In cases where cutting with a string is contra-indicated by the fear of haemorrhage; as in a fistula running high up the bowel where haemorrhage may be serious; or where the patient refuses to submit to a cutting operation. Of all methods, using a string is best but only a substitute for the knife. Incision for fistula can be facilitated by emptying bowels thoroughly on previous day and ensuring no diarrhoea is excited. Ether should be given if track is deep or complex. Position varies between side or back; women often prefer side position. A director with probe point should be passed through external orifice into bowel, brought out at anus by index finger of other hand. Track must be explored thoroughly before cutting. In simple cases, a knife resembling those from 14th and 15th centuries can be used for speedy and less painful operation without ether. For deep fistulas, heavy steel director may snap; wooden gorget guards opposite side of rectum after knife passes through. Some debate exists on necessity to divide track running along bowel above internal orifice. Hemorrhage risk increases but leaving sinus uncut may lead to unsuccessful outcome. If no internal opening found but probe can be felt by finger in rectum, force an internal opening and treat as complete fistula. In cases of horse-shoe fistula with two external and one internal orifice, operate on one side only and dilate opposite side for free pus escape. Many tracks may run under skin of buttock or toward scrotum; these can be induced to heal by laying open without interfering sphincters. If multiple operations are needed, focus on primary tracks first. Hemorrhage in fistula operation is usually controlled with lint packing and pressure. Blind internal fistulas require incision into bowel guided by silver director bent as hook. Abscesses of superior pelvi-rectal space may result in deep fistulas not to be operated upon but external free incisions can drain abscess cavity. External hemorrhoids originate from subcutaneous veins around anus; internal from rectum and may appear externally due to straining or lax sphincter condition. Internal hemorrhoids are varicosities of middle or internal hemorrhoidal veins part of visceral venous system.
Key Takeaways
- Incision for fistulas should be preceded by thorough bowel emptying and ether anesthesia if track is complex.
- Hemorrhoids are varicosities of rectal or anal vessels, divided into external and internal based on their origin and characteristics.
- Deep fistula tracks require heavy steel directors to prevent snapping during operation.
Practical Tips
- Ensure thorough bowel emptying the day before surgery for better exploration and less risk of complications.
- Use a wooden gorget to protect opposite side of rectum when making deep incisions with a knife.
- For external hemorrhoids, manage them through palliative treatments like injections or caustic applications.
Warnings & Risks
- Deep fistulas may break instruments if not handled carefully; use heavy steel directors and be prepared for potential snapping.
- Failing to properly explore the extent of a fistula can lead to incomplete treatment and recurrence of symptoms.
- Blind internal fistulas require careful incision into bowel guided by a director, otherwise they cannot be effectively treated.
Modern Application
While surgical techniques have advanced significantly since this chapter was written, understanding historical methods provides valuable insights into the anatomy and pathology of rectal diseases. Modern readers can apply principles like thorough pre-operative preparation and careful exploration to improve outcomes in less invasive treatments.
Frequently Asked Questions
Q: What is recommended for bowel emptying before fistula surgery?
The chapter recommends thoroughly emptying the bowels on the previous day to ensure better exploration during surgery.
Q: Why might a wooden gorget be used in deep incision operations?
A wooden gorget is recommended to protect the opposite side of the rectum when making deep incisions with a knife, preventing injury and ensuring proper drainage.
Q: What are the differences between external and internal hemorrhoids?
External hemorrhoids originate from subcutaneous veins around the anus and do not come from the rectum. Internal hemorrhoids start within the rectum and may appear externally due to straining or a lax sphincter condition.
Q: What is the significance of dividing tracks running along the bowel above internal orifice?
Dividing such tracks can be necessary for complete treatment, though it increases risk of hemorrhage. Leaving them uncut may result in unsuccessful outcomes and recurrence of symptoms.