and blood that might be lost. Pads and dressings are held in place by a T binder.
POSTOPERATIVE REGIME The patient is allowed to remain undisturbed for 36 hours. Dressings are only changed if a bowel action occurs. Analgesia, both oral and parenteral, is given as required. After 36 hours the patient hasa twice-daily bath followed by 1 in 80 Milton lay-on dressings. The patients are encouraged to open fheir bowels early, and aperients are used initially to producea soft stool. Ten rnillilitres of Agarol each night forthe first three nights has been found to be the most effective agent. This is followed by a high residue, hydrophilic aperient such as Norrnacol, 5 ml each
FIGURE 4: (left) a linear "Y" incision as an alternative for very large prolapsed haemorrhoids; (right) the haemorrhoid dissected from the internal sphincter, conserving two triangular flaps of anal mucosa and skin.
118
IS
AUST N.Z. J. SURG.VOL 49 - No 1, FEBRUARY, 1979
ADVANCEMENT FLAP HAEMORRHOIDECTOMY
SAKKER
FIGURE5 A purse-string suture of 00 chrornicized catgut, incorporating the apices of the two skin flaps, is placed around the pedicle This advances the flaps into the anal canal Several Interrupted sutures are placed on each side of the purse-string converting the wound into a "T" shape The stem of the T IS left unsuture
night, to produce a formed action It takes approximately three to four days for the bowels to achieve some order, and the patient is kept in hospital until this is satisfactory, about seven days The patients are subsequently encouraged to supplement their diet with bran AND CONCLUSIONS SUMMARY This operation has been carried out on 132 patients with good results The anal wounds were usually healed at the time of the patients'discharge from hospital The patients were reviewed three weeks after the operation, and about 75% were then ready to return to work The author believes that the advancement flap haemorrhoidectomy follows sound scientific
AUST N.Z. J. SURGVOL 49
-
No 1, FEBRUARY, 1979
principles, utilizes a sophisticated surgical technique, and is an advance on the standard Milligan-Morgan operation. ACKNOWLEDGEMENTS I thank Sir Alan Parks for his teaching and encouragement. I also thank Mr John Colins, Medical Artist, and Mr Reginald Money, of the Photographic Department of Sydney Hospital, for the excellent illustrations. I am particularly appreciative of my secretary, Mrs A. Farrawell, for preparing the manuscript. REFERENCES H. L and GAIRNS, F W . (1960). E r l f . J. Sufg. 47- 585. E. T C , MORGAN, C N , JONES L E and OFFICER, R. (1937), Lancef, 2. 1119 PARKS.A . G. (1956). Brit J. Surg., 63. 337. PETIT, J L (1774). cited by A G Parks THOMPSON, W H F (1975). E r l t J. Sufg.. 62: 642' DUTHIE.
MILLIGAN,
119
