rectal instruments

OPERATIONS FOR ACUTE ANORECTAL ABSCESSES


By • Дек 26th, 2010 • Category: Anus

A patient with an acute anorectal abscess must be operated on within a few hours after the establishement of diagnosis. Anorectal abscesses are usually located in the perirectal or perianal fatty tissues and may be clas­sified, according to their site of origin, into the following four types (Fig. 57, 1, 2 and 3, and Fig. 58): (I) subcu­taneous (perianal), in 50 per cent of patients (3): (2) is-chiorectal, in 40 per cent (2); (3) pelvirectal, in 8 per cent (1); and (4) retrorectal, in 2 per cent of patients (Fig. 58). In anorectal abscess, the internal opening, (portal of infection) is invariably located in the rectal lumen. (Fig. 59, 60). In 55 per cent of cases, it is loca­lized in a posterior crypt of Morgagni, in 35 per cent in an anterior crypt, and only in 10 per cent in a lateral crypt.

If the internal opening is left open an anal fistula will be formed. If it is closed with a weak drawn-in scar the abscess tends to recur. For that reason, the surgeon must not only lay the abscess open but also obliterate its internal opening.

OPERATIVE TECHNIQUE

The operation for opening an abscess into the rectal lumen (A. N. Rygick and A. G. Bobrowa’s method) is resorted to only in cases with a perianal (subcutaneous) abscess. It is performed under local or general anesthesia with nitrous oxide and oxygen.

A semilunal incision is made over the abscess site (Fig. 61, 1) and the abscess cavity is opened and explo­red with a finger. A grooved director is then passed into that part of the abscess which extends downwards under the skin toward the rectal lumen (Fig. 61.2). Next, a rec­tal speculum is introduced into the rectum, and its blades are drawn apart to expose the anal canal wall which is elevated with the end of the director (Fig. 61.3). A li­near incision is now made over the director through the skin and mucosa of the anal canal, a triangle-shaped flap (Fig. 61.4) of peiianal skin is excised along with anal mucesa, and at least two crypts of Morgagni removed. Final appearance of the wound is shown in Fig. 61.5. Ointment packs are applied t” the wound in the usual manner: dressings are performed 3 days and 5 days after the operation and each day thereafter, following, a bath. Opium tincture and low-residue diet should be given to the patient for 5 days postoperatively.

Schematic representation of a perirectal abscess with its internal opening in a posterior crypt

Fig. 57 Diagram to show the disposition of acute ano­rectal abscesses.

Fig, 58 Diagram to show the location of a retrorectal abscess.

Fig. 59 Schematic representation of a perirectal abscess with its internal opening in a posterior crypt.

Fig. 60 Schematic representation of a perirectal abscess with its internal opening in an anterior crypt.

proctology_61

Fig. 61. The steps in the operation for laying open peri-anal abscess into the rectal lumen:

1. Semilunar incision is made over the abscess site.

2. Grooved director is introduced intfi the rectal lu­men.

3. Rectal lumen is enlarged with rectal speculum.

4. Perianal skin and anal mucosa are dissected.

5. Final appearance of wound after the abscess has been opened into the rectal lumen.



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