Chapter 5. Operative Techniques

Principle

Compression and tamponade of the anal canal in case of acute distal hemorrhage as bridging for stabilization until definitive assessment or procedure is possible (Figure 5–1).

Setting

Where needed, when no immediate access to OR.

Alternatives

Examination and surgical hemostasis in OR.

Indication

Massive hemorrhage (postsurgical, spontaneous hemorrhoidal, or Dieulafoy hemorrhage).

Preparatory Considerations

None.

Surgical Steps

• 1. Patient positioning: any position.
• 2. Insertion of largest available Foley catheter into anal canal.
• 3. Insufflation of balloon with 60 mL of water/saline.
• 4. External traction on catheter to allow balloon to exert pressure on anal canal.
• 5. Placement of external pad pack (gauze, towels) around catheter (external counter pressure).
• 6. Placement of hemostat clamp to catheter (under tension) at level of external packing.

Anatomic Structures at Risk

Anal canal.

Aftercare

Hemodynamic stabilization, monitoring.

Antibiotic coverage as long as balloon in place.

Maximal length of tamponade: 24 hours.

Plan for definitive surgical care.

Complications

Continued bleeding, anal canal necrosis, infection.

Cross-Reference

Bleeding per rectum (Ch. 1)

Liability in colorectal surgery (Ch. 2)

Clinical examination (Ch. 2)

Complications—delayed wound healing (998.3) (Ch. 4)

Hemorrhoid office procedures (banding, sclerosing, infrared coagulation) (Ch. 5)

General perioperative management—anorectal (Ch. 7)

Comorbidities—liver disease (Ch. 7)

Principle

Decompression of perirectal abscess to allow resolution of acute inflammation and pressure (pain!). Management of fistula only of secondary priority: if I&D is performed under general anesthesia, excision of the cryptoglandular origin and definitive fistula procedure may be reasonable, but there is increased risk of creating tracts that are not truly there (inflamed tissue).

Setting

Outpatient, office (or inpatient, bedside/OR procedure in selected cases).

Alternatives

Nonoperative management: generally not indicated except if abscess spontaneously perforated.

Modified Hanley procedure for horseshoe abscess.

Indication

Every perirectal abscess.

Preparatory Considerations

Clinical assessment, ie, pain and local inflammatory signs; do not wait for fluctuance in perirectal area. Neither WBC nor imaging studies are needed (except in very unusual circumstances).

In all patients receiving general anesthesia: at least rigid sigmoidoscopy.