rectal instruments


By • Дек 26th, 2010 • Category: Anus

Fistulectomy with dissection of the sphincter through the internal fistulous opening (Rygick’s method).

Second main operation.

Under local anesthesia (see Fig. 30,1 and 2) or gene­ral anesthesia with azeotropic mixture, a 1 per cent methylene blue solution is injected into the fistulous tract and a vertical incision of perineal skin is made so that its center encircles the fistulous opening. The fis­tulous tract is then grasped with Billroth forceps and dissected off, by means of a sharp scalpel, in the form of strand or cord (Fig. 77,1) (which has a bluish tinge due to the methylene blue), while the assistant draws the wound margins apart first with small retractors and then, as the tissue is being dissected deeper higher and lower of the fistulous tract, with large four-pronged re­tractors.

The fistulous tract is dissected free to a depth of 3—5 cm, almost as far as the rectal wall, taking care not to damage the rectum, and cut off with scissors at its base. The remainder of the tract, which is visible in the depths of the wound as a blue spot, is scraped away with a sharp curved spoon previously filled with iodine tincture. With the wound margins retracted, the surgeon then closes this remaining portion of the fistulous tract with two or three catgut sutures by means of a small curved needle (Fig. 77,2). Next, a posterior sphincteroto-my is performed, through the internal fistulous opening, to a depth of 1 cm in females and 1.2—1.5 cm in males (Fig. 77,3), after which the rectal wound and the large perineal wound are painted with a 2 per cent iodine tin­cture and packed with ointment strips, as previously des­cribed. Opium tincture is given for 8—10 days, and dressings applied after baths. In females the rectal wound should be packed for 5 days. In males, a narrow oint­ment pack may be inserted to the rectum for 8—10 days. In those cases when a large suppurating cavity is found in the course of the fistulous tract (Fig. 78,1), it is scraped off with a sharp spoon until the blue colour­ing (due to the methylene blue) disappears. Deep within the cavity a fistulous tract can be identified leading to­wards the rectum. The wound bottom should be deepened with the scalpel so that the fistulous opening lies on the inner wall of the wound rather than on its floor. This opening is then closed with catgut (Fig. 78,2).

In high-level pelvirectal fistula (see Fig. 72), the fis­tulous tract is dissected free up to the pelvic diaphragm and cut off. The underlying suppurative tract is then wi­dened first with a finger and then with a knife, by dissec­ting the pelvic diaphragm dorsalward.

The high cavity is scraped off with a large sharp spoon filled with iodine fincture. A tract leading towards the rectum may be found in the wound distal to this ca­vity (in most cases in the ischiorectal fossa) (Fig. 79,1), which should be closed with catgut from the wound side (Fig. 79,2). Next, sphincterotomy is performed through the internal fistulous opening (Fig. 79,3).

Operation for excision of fistulous tract with sphincterotomy through the internal fistulous opening (Rygick's method)

Fig. 77 Operation for excision of fistulous tract with sphincterotomy through the internal fistulous opening (Rygick’s method):

1. Excision of the fistulous tract by perineal tissues route.

2. Suturing the remnant of the fistulous tract from the wound side.

3. Dissection of the posterior rectal wall through the internal fistulous opening (posterior sphincterotomy).

Variant of operation performed when a suppurative cavity is present in the course of the fistulous tract

Fig. 78 Variant of operation performed when a suppura­tive cavity is present in the course of the fistulous tract:

1. Opening and curetting a suppurative pocket loca­ted in the fistulous tract.

2. After the wound has been deepened the fistulous remnant is sutured with catgut.

Fig. 79 Variant of operation for pelvirectal fistula:

1. Appearance of a deep wound which penetrates the pelvirectal space, and of the internal fistulous opening in a posterior crypt.

2. Fistulous remnant on the side wall of the wound is sutured with catgut.

3. Posterior sphincterotomy to a depth of 1.2—1.5 cm.

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