Laser Fissurectomy Sphincterotomy and Rubber Band Ligation of Hemorrhoid
Conference Name: LASER INTERVENTIONS IN PROCTOLOGY AND ENDOVASCULAR SURGERY
Conducted by: Dr. Rajan Modi, Kapadia Hospital, Mumbai
Surgeon(s)/Speaker(s): Dr. Rajan Modi
Surgical Procedure: Colorectal-Piles Surgery
Location: Kapadia Multispeciality Hospital, Mumbai.
Indexsteps
1. ▪ The patient is placed in a steep Trendelenburg position under saddle anesthesia. :
2. ▪ Engorged hemorrhoids are compressed, massaged manually, and reduced in size. :
3. ▪ Deflated hemorrhoids are pushed in by the introduction of proctoscope and repositioned above the dentate line to their original position. :
4. ▪ Suturing is performed through the window within the proctoscope; the repositioned rectal mucosa is fixed to muscles of the rectal wall 2 cm proximal to the dentate line. :
5. ▪ The suturing can be started at any point using 2-0 polyglycolic acid suture, on a round body, 30-mm half-circle needle. :
6. ▪ The first suture tied, is pulled tight to create a tent of the fixed mucosa and muscle. :
7. ▪ Next, suture of the same length is started, overlapping the first suture by few mm. Once the needle is brought out, the suture is locked twice through the loop, the thread pulled, and the knot tightened. :
8. ▪ Similar sutures are continued by double-locking after each suture along the entire circumference of the rectum at the same level. :
9. ▪ The 2 circumferential rows of sutures are placed at 2 and 4 cm proximal to the dentate line. :
10. ▪ Precautions should be taken so that sutures should go through part of the internal sphincter muscle but not beyond it. :
11. ▪ The proctoscope is rotated after completion of suturing in the aperture. :
12. ▪ There should be no skip area between any two sutures, as that may cause a purse-string or plication effect and may lead to bowel obstruction. :
13. ▪ The sutures may cut through and cause bleeding among fragile hemorrhoids. The sutures can be repeated at the same site proximal level. Oozing from needle pricks can be controlled by wet gauze soaked in saline :
pre_post_measures
1. Preoperative investigations : Before the surgical procedure, the following preoperative tests should be conducted- :new:A proctologic examination and diagnosis of hemorrhoids . Sigmoidoscopy for bleeding per rectal will be mandatory. :new:Assessment of the degree of hemorrhoids :new:Patient’s age, symptoms, medical history, physical examination findings, and laboratory test results :new:Recording of the presence of symptoms of bleeding, prolapse, pain, and burning
2. Preoperative measures : Patient should be given clear liquids and 3 doses of lactulose (60 mL) at 4 hourly intervals on the prior day of the procedure. :new:One gram of cefoperazone 1 gram to be administered intravenously before induction
3. Postoperative measures : Some general measures that should be taken to minimize the pain and prevent the recurrence of the hemorrhoids after the surgery- :new:The patient should not consume anything for 4 hours after the piles operation. Later, start with liquids and eat a soft diet. Patient can be discharged after 25 hours if spinal is given. Patient operated under local can be discharged after 4 hours observation. :new:Avoid strenuous activities that include heavy lifting, running, jogging, football, and cycling, etc. for 1-2 weeks after the surgery. :new:The patient should avoid straining for a longer time during their bowel movements. They given mild purgatives for 15 days. :new:Stop eating foods that cause constipation, such as cheese, white bread, dairy products, processed food, etc.
4. Risk : Minor bleeding episodes (1-2 weeks after the surgery) :new:Pain, if inferior suture line is taken inadvertently below the dentate line.
Surgical Instruments
1. Operating proctoscope with obturator and light fountain
2. 2-0 polyglycolic acid suture on 30-mm half-circle round body needle
3. Wet gauze soaked in saline solution
4. Dr. Chivate Proctoscope
5. Conical Fibre for Piles Surgery
6. 14-17 Laser Machine
7. 2 hand piece - Curved and straight handpiece
8. Non-traumatic grasper
9. Suction machine
10. Allis Forcep