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Minor anorectal surgery in the office.

Changing patterns of management options

This short article deals with modern-day selection of cases and procedure-room tactics in the management of benign anorectal diseases. Many conditions can be dealt with in the office, and most of the remainder can be treated on an ambulatory basis. Nevertheless, we need more patient and doctor education to shake off the old traditions.

Range of facilities

Previously, management of benign anal disease involved an office consultation and digital rectal examination. In many countries, (rigid) sigmoidoscopy would have been carried out in an operating room prior to surgical haemorrhoidectomy, fistulectomy, anal dilatation, etc.

Just as 'exploratory laparotomy' has virtually disappeared from the operating list due to the quality of pre-operative diagnostic assessment, so it should be possible to have made a management decision regarding benign anal disease by the time most patients leave the office. Indeed, the majority of patients will have been treated at the conclusion of the consultative process. No longer should (the majority of) haemorrhoids be removed surgically; most simple fistulae can be dealt with by a minor procedure involving a stay of no more than 2 hours; anal dilatation for fissure has been shown to damage the internal sphincter and a simple tailored sphincterotomy is completely amenable to day-patient management. A history of rectal bleeding should not automatically result in a colonoscopy, an examination under anaesthetic or a haemorrhoidectomy.

The office

The examination area should have available a range of proctoscopes, rigid sigmoidoscopes, haemorrhoidal banding, probes, local anaesthetic and instrumentation to allow excision of cutaneous pathology such as perianal haematomas, small skin tags, banding of haemorrhoids, simple haemorrhoidectomy, low fistulotomy, sphincterotomy and excision of anal warts, abscess drainage, etc. Additional lighting in the form of adjustable goose-neck or headlamps is recommended.

A simple diathermy machine and the facilities for instrument sterilisation such as an ultrasonic cleaner and a small autoclave can be accommodated.

An on-site office flexible sigmoidoscope is a very helpful asset, but a decision to acquire this instrument should be made on economic and geographical grounds.

The office is not a sterile environment but involves the use of equipment which has been sterilised to remove transmissible biological material.

Technical aspects

Potentially unsuitable patients are the obese and those with a bleeding risk. The more extensive the surgery, particularly below the dentate line, the greater the likelihood of pain; the more anxious patient will present a greater challenge with regard to the minimisation of postoperative discomfort.

Minor office procedures are carried out with no sedation or local anaesthetic infiltration (haemorrhoid banding) or under local anaesthesia (excision of tags or peri-anal haematomas). More extensive procedures involving anal skin, and particularly the internal sphincter, are optimally performed under local anaesthetic infiltration and intravenous sedation.

Surgical principles

Although anorectal procedures that are suitable for day surgery can be performed without bowel preparation, it is of benefit to provide oral bowel prep or to administer an enema on arrival to reduce the need for early postoperative evacuation and to lessen the chance of impaction following haemorrhoidectomy. If colonoscopy is to be performed, full bowel preparation is necessary.

The majority of day procedures can be performed with the patient sedated in the left lateral position, an assistant elevating the right buttock. Haemostasis should be assured prior to completion of the procedure.

Anaesthesia

Optimal anaesthesia is mandatory. Several techniques can be used: local anaesthesia, local infiltration analgesia with sedation, posterior perineal block, caudal block, epidural anaesthesia or general anaesthesia.

Technique of local anaesthesia

The skin is cleaned and disinfected with an antiseptic solution. The anaesthetic solution is injected subdermally and submucosally around the lesion to be treated, with a continuous motion of the needle or frequent aspiration to prevent intravascular injection. Injection into the muscle may be avoided depending on the depth of the lesion.

Posterior perineal block

Suggested mixture--40 ml lignocaine 0.5%, adrenalin 1:100 000 (0.4 mg), 6 ml bicarbonate 8.4%. After subdermal infiltration at two sites anterior and posterior of the anal ring, the anococcygeal ligament is deeply infiltrated with 5 ml; 8 - 10 ml are injected into both ischioanal spaces while withdrawing the needle to anaesthetise the deep nerve endings. Through the anterior puncture in front of the anus, 5-10 ml solution is then infiltrated subdermally on each side at the level of the anal verge to secure superficial analgesia.

Summary

A simple paradigm shift has brought the management of many benign anorectal disorders within reach of a well-appointed office. However, most surgeons have not yet moved in this direction.

Recommended reading

Neto JAR, ed. New Trends in Coloproctology. Livraria Editora Revinter, 2000. E-book. http://www.proctosite.com/library/ books/livro_jreis_neto/index_new_trends.htm.

Place R, Hyman N, Simmang C, et al. of the Standards Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for ambulatory anorectal surgery. Dis Colon Rectum 2003; 46(5): 573-576.

STEPHEN GROBLER, MB ChB, MMed (Chir)(Cert Gastroenterol) Specialist Surgeon and Gastroenterologist, Universitas Netcare Private Hospital and Part-time Consultant Surgeon, Department of Surgery, Universitas Hospital, Bloemfontein

E-mail: sgrobler@global.co.za
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Title Annotation:More about ... office-based surgery
Author:Grobler, Stephen
Publication:CME: Your SA Journal of CPD
Geographic Code:6SOUT
Date:Sep 1, 2009
Words:844
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