Page 443 - TNFlipTest

Toronto Notes 2019 Anorectum
• surgery
■ fistulotomy: unroof tract from external to internal opening, allow drainage, heals by secondary
intention
■ low lying fistula (does not involve external sphincter) → primary fistulotomy
■ high lying fistula (involves external sphincter) → staged fistulotomy with Seton suture placed
through tract
◆ promotes drainage
◆ promotes fibrosis and decreases incidence of incontinence ◆ delineates anatomy
◆ usually done to spare muscle
■ alternative for high lying fistula → ligation of intersphicteric fistula tract (LIFT) procedure ◆ access fistula between sphincter muscles, sparring them
Post-Operative
• sitzbaths,irrigation,andpackingtoensurehealingproceedsfrominsidetooutside
Complications
• recurrence
• rarelyfecalincontinence
Pilonidal Disease
Definition
• pilo=hair,nidal=nest;cystorabscessnearorontheinterglutealcleftofthesacrococcygealarea containing hair and skin debris
Epidemiology
• occursmostfrequentlyinyoungmenage15-35yr;rarein>50yr
Etiology
• obstructionofthehairfolliclesinthisarea→formationofcysts,sinuses,orabscesses
• associatedwithoccupationsthatrequireprolongedsitting,obesity,andhighamountsofbodyhair
Clinical Features
• asymptomaticorchronicallyitchyuntilacutelyinfected,thenpain/tenderness,purulentdischarge,and increased moisture near the tailbone
Treatment
• acuteabscess
■ I&D (often performed by primary care doctors) ■ wound packed open
■ 40% develop chronic pilonidal sinuses
• surgery
■ indication: failure of healing after I&D, recurrent disease, or complex disease
■ pilonidal cystotomy: excision of sinus tract and cyst; wound closed by secondary intention, primary
closure with tissue flap, or marsupialization (cyst edge sewn to surrounding tissue to leave sinus tract open)
Rectal Prolapse
Definition
• protrusionofsomeorallofrectalmucosathroughexternalanalsphincter
Epidemiology
• extremesofages:<5yrand>50yr • 85%women
Etiology
• lengthenedattachmentofrectumsecondarytoconstantstraining • 2types
1. false/partial/mucosal: protrusion of mucosa only, radial furrows at junction with anal skin; most common type of rectal prolapse in childhood
2. true/complete (most common): full thickness extrusion of rectal wall, concentric folds in: ◆ first degree: prolapse includes mucocutaneous junction
◆ second degree: without involvement of mucocutaneous junction
◆ third degree (internal intussusception): prolapse is internal, concealed, or occult
Risk Factors
• gynecologicalsurgery
• chronicneurologic/psychiatricdisordersaffectingmotility
Fistula tract
Seton
Drainage © Agnes Chan 2013
General Surgery and Thoracic Surgery GS41 Rectum
Internal sphincter
External sphincter
Anus
Figure22.Fistulotomy
True rectal prolapse
External hemorrhoids
Figure 23. Rectal prolapse (true vs. false)
© Katie McCormack