rectal instruments

LIGATURE TECHNIQUE FOR TREATING HIGH-LEVEL FISTULAS


By • Дек 26th, 2010 • Category: Rectum

In cases with a neglected complicated anal fistula, with a dense scar tissue, it may occasionally be found impossible to perform our operation of choice (Fig. 77, p. 83). Instead, we employ the ligature technique, using local or combined inhalation anesthesia. The fistulous tract is dissected free and cut off deep within the wound (Fig. 81.1). The wound cavity and the fistulous remnant are curetted with a spoon, the rectum is dilated with a speculum, and a ligature is passed into the rectum from the wound side (Fig. 83,2) and made to emerge on the outside. Subsequently, this ligature will tighten and cut through the sphincter. It is required that ligature pass just along the coccygeal raphe, and to ensure this, it may sometimes be found necessary to extend the lower angle of the wound by making an additional incision to­ward the midline (Figs 83,3 and 83,4). Ointment packs, dressings and baths are done as usual (see pp. 41 and 83). Opium tincture is given for 7 days. Tightening of the wound is begun under local anesthesia 18—25 days postoperatively (Fig. 83,5). The ligature is tightened sta­ge by stage, until the sphincter is cut through.

We employ the ligature technique only in 5 per cent of operation for fistulas. More than 12 per cent of the patients operated on using this method subsequently ex­hibited weakness of the sphincter. This technique is also employed in cases of a complicated fistula with multiple external openings (from) 3 to 20 or more openings; see Fig. 84,1). In this type of fistula, the internal opening occurs generally in a posterior crypt.

Under inhalation anesthesia, the perineal skin is dis­sected by making 2—3 or more incisions through the ex­ternal fistulous opening, the granulation tissue and pus are removed with a sharp spoon, and a silk ligature is passed by means of a forceps from the lower angle of the wound into the rectal lumen previously dilated with a speculum (Fig. 84,2). An identical maneuvre is carried out from the opposite perineal side (Fig. 84,3). All ex­tensive wounds are packed with Vishnevsky ointment (see p. 41), Opium tincture is given for 6 days, with dressing and baths as usual. On the 25th post-operative day the tightening of the ligature over a rubber tube is started (see Figs 83,4 and 83,5).

Ligature technique

Fig. 83. Ligature technique:

1. Excision of the fistulous tract from peri-neal tis­sues.

2. Passing silk ligature from the wound into the rec­tal lumen.

3. Additional incision along the lower edge of the wound carried up to the coccygeal raphe of the perineum.

4. Appearance of the wound before the ligature is tightened.

5. The ligature has been tightened on a rubber tube laid under it.

Operation in multiple bilateral fistula

Fig. 84. Operation in multiple bilateral fistula.

1. Posterior bilateral anal fistula with multiple exter­nal openings.

2. Passing silk ligature in the rectal lumen follow­ing dissection and curettage of the fistulous tracts.

3. Appearance of the perineum after bilateral dissec­tion of fistulous tracts and passage of the ligature.



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