rectal instruments


By • Дек 26th, 2010 • Category: Anus

Epithelized pilonidal sinus occurs in young individu­als in association with a blind tract or small cyst lined with flat skin epithelium found in the subcutaneous tis­sues of the sacral region. In 45—50 per cent of cases, a shaft of thin hair protrudes from the sinus opening (Figs 91,1 and 91,2).

Operative technique. Under local or combined inhala­tion anesthesia and with the patient in the Depage’s po­sition (see Fig. 25,1 and 2) 0.5 to 1.5 ml of 1 per cent methylene blue solution is injected by means of a syringe into the external sinus opening (this opening is invariably situated in the intergluteal fold). An oval incision 7— 10 cm long and 4—6 cm wide is then made to circums­cribe the sinus tract (Fig. 92,1), and the entire skin flap thus marked out is excised together with fat from above downwards up to the coccygeal periosteum which is left intact (Fig. 92,2). Hemostasis is secured by compressing the bottom and walls of the wound with dry gauze. After hemostasis and provided there is no infection the wound is completely closed with vertical mattress sutures so as to prevent formation of dead spaces and not to allow the skin margins of the wound to turn inward. The procedure for applying these sutures is shown in Fig. 92,3; 92,4 and 52,5. The both ends of thick silk threads are made to emerge on one side of the wound, without tying the threads, 4—6 vertical mattress sutures are then pla­ced so as to include the wound bottom, after which the sutures are in turn tied tightly with triple knots, with the assistant approximating the wound edges with the palms of his hands placed on the patient’s buttocks (Fig. 92,6). After all the sutures have been laid, the threads are cut off leaving long tails (3—4 cm), as shown in Fig. 92,7. A firm bandage is then applied to the wound. The patient is put on a diet and given opium tincture for 6 days. The sutures are carefully removed on the eleventh posto­perative day.

Operation lor excision of pilonidat sinus with partial suture. If the possibility of an infectious exacerbation is suspected, the wound, following the excision of a piloni-dal sinus, is sewn at its angles only, by placing 2 or 3 vertical mattress sutures as indicated in Fig. 93. The wound centre is widely packed with Vishnevsky ointment (see p. 40).

The operation for excision of pilonidal sinus with wound packing is performed when infection, fistulous tracts, or supurative pockets are present. As Fig. 94,1 and 94,2 indicate, this operation involves a wide oval excision of the whole pilonidal sinus and dissection and curettage of all suppurative fistulas and pockets. All the resulting wounds are tightly packed with Vishnevsky ointment (see p .42). Three or 4 days after operation, dressing and baths are started.

Operation for gluteal dermoid cysts.

Dermoid cysts which are occasionally encountered in the gluteal skin and which are accompanied with perio­dic suppurations, are excised securing a margin of healthy skin all around the cyst. (Fig. 95).

The wound is closed with catgut either completely or, more frequentlp, with leaving a pack.

Schematic representation of epithelized pilonidal sinus

Operation for pilonidal sinus with complete closure of the wound

Fig, 91 Schematic representation of epithelized pilonidal sinus.

1. Appearance from the outside.

2. Sagittal section of a pilonidal sinus in the poste­rior part of the pelvis.

Fig. 92. Operation for pilonidal sinus with complete clo­sure of the wound.

1. Local anesthesia c-f the skin and subcutaneous fat along the line of the contemplated incision.

2. Excision of an oval tissue flap together with the pilonidal sinus.

3. A vertical mattress suture is passed around the wound circumference and the needle is brought out on the wound bottom to be reinserted it.

4. The skin wound edges are sutured with the right-hand end of thread.

5. Application of a vertical mattress suture; both ends of the thread are brought out on the left side of’the wound. (Schematic).

6. Pressing his fingers and palms against the skin, the assistant approximates the wound margins while tying the vertical mattress suture.

7. After the suture has been tied, the threads are cut off leaving long tails.

Localization of dermoid cysts of the perineal and gluteal region, (Schematic)

Fig. 93 Appearance of partially closed wound following removal of a pilonidal sinus.

Fig. 94 Operation for excision of pilonidal sinus with subsequent packing of the wound:

1. Making a counter-opening on the skin in subsidiary suppurating cavities.

2. A suppurating tract is curetted with a sharp spoon.

Fig. 95 Localization of dermoid cysts of the perineal and gluteal region, (Schematic).

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