Chapter 26. Benign Anorectal Procedures

Hemorrhoidectomy

• Internal hemorrhoids: grade III and IV hemorrhoids, symptomatic combined internal and external hemorrhoids, bleeding, incarceration, or failure of conservative management.
• External hemorrhoids: acute thrombosis < 72 hours post-onset.

Pilonidal Cyst Excision and Marsupialization

• Recurrent acute pilonidal infections.
• Chronic pilonidal sinus.

Anorectal Abscess and Fistula

• Acute perirectal abscess.
• Anorectal fistula.

Hemorrhoidectomy

Absolute

• Anorectal Crohn's disease or Crohn's proctitis.
• Acquired immunodeficiency syndrome.

Relative

• Portal hypertension.
• Pregnancy.
• Coagulopathy.

Pilonidal Cyst Excision and Marsupialization

• The presence of cancer requires additional treatment.

Anorectal Abscess and Fistula

• Multiple fistulous tracts in a patient with Crohn's disease may require additional studies of the colon and sphincter mechanism prior to definitive surgical treatment.

Hemorrhoidectomy

• The patient should be in the prone jackknife position with buttocks taped aside.
• The procedure is performed under general anesthesia or intravenous sedation with local anesthesia.
• Left anterolateral positioning and local anesthesia are suggested for pregnant patients.

Pilonidal Cyst Excision and Marsupialization

• The patient should be in the prone jackknife position; lateral decubitus position may also be used.
• The procedure may be performed under general anesthesia or local anesthesia with intravenous sedation.

Anorectal Abscess and Fistula

• The patient should be in the prone jackknife position with buttocks taped aside.
• The procedure is performed under general anesthesia, regional anesthesia, or intravenous sedation with local anesthesia.

Hemorrhoidectomy

• Postoperative care includes analgesia, stool softeners, fiber supplementation, and sitz baths.

Pilonidal Cyst Excision and Marsupialization

• Wound care includes daily showers or sitz baths, cleansing of wound, and removal of all hair within 3–4 cm of wound edges. The wound should be packed wet-to-dry with normal saline twice daily.

Anorectal Abscess and Fistula

• Antibiotics are generally not indicted in healthy patients with a simple abscess. Antibiotics should be given for abscesses in patients with immunosuppression, diabetes, valvular heart disease or prosthetic valves, extensive soft tissue cellulitis, and signs of systemic infection or sepsis.
• Wound care includes sitz baths twice daily and after bowel movements. Following abscess drainage, the cavity is lightly packed with a gauze tape.
• Patients should receive adequate analgesia and stool softeners.

Hemorrhoidectomy

Early

• Pain.
• Urinary retention.
• Bleeding.
• Infection.
• Fecal impaction.

Late

• Anal stricture.
• Anal tags.
• Incontinence.
• Mucosal prolapse.
• Ectropion.

Pilonidal Cyst Excision and Marsupialization

• Recurrent pilonidal sinus ...