Lasers in Proctology

Foreword
Foreword
Foreword
Foreword
Foreword
Preface
Acknowledgments
Contents
About the Author
1: Lasers in Surgery: From Past to Present
1.1 Introduction
1.2 History of Lasers
1.3 Classification
1.4 Laser Light Characteristics
1.5 Thermal Relaxation Time
1.6 Delivery Systems
1.7 Laser and Tissue Interaction
1.7.1 Photothermal Interactions
1.7.2 Photochemical Interactions
1.7.3 Photodisruption (Photoacoustic) Interactions
1.7.4 Photoablation Interactions
1.7.5 Plasma-Induced Ablation
1.8 Interaction Parameters
1.9 The Optical Fibers: Size, Structure, and Power Density
1.10 Types of Fibers to Be Used in Proctology
1.11 A Comparative Study of the Various Wavelengths of Diode Laser
1.12 Tips Before Use of Lasers
1.13 Laser Safety
1.13.1 Safety Measures While Using Laser Fibers
1.13.2 Precautions
1.14 Laser Versus Cautery
1.15 Your Queries! My Answers!
1.16 Discussion
1.17 Terminology
References
2: Surgical Anatomy of Anal Canal
2.1 Introduction
2.2 Anatomical Relations of Anal Canal
2.3 Urogenital Triangle
2.4 Interior of Anal Canal
2.5 Upper Columnar Zone: Contents
2.5.1 Morgagni Columns
2.5.2 Anal Valves
2.5.3 Anal Crypts and Anal Glands
2.5.4 Dentate Line
2.5.5 Anal Papillae
2.5.6 Anal Cushions
2.5.7 Anal Transitional Zone (ATZ)
2.6 Intermediate Zone
2.7 Lower Cutaneous Zone
2.8 Internal Anal Sphincter (IAS)
2.8.1 Origin and Insertion
2.8.2 Thickness
2.8.3 Importance
2.8.4 Innervation
2.8.5 Blood Supply
2.8.6 Functions
2.8.7 Features
2.9 Conjoined Longitudinal Muscle (CLM)
2.9.1 Thickness
2.9.2 Functions
2.10 EAS (External Anal Sphincter)
2.10.1 Origin and Insertion
2.10.1.1 Subcutaneous Part
2.10.1.2 Superficial Part
2.10.1.3 Deep Part
2.10.2 Thickness
2.10.3 Relations of External Anal Sphincter with Muscles of Perineum
2.10.4 Innervation
2.10.5 Blood Supply
2.10.6 Functions
2.10.7 Features
2.11 Blood Supply to Anal Canal
2.11.1 Arterial Supply
2.11.2 Venous Supply
2.12 Escape Valve Mechanism: A Significant Finding
2.13 Anal Canal Lymphatic Drainage
2.14 Anal Canal Innervation
2.14.1 Above Dentate Line
2.14.2 Below Dentate Line
2.15 Anal Canal Histology
2.16 Pelvic Floor Muscles
2.16.1 Levator Ani
2.16.2 Blood Supply
2.16.3 Innervation
2.16.4 Functions
2.16.5 Features
2.17 Anorectal Ring
2.18 Anorectal Triangle
2.19 Anorectal Angle
2.20 Physiology of Anal Canal and Defecation
References
3: Anal Cushions and Pathophysiology of Hemorrhoids
3.1 Introduction
3.2 Anatomy of Anal Cushions and Hemorrhoids
3.2.1 Nonvascular Component of Anal Cushions
3.2.2 Vascular Component of Hemorrhoids
3.3 Functions of Anal Cushions
3.4 Superior Hemorrhoidal Artery (SHA) and Formation of Corpus Cavernosum Recti (CCR)
3.5 Physiological Significance of Anal Cushions and Their Relation to Defecation
3.6 Pathophysiology of Hemorrhoids
3.6.1 Sliding Anal Cushion Theory
3.6.2 Hypervascularization Theory
3.6.3 Theory of Straining and Constipation
3.7 Correlation Between Anal Tone and Formation of Hemorrhoids
3.8 The Fate of Anal Cushions
3.9 Classification of Hemorrhoids
3.9.1 Internal Hemorrhoids
3.9.2 External Hemorrhoids
3.9.3 Mixed Hemorrhoids
3.10 Rectal Varices and Hemorrhoids
References
4: Clinical Evaluation of Hemorrhoids
4.1 Introduction
4.2 Clinical Features
4.2.1 Bleeding
4.2.2 Prolapse
4.2.3 Thrombosis
4.2.4 Mucus Discharge
4.2.5 Pain
4.2.6 Pruritus Ani
4.2.7 Feeling of Lump
4.3 History for Evaluation of Hemorrhoids
4.4 Physical Examination
4.4.1 Inspection
4.4.2 Palpation
4.4.3 Digital Rectal Examination (DRE)
4.4.4 Proctoscopy
4.4.5 Symptoms, Signs, Examination Findings and Differential Diagnosis at a Glance
4.5 Evaluation and Clinical Correlation of Anorectal Symptoms
4.5.1 Rectal Bleeding
4.5.2 Pain
4.5.3 Perianal/Rectal Mass
4.5.4 Mucus Discharge
4.6 Diagnostic Evaluations
4.6.1 Sigmoidoscopy
4.6.2 Colonoscopy
4.7 Indications and Contraindications of Colonoscopy and Sigmoidoscopy (Tables 4.9 and 4.10)
References
5: Nonsurgical Management of Hemorrhoids
5.1 Introduction
5.2 History
5.3 Nonsurgical Management of Hemorrhoids
5.3.1 Lifestyle and Dietary Modification
5.3.2 Medical Management
5.3.2.1 Role of Flavonoids
5.3.2.2 Topical Treatment of Hemorrhoids
5.3.2.3 Sitz Bath
5.3.3 Ambulatory Treatment (Office Procedures)
5.3.3.1 Infra-Red Coagulation
5.3.3.2 Sclerotherapy
5.3.3.3 Rubber Band Ligation
5.4 A Word About Cryotherapy
5.5 Discussion
5.6 Which Is the Best Office Procedure Out of Sclerotherapy, Infrared Coagulation, and Rubber Band Ligation?
References
6: Hemorrhoidectomy: The Gold Standard
6.1 Introduction
6.2 Historical Background
6.3 Indications of Hemorrhoidectomy
6.4 Principle of Hemorrhoidectomy
6.5 Modifications in Hemorrhoidectomy Over the Years
6.6 Evolution of Hemorrhoidectomy
6.6.1 Excision and High Ligation
6.6.1.1 Technique
6.6.1.2 Pitfalls of Salmon’s Technique
6.6.2 Miles’ Hemorrhoidectomy (Excision with Low Ligation)
6.6.2.1 Pitfalls of the Miles’ Technique
6.6.3 Milligan-Morgan’s Hemorrhoidectomy
6.6.3.1 Technique
6.6.3.2 Pitfalls of Milligan-Morgan Hemorrhoidectomy
6.6.4 Ferguson’s Closed Hemorrhoidectomy
6.6.4.1 Advantages of Ferguson’s Over Milligan Morgan
6.6.5 Whitehead Hemorrhoidectomy
6.6.5.1 Pitfalls of Whitehead Hemorrhoidectomy
6.6.6 Submucosal Hemorrhoidectomy (Park’s Procedure)
6.6.7 Rise and Fall of Lord’s Procedure
6.6.7.1 Principle
6.6.7.2 Indications
6.6.7.3 Technique
6.7 Thermal Devices in Hemorrhoidectomy
6.7.1 Bipolar Diathermy in Hemorrhoidectomy
6.7.1.1 Indication
6.7.1.2 Technique
6.7.1.3 Results
6.7.2 Ligasure in Hemorrhoidectomy
6.7.2.1 Indications
6.7.2.2 Technique
6.7.2.3 Results
6.7.3 Harmonic Scalpel in Hemorrhoidectomy
6.8 Carbon Dioxide Laser Hemorrhoidectomy
6.8.1 Principle
6.8.2 Technique
6.8.3 Advantages
6.9 Radiofrequency Ablation
6.9.1 Principle
6.9.2 Technique
6.9.3 Advantages of Radiofrequency Ablation
6.10 Complications of Excisional Hemorrhoidectomy
6.11 Management of Commonest Complications After Hemorrhoidectomy
6.11.1 Bleeding
6.11.2 Postoperative Pain
6.11.3 Urinary Retention
6.11.4 Local Infection and Sepsis
6.11.5 Anal Tags
6.11.6 Anal Stenosis
6.12 Comparative Study of Hemorrhoidectomy with Minimally Invasive Techniques
6.13 Discussion
References
7: Minimal Invasive Procedures for Hemorrhoids
7.1 Introduction
7.2 Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL)
7.2.1 Principle
7.2.2 Indication
7.2.3 Contraindication
7.2.4 Instrumentation
7.2.5 Technique
7.2.6 Advantages
7.2.7 Results
7.3 Stapled Hemorrhoidopexy (Procedure for Prolapsed Hemorrhoids: PPH)
7.3.1 Principle
7.3.2 Indication
7.3.3 Contraindication
7.3.4 Instrumentation
7.3.5 Technique
7.3.6 Results
7.3.7 Complications
7.4 Comparison of Excisional Hemorrhoidectomy with DGHAL and PPH
7.5 Transanal Suture Rectopexy
7.5.1 Principle
7.5.2 Indications
7.5.3 Technique
7.5.4 Results
7.6 Superior Hemorrhoidal Artery Embolization
7.6.1 Principle
7.6.2 Indications
7.6.3 Technique
7.6.4 Results
7.7 Discussion
References
8: Laser Hemorrhoidoplasty
8.1 Introduction
8.2 Principle of Laser Energy
8.3 Laser Hemorrhoidoplasty
8.3.1 Indications
8.3.2 Contraindications
8.4 Hybrid Procedure: A Combination of Finger-Guided Hemorrhoidal Artery Ligation and Laser Hemorrhoidoplasty (FGHAL with LHP)
8.4.1 Procedure for FGHAL and LHP
8.4.2 Instrument Required (Figs. 8.1 and 8.2) Steps
8.4.3 Finger-Guided Hemorrhoidal Artery Ligation - An Introduction
8.4.3.1 Technique
8.4.4 Laser Hemorrhoidoplasty
8.4.4.1 Energy! Dosage! Fiber! Mode
8.4.4.2 Point of Entry of Fiber
8.4.4.3 The Technique of Laser Hemorrhoidoplasty
8.4.4.4 Postoperative Care
8.5 Hemorrhoids in Patients with Anticoagulants
8.6 Why Recurrence After Surgical Procedures for Hemorrhoids?
8.6.1 Diversion of Blood Flow and Formation of Collaterals
8.6.2 Persistence of the Greater Caliber of the Superior Hemorrhoidal Artery in Hemorrhoidal Disease
8.6.3 Inability to Ligate Posterolateral Branches of SHA
8.7 Recurrence After Laser Hemorrhoidoplasty
8.8 Complications Following FGHAL and LHP: Why and How to Manage?
8.8.1 Hematoma Formation at the Site of HAL
8.8.2 Bleeding at the Point of Entry of Laser Fiber
8.8.3 Pain: VAS Score of 4–5 Within 24 h
8.8.4 Postoperative Edema: (2.34%)
8.8.5 Thrombosis: (0.89%)
8.8.6 Burning and Itching: (10.1%)
8.8.7 Hemorrhage and Abscess: (0.58%)
8.8.8 Skin Tags: (0.2%)
8.9 Your Queries, My Answers!
8.10 Discussion
8.11 Case Presentations
8.12 Bottom Line
References
9: Lasers in External and Complicated Internal Hemorrhoids
9.1 Introduction
9.2 External Hemorrhoids
9.2.1 Thrombosed External Hemorrhoids
9.2.1.1 Pathophysiology of Thrombosed External Hemorrhoids
9.2.1.2 The Pathophysiology of Pain
9.2.1.3 Clinical Evaluation
9.2.1.4 Management of Thrombosed External Hemorrhoids
9.2.1.5 Role of Lasers in Thrombosed External Hemorrhoids
9.2.1.6 Postoperative Care
9.3 Thrombosed Internal Hemorrhoids
9.3.1 Pathophysiology of Thrombosed Internal Hemorrhoids
9.3.2 Management of Thrombosed Internal Hemorrhoids
9.4 Strangulated Internal Hemorrhoids
9.4.1 Pathophysiology of Strangulated Hemorrhoids
9.4.2 Management of Strangulated Hemorrhoids
9.5 Discussion
References
10: Anatomy of Para-Anal and Pararectal Spaces
10.1 Introduction
10.2 Anatomy of Para-Anal and Pararectal Spaces
10.2.1 Ischioanal/Ischiorectal Space
10.2.1.1 Boundaries
10.2.1.2 Contents
10.2.2 Perianal Space
10.2.2.1 Boundaries
10.2.2.2 Contents
10.2.3 Intersphincteric Space
10.2.3.1 Boundaries
10.2.3.2 Contents
10.2.4 Submucosal Space
10.2.4.1 Boundaries
10.2.4.2 Contents
10.2.5 Superficial Postanal Space
10.2.6 Deep Postanal Space
10.2.6.1 Boundaries
10.2.7 Supralevator Space
10.2.7.1 Boundaries
10.2.8 Retrorectal Space
10.2.8.1 Boundaries
10.3 Anal Glands
10.3.1 Location of Anal Glands
10.3.2 The Fate of Anal Glands
10.3.3 Surgical Importance of Anal Glands
10.4 The Relation of Anal Glands with Crohn’s Disease, Ulcerative Colitis, and Carcinoma Rectum
10.5 Importance of Anatomical Landmarks Related to the Conjoined Longitudinal Muscle
10.6 A Word About Milligan’s Septum
10.7 Anococcygeal Ligament and Anococcygeal Raphe
10.8 A Word About Deep Intersphincteric Space
10.8.1 Boundaries
10.8.2 Surgical Relevance of Deep Intersphincteric Space
10.9 A Word About Deep Anterior Anal Space
10.9.1 Surgical Relevance
10.10 A Word About Infralevator Space
10.10.1 Surgical Importance
10.11 Discussion
References
11: Evaluation and Management of Anorectal Abscess
11.1 Introduction
11.2 Epidemiology
11.3 Etiology of Anorectal Abscess
11.4 Pathogenesis of Abscess
11.5 Organisms Responsible for Abscess
11.6 Relation Between Fistulas and Abscess
11.7 Fate of Abscess
11.8 Types of Abscesses
11.9 Pathway of the Spread of an Abscess
11.9.1 Formation of a Horseshoe Abscess and Fistula
11.10 Clinical Evaluation
11.11 Imaging in Anorectal Abscesses
11.12 Perianal Abscess
11.12.1 Differential Diagnosis
11.12.1.1 Diagnosis
11.12.1.2 Managing Perianal Abscess
11.13 Ischiorectal Abscess
11.13.1 Managing Ischiorectal Abscess
11.13.2 How to Identify Communicating Fistula Tract?
11.14 Intersphincteric Abscess
11.14.1 Differential Diagnosis
11.14.2 Managing Intersphincteric Abscess
11.15 Supralevator Abscess
11.15.1 Managing Supralevator Abscess
11.15.2 Principle of Drainage of Supralevator Abscess: A Paradigm Shift
11.16 Deep Postanal Abscess
11.16.1 Managing Deep Postanal Abscess (Hanley’s Technique)
11.16.1.1 Disadvantages of Hanley’s Technique
11.16.2 Modified Hanley’s Technique
11.16.3 Core Tip
11.17 Deep Anterior Anal Space Abscess
11.17.1 Management of Deep Anterior Abscess
11.18 Superficial Postanal Space Abscess
11.19 Horseshoe Abscess
11.19.1 Managing Horseshoe Abscess
11.20 A Word About Retrorectal Abscess
11.20.1 Management
11.21 Whether to Perform Primary Fistulotomy in Patients with Anorectal Abscess!
11.21.1 Absolute Contraindications for Primary Fistulotomy
11.21.2 Tips and Tricks of Doing Primary Fistulotomy
11.22 Complications of Anorectal Abscess
11.23 Postoperative Care
11.24 Case Studies
11.25 Discussion
References
12: Clinical Evaluation and Classification of Anal Fistula
12.1 Introduction
12.2 Symptoms
12.3 History
12.4 Clinical Examination
12.4.1 Inspection
12.4.2 Palpation
12.4.3 Digital Rectal Examination (DRE)
12.4.3.1 The Internal Opening
12.4.3.2 The External Opening
12.4.4 Proctoscopy
12.4.5 Sigmoidoscopy
12.4.6 Fistula Tract Identification
12.5 Goodsall’s Rule and Its Clinical Significance
12.5.1 Exceptions to the Rule
12.6 Classification of Fistula! Why Do We Classify Them?
12.7 Park’s Classification
12.7.1 Intersphincteric Fistula
12.7.1.1 A1: Intersphincteric Fistula with Low Tract
12.7.1.2 A2: Intersphincteric Fistula Having a High Blind Tract
12.7.1.3 A3: Intersphincteric Fistula with a Rectal Opening
12.7.1.4 A4: Intersphincteric Fistula with No Perineal Opening
12.7.1.5 A5: Intersphincteric Fistula with Pelvic Extension
12.7.1.6 A6: Intersphincteric Fistula Secondary to Pelvic Infection
12.7.2 Trans-Sphincteric Fistula
12.7.2.1 B1: Uncomplicated
12.7.2.2 B2: Trans-Sphincteric Fistula Associated with the High Blind Tract
12.7.3 Suprasphincteric Fistula
12.7.4 Extrasphincteric Fistula
12.7.4.1 Extrasphincteric Fistula Resulting from Trans-Sphincteric Fistula
12.7.4.2 Extrasphincteric Fistula Resulting from Trauma
12.7.4.3 Extrasphincteric Fistula Due to Specific Anorectal Diseases
12.7.4.4 Extrasphincteric Fistula as a Consequence of Pelvic Inflammation
12.8 Simple and Complex Fistula
12.8.1 Simple Fistula
12.8.2 Complex Fistula
12.9 Preoperative Evaluation and Imaging in Anal Fistula
12.9.1 Anal Endosonography
12.9.2 Magnetic Resonance Imaging (Fig. 12.14a–c)
12.9.2.1 Indications
12.9.2.2 Advantages
12.9.2.3 Classification of St James’s University Hospital
12.9.2.4 Efficacy Results
12.9.2.5 Can MRI Be Deceptive?
12.10 Differential Diagnosis
12.11 Evaluating Incontinence
12.11.1 Wexner’s Score
References
13: Fistulotomy: Still a Gold Standard!
13.1 Introduction
13.2 Fistulotomy
13.2.1 Principle
13.2.2 Indications
13.2.3 Contraindications
13.3 Management of Intersphincteric Fistula
13.3.1 Simple Intersphincteric Fistula (A1)
13.3.2 Intersphincteric Fistula with High Blind Tract (A2)
13.3.3 Intersphincteric Fistula with an Opening in the Lower Rectum (A3)
13.3.4 High Intersphincteric Fistula Without an External Opening (A4)
13.3.5 High Intersphincteric Fistula with Pelvic Extension (A5)
13.3.6 Intersphincteric Fistula Extending from Pelvic Disease (A6)
13.4 Management of Trans-sphincteric Fistula
13.4.1 B1 Uncomplicated
13.4.2 B2 Complicated
13.5 Management of Suprasphincteric Fistula
13.6 Management of Extrasphincteric Fistula
13.7 Simple Fistulotomy Technique
13.7.1 Advantages of Marsupialization
13.7.2 Results
13.8 Discussion
13.8.1 Intersphincteric Fistula
13.8.2 Trans-sphincteric Fistulas
13.8.3 Suprasphincteric Fistula
13.8.4 Extrasphincteric Fistula
13.9 Points to Ponder
13.10 Core Tips
13.11 Fistulectomy
13.11.1 Indications
13.11.2 Technique
13.11.3 Advantages
13.11.4 Disadvantages
13.12 Fistulotomy Versus Fistulectomy: A Surgeon’s Dilemma!
13.13 Primary Sphincter Repair
13.13.1 Indications
13.13.2 Advantages
13.13.3 Technique
13.13.4 Postoperative Care
13.13.5 Core Tips
13.13.6 Discussion
13.13.7 Core Tips
13.14 Case Studies
References
14: Sphincter-Saving Techniques
14.1 Introduction
14.2 Principle
14.3 Endorectal Advancement Flap
14.3.1 Principle
14.3.2 Indications
14.3.3 Contraindication
14.3.4 Some Aspects of the Surgical Technique
14.3.4.1 Type of Flap
14.3.4.2 Shape of Flap
14.3.4.3 Flap Thickness
14.3.5 Technique
14.3.6 Core Tip
14.3.7 Advantage
14.3.8 Results
14.4 Fibrin Glue
14.4.1 Principle
14.4.2 Mechanism of Action
14.4.3 Indications
14.4.4 Technique
14.4.5 Results
14.4.6 Advantages
14.4.7 Complications with Fibrin Glue
14.5 Fistula Plugs
14.5.1 Principle
14.5.2 Indications
14.5.3 Contraindications
14.5.4 Technique
14.5.5 Core Tips for Fistula Plug Usage
14.5.6 Complications
14.5.7 Results
14.6 Seton
14.6.1 Principle
14.6.2 What All to Include While Placing Seton?
14.6.3 Types of Seton
14.6.4 Loose Setons
14.6.5 Tight Setons
14.6.6 Materials Used for Setons
14.6.7 Indications
14.6.8 Complications
14.6.9 Technique
14.6.10 Seton and Staged Fistulotomy
14.6.11 Snug Seton Technique
14.6.12 Double Seton Technique
14.6.13 Kshar Sutra
14.6.14 Results
14.6.15 Core Tips
14.7 Ligation of Intersphincteric Fistula Tract (LIFT)
14.7.1 Principle
14.7.2 Indication
14.7.3 Technique
14.7.4 Results
14.7.5 Advantages of LIFT
14.7.6 Pitfalls of LIFT
14.7.7 Complications After LIFT
14.8 Video-Assisted Anal Fistula Treatment (VAAFT)
14.8.1 Principle
14.8.2 Indications
14.8.3 Contraindications
14.8.4 Equipment
14.8.5 Technique
14.8.5.1 Operative Phase
14.8.6 Advantages
14.8.7 Results
14.8.8 Pitfalls of VAAFT
14.9 Stem Cells
14.9.1 Principle
14.9.2 Indications
14.9.3 Technique
14.9.4 Results
14.9.5 Core Tip
14.9.5.1 Choosing Stem Cells
14.10 Submucosal Ligation of Fistula Tract (SLOFT)
14.10.1 Principle
14.10.2 Indications
14.10.3 Contraindications
14.10.4 Technique
14.10.5 Results
14.10.6 Comparison with LIFT
14.11 Discussion
References
15: Role of Lasers in Fistula: Fistula Laser Closure (FiLaC)
15.1 Introduction
15.2 Principle
15.3 Indications
15.4 Contraindications
15.5 Technique
15.6 Pitfalls
15.7 Results
15.8 Discussion
15.9 Core Tips
15.10 Your Queries! My Answers!
References
16: Hybrid Procedures-Future of Fistula Surgery!
16.1 Introduction
16.2 Why Hybrid Procedures! Aims and Objectives!
16.3 Indications
16.4 Contraindications
16.5 Hybrid Procedures
16.6 Distal Laser Proximal SLOFT (DLPS)
16.6.1 Principle
16.6.2 Indications
16.6.3 Advantages
16.6.4 Technique
16.6.5 Results
16.6.6 Discussion
16.7 Distal Coring Using FiXcision with Proximal SLOFT (DCPS)
16.7.1 Principle
16.7.2 Indications
16.7.3 Contraindications
16.7.4 FiXcision Instrument
16.7.5 Technique
16.7.6 Pitfalls
16.7.7 Discussion
16.8 Distal Laser with Proximal LIFT (DLPL)
16.8.1 Principle
16.8.2 Technique
16.8.3 Results
16.8.4 Discussion
16.9 VAAFT with LIFT with Laser Ablation of the Distal Tract (VA-LIFT)
16.9.1 Principle
16.9.2 Indications
16.9.3 Technique
16.9.4 Results
16.9.5 Discussion
16.10 Distal Coring with Proximal Fistulotomy and Laser Ablation (DCPF)
16.10.1 Principle
16.10.2 Indications
16.10.3 Technique
16.10.4 Discussion
16.10.4.1 The Difference Between Park’s Procedure and Our Approach
16.10.4.2 Why Do I Prefer Coring of the Distal Fistula Tract?
16.10.5 Results of Histopathology Examination of Fistula Tracts
16.11 Anal Glands: Pathological Insight!
16.11.1 Does Epithelialization of the Tract or Anal Glands Have Any Role in Persistent Fistula!
16.12 How to Select a Hybrid Procedure
16.12.1 What to Do and When to Do It?
16.12.1.1 Intersphincteric Tract
16.12.1.2 Trans-sphincteric Tract
16.12.1.3 Suprasphincteric Fistulas
16.12.1.4 Extrasphincteric Fistula
16.12.1.5 Horseshoe Fistula
16.13 Core Tips While Performing Fistula Surgery
16.14 Your Queries! My Answers!
16.15 Case Presentations
16.16 Conclusion
References
17: Role of Lasers in Pilonidal Sinus
17.1 Introduction
17.2 Epidemiology
17.3 Location
17.4 Risk Factors of Pilonidal Sinus
17.5 Etiology
17.5.1 Bascom Theory
17.5.2 Karydakis Theory
17.5.3 Stelzner Theory
17.6 Pathophysiology
17.7 Histopathology
17.8 The Direction of the Sinus Tract
17.9 Clinical Presentation of the Disease
17.9.1 History
17.9.2 Physical Examination
17.10 Navicular Area
17.11 Classification of Pilonidal Sinus
17.12 Imaging
17.13 Differential Diagnosis
17.14 Management of Pilonidal Sinus Disease
17.14.1 Minimally Invasive Techniques for Pilonidal Sinus: Newer Surgical Modalities
17.15 Video-Assisted Laser Ablation of the Pilonidal Sinus (VALAPS)
17.15.1 Principle
17.15.2 Device for Video-Assisted Endoscopy
17.15.3 Device for Pit Excision
17.15.4 Energy! Dosage! Fiber!
17.15.5 Technique
17.15.6 Postoperative Care
17.15.7 Results of VALAPS
17.15.8 Results of Minimally Invasive Procedures
17.16 Discussion
17.17 Case Presentation
17.17.1 Opinion
17.18 Your Queries, My Answers
References
18: Role of Lasers in Anal Fissures
18.1 Introduction
18.2 Historical Aspect
18.3 Epidemiology
18.4 Etiology of Anal Fissure
18.5 Risk Factors
18.6 Pathophysiology of Anal Fissure
18.7 Types of Anal Fissures
18.8 Classification of Anal Fissures Based on Morphology
18.8.1 Characteristics of Superficial Anal Fissure
18.8.2 Characteristics of Deep Anal Fissure
18.9 Grading of Anal Fissures
18.10 Location of Anal Fissure
18.11 Anatomical Considerations: Why Anal Fissures Are Painful?
18.12 Why Does a Sentinel Pile Form in an Anal Fissure?
18.13 Clinical Evaluation of Anal Fissure
18.13.1 History
18.13.2 Physical Examination
18.13.3 Inspection
18.13.4 Palpation
18.13.5 Digital Rectal Examination (DRE)
18.13.6 Proctoscopy
18.14 Role of Anal Manometry in the Diagnosis of Anal Fissure
18.15 Differential Diagnosis of Anal Fissure
18.16 Complications of Anal Fissure
18.17 Why Is an Anal Fissure Described as an Ischemic Ulcer?
18.18 Management of Anal Fissures
18.18.1 Dietary Modification
18.18.2 Sitz Bath
18.18.3 Medical Management
18.18.3.1 Laxatives
Mechanism of Action of Laxatives
18.18.3.2 Topical Agents and Their Mechanism of Action
18.18.3.3 Botulinum Toxin (Botox)
18.18.4 Surgical Management
18.18.4.1 Anal Dilatation
18.18.4.2 Fissurectomy
18.18.4.3 Lateral Internal Sphincterotomy
Open Lateral Internal Sphincterotomy
Closed Lateral Internal Sphincterotomy (CLIS)
18.18.4.4 Advancement Flap (Anoplasty)
18.19 Laser Lateral Internal Sphincterotomy
18.20 How Much Sphincter Should Be Divided?
18.21 Why Should Posterior Sphincterotomy Not Be Done?
18.22 Results of Closed Versus Open Lateral Internal Sphincterotomy
18.23 Anal Fissure in Crohn’s Disease
18.23.1 Management
18.24 Management of Anal Fissure in HIV
18.25 A Word About Relapsing and Refractory Fissures
18.26 Discussion
18.27 Case Presentation
18.27.1 Opinion
18.28 Your Query, My Answer
References
19: Postoperative Management of Anorectal Wounds
19.1 Introduction
19.2 Aims and Objectives
19.3 Why Is Wound Care Necessary After Anorectal Surgeries?
19.4 Healing Phases of Wound
19.5 Postoperative Wound Care After Anorectal Surgery
19.5.1 Ice Packs
19.5.1.1 The Principle Behind Using Ice Finger
19.5.2 Sitz Bath
19.5.3 Topical Ointments After Surgery
19.5.3.1 A Combination of Metronidazole, Sucralfate, and Lidocaine
Mechanism of Action
Metronidazole
Mechanism of Action
Sucralfate
Mechanism of Action
Lidocaine
Mechanism of Action
Commonest Uses
19.5.3.2 Calcium Dobesilate for Local Application in Hemorrhoids
Mechanism of Action
19.5.3.3 A Combination of Lidocaine and Nifedipine and Diltiazem
Mechanism of Action
Commonest Uses
19.5.4 Use of Laxatives
19.5.4.1 Mechanism of Action of Bulk-Forming Laxatives
19.5.4.2 Mechanism of Action of Osmotic Agents
19.6 Wound Cleaning
19.6.1 The Best Cleansing Agent: Povidone-Iodine or Water!
19.6.2 Cleaning of the Wound After Fistula and Fissure Surgery
19.6.3 Cleaning of Wounds After Pilonidal Sinus
19.7 Special Dressings for Anal Fistula and Pilonidal Sinus Wounds
19.7.1 Hemoglobin Spray
19.7.1.1 Mechanism of Action
19.7.2 Dried Amnion Chorion Granules with PHMB
19.7.2.1 Mechanism of Action
19.7.3 Use of Silver Dressings for Pilonidal Sinus
19.7.3.1 Mechanism of Action
19.8 Discussion
References
Hemorrhoids
Fistula in Ano
Pilonidal Sinus
Fissure in Ano