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HOW I DO IT / HOW I DID IT SURGICAL PROCEDURES |
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HEMORRHOIDECTOMY
OPERATIVE TECHNIQUE § Semiprone jacknife position with a rolled‑up sheet under the hips and a small pillow to support the feet § Apply wide adhesive tape to buttock and attach other end of adhesive strap to operating table § Gently dilate the anal canal so that it admits two fingers § Insert a Hill‑Ferguson retractor § Identify all of the hemorrhoidal masses § Grasp most dependent portion of largest hemorrhoidal mass in a Babcock clamp § Make an elliptical incision in anoderm outlining the distal extremity of the hemorrhoid § Initiate a submucosal dissection to elevate mucosa and anoderm and carry dissection of hemorrhoidal mass down to the internal sphincter muscle § Shell out a mass of dilated veins from underlying aphincter muscles § Draw hemorrhoid away from the sphincter, using blunt dissection, and demonstrate lower border of internal sphincter § Dissect hemorrhoidal mass for a distance of 1cm above dentate line then divide with electrocoagulator § Oversew hemorrhoidal pedicle with a running lock-stitch of chromic 2-0 § Remove any residual internal hemorrhoids from beneath adjacent mucosa § Achieve complete hemostasis § Insert an atraumatic 3‑0 chromic suture into apex of hemorrhoidal defect and close defect with a continuous suture, continuing the suture line until entire defect has been closed § Repeat same dissection and procedure for each of the other hemorrhoidal masses Radical Open Hemorrhoidectomy § Outline incision on both sides of the anus § Elevate skin flap together with underlying hemorrhoids by sharp and blunt dissection until lower border of internal sphincter muscle has been unroofed § Elevate anoderm above and below incision § Mobilize the mass of hemorrhoidal tissue with overlying mucosa to the level of the normal location of the dentate line § Amputate mucosa and hemorrhoids with the electrocoagulator at the level of dentate line, leaving a free edge of rectal mucosa § Suture mucosa to underlying internal sphincter muscle with a continuous 5‑0 atraumatic Vicryl suture § Do not bring the rectal mucosa down to the area that is normally covered by anoderm or skin § Execute same dissection to remove all hemorrhoidal tissue between 1 and 5 o'clock on the right side and reattach the free cut edge of rectal mucosa to the underlying internal sphincter muscle § Do not attempt to remove every last bit of external hemorrhoid § Complete and meticulous hemostasis using electrocoagulator and occasional suture‑ligatures of 3-0 chromic catgut
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