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Painless Cure for Piles

WHAT IS FUNDA FOR CURE ?

MASS                 Vascular, Arteries  +Veins Carpora Cavernosa Recti

PROLAPSE          Lax connective tissue
RECURRENCE       Collaterals

SUTURE RECTOPEXY AND HAEMORRHOID VESSEL LIGATION
Procedure
Under saddle block patient was positioned in lithotomy with steep head low position. It helps in reducing piles mass in grade III & IV cases and gravitates the lax tissue up ward. Closed internal lateral sphincterotomy was done for dilatation to increase space & better visualization.. A Sims speculum of medium size was inserted into anal canal and forwarded into the rectum and evaluation of size & sites of piles mass was done. The Sims speculum used to compress and milk the piles mass eventually lax mucosal and submucosal layer is pushed up. A slit self illuminated ano rectosope is preferred. At the distance of 4 Cm. above the dentate line mucosa protruding in to the scope a suture is passed with three o vicryl rapid in to muco muscular level at 6 o clock position. The stitch should not be passed through and through rectal wall. During the time of pulling needle out the stitch is double locked. It is knotted and just not locked.   Next stitch is started 2 mm over lapping to the end of last stitch. The double locking should be continued all along the full circumference of the rectum. One more circle is completed 2 Cm. proximal to the dentate line. The large haemorrhoids should be under run with vicryl rapid. The surgery requires no incision or cutting any where and as suture line is above dentate line which causes nearly no pain. The can be done in II, III and IV grades of the piles.
In all two circumferential suturing of the rectal wall is achieved.
Thromboses prolapsed pile were not included in the series.
Results
  1. Bleeding from the hemorrhoid stops..
  2. Piles mass starts reducing shrinks in 3 to 8 days.
  3. Internal spincterotomy reduces further pain and relaxes sphincter.
  4. Patient can be discharged on same day
  5. No dressings required
  6. No Sitz bath is necessary.
  7. No laxatives are necessary.
  8. Due to small bites or stitches less than 5 mm. causes no constriction of the rectum.
  9. During follow up no stricture of the rectum at site of circumferential sutures was noted.
  10. No stapler or Doppler is necessary.
  11. No costly instruments are needed
  12. No costly disposables are necessary.
  13. No necrosis of the rectal mucosa over the follow up of six months.
  14. The systemic blood supply from anal region continues
  15. The portal blood supply from veins and arterilsation of veis  and arterial supply from superior rectal artery is stopped.
  16. The operation can be used in case of post operative bleeding in open haemorrhoidectomy
Statistics
The series included 102 males and 64 females, average age 47.5 years ranged between 22 to 76 years. The haemorrhoids grading was indicated; grade II—54, grade III- 88 and grade IV – 24in 166 cases. In all cases frequent episodes of bleeding per rectum was noted. In grade II 24, grade III -38 and grade IV-19 cases had itching around the anus. In grade II- 16, grade III- 20 and grade IV – 16 cases were suffering from discharge per rectum.  Sigmoidoscopy revealed no malignancy in 166 cases.
Post operative all patients were discharged after 24 hours. There was no post operative bleeding noted. The haemorrhoid masses were reduced 70% immediately post operatively on table and further reduced in 3 to 8 days. The suture haemorrhoidopexy had minor oozing from some stitches in 11% of cases which was controlled by compression. The Mucosal tear was noted in early 5 cases required no treatment.
Mucosal edaema was present in 6/ 166 cases required no special treatment. Internal spincterotomy relaxed sphincter which allowed introduction of large proctoscope of 3.8 centimeter diameter without automatic mechanical dilatation of the anal sphincters. Only in 16 /166 cases required closed internal sphincterotomy.
The patients were called for follow up after 1.2.4.6.12.24 weeks. After six month in 3 cases haemorrhoid of grade I with out bleeding were noted.  There was no ischaemia or stenosis in the 2 cm. area between the two circumferential suturing lines. No recurrence or no incidence of impairment of continence noted. Post operative minimum pain was present in 12/166 cases. Oral antibiotics and analgesics were given for 3 days.
TRANSANAL SUTURE RECTOPEXY
Method
Under the saddle block / spinal anesthesia, patient was positioned in lithotomy with steep head low position, which helped in reducing piles mass in grade II, III & IV cases & lax mucosal and sub mucosal tissue was replaced up ward at its original position. The closed lateral internal sphincterotomy was done to avoid mechanical dilatation of the anus by proctoscope in the cases where tight sphincter was present. In case of lax sphincter there was no need for sphincterotomy. The anal canal was lubricated generously with lot of anesthetic jelly and massaged. The Sim’s speculum was used to compress and push the piles masses up wards, eventually lax mucosal and sub mucosal layer containing vessels, were replaced up. A self illuminated slit with sliding valve ano-proctosope was used. [Fig no1] The proctoscope with 3.6 centimeter inner diameter helped retracting rectum from all the sides and haemorrhoid masses too. The sliding plate was removed. The dentate line and engorged mucosa was visualized and stretched due to the proctoscope. The replaced lax mucosa and sub mucosa was fixed to the deeper muscles of the rectum by the stitches of 0.5 to 1 cm. length. The stitch was passed through the depth of the mucus- sub mucous and part of muscle, started at 3 o clock position at the 4 cm. distance proximal to the dentate line. For the stitch a 2/o polyglactin on atraumatic 30 m. m. ½ circle needle was used. The precaution was taken that stitch was not passed through and through the rectal wall but only part of the rectal muscles was taken. The first stitch was tied and the next stitch was started 1-2 mm over lapping to the end of first stitch which was double locked.  The double locking was continued for every stitch to avoid purse sting effect. The suturing was continued all along the complete circumference of the rectum at same level. The second circumferential suture line was completed at 2 Cm. level proximal to the dentate line. Minor oozing occurred with few stitches, stopped automatically. In the surgery no incision or cutting was required anywhere in anal mucosa or in perianal region. The both suture lines were above dentate line which caused no pain in the post operative period. The simple procedure was used in II, III and IV grade of the piles.
In short only two circumferential suturing lines were implemented at 2 & 4 cm. proximal to the dentate line in the rectal wall in the procedure.
Thrombosed prolapsed piles were excluded from the series. These trombosed piles were treated after conservative treatment.
Proctoscope
The proctoscope is made up of a uniform metal tube of 3.6 inner and 3.7 cm. outer diameters; along with fibro optic connection. The tube is cut of its 1/8 diameter and sliding flap is prepared opposite to the fibro optic connection. The leading end of the tube is conical and smooth which closes tube, which facilitates the introduction of the proctoscope and prevents faecal matter to enter in the operation field. The slide can be adjusted at any length. The proctoscope has calibered of one centimeter marking all over the inner aspect of the tube. The scope retracts anus and rectum with out exsive dilatation. It is good as operative scope. In other scopes the retraction is not controlled.
Results
The series included 102 males and 64 females, average age was 47.5 years; ranged between 22 to 76 years. The haemorrhoids grading II—54, grade III- 88 and grade IV – 24 were included in the series of 166 cases. In all cases frequent episodes of bleeding per rectum was noted. In grade II 24, grade III -38 and grade IV-19 cases had itching around the anus was present. In grade II- 16, grade III- 20 and grade IV – 16 cases were suffering from discharge per rectum and spoiling under wears. [ Table No.1]  Sigmoidoscopy revealed no malignancy in all cases.
Post operative all patients were discharged after 24 hours, except two cases. There was  post operative minor bleeding noted in 3 cases required no treatment. The haemorrhoid masses were reduced 70% immediately post operatively on table and further reduced in 3 to 7 days. The suture rectopexy for haemorrhoids had minor oozing from some stitches in 11% of cases during operation which was controlled by compression. The small area of the mucosal tear was noted in early 3 cases required no treatment.
Mucosal edema was present in 6/ 166 cases required no special treatment. Internal spincterotomy relaxed sphincter which allowed introduction of large proctoscope of 3.7 centimeter diameter without traumatic mechanical dilatation of the anal sphincters. Only in 11 /166 cases, required closed internal sphincterotomy.
The patients were called for follow up after 1, 2, 4, 6, 12, 24 weeks and later on yearly communicated by post for 2 years.  After six month in 3 cases haemorrhoid of grade I with out bleeding were noted.  There was no ischaemia or stenosis was observed in the 2 cm. area between the two circumferential suturing lines on per rectal and proctoscopy examination. No recurrence haemorrhoids or no incidence of impairment of continence was noted. Post operative minimum pain was present in 12/166 cases. Oral antibiotics and analgesics were given all the patients for 5 days.
The patients were satisfied with the new procedure. There was no special cost for machine or disposibles. Laxitives were continued in constipated patients.
  • Reduction of piles mass
  • Vascular block by  Stitch
  • Fixation of reduced prolapse
REDUCTION OF PILES
S/A, G/A, L/A
Bowel Prepared
Pre op. Antibiotics.
Steep Head low position
Jelly
Massage
Compression
By Fingers
By Speculum
  • Self illuminated
  • Tube of 3.6 Cm.
  • 1/8 circle is cut
  • Sliding flap created
  • Length 11 Cm.
  • Open area for operation
  • Used for sutures
Control of bleeding from stapler & M.M

FIXATION OF MUCOSA & LIGATION OF VESSELS

Material :- 2/0 polyglactic  on 30mm.  ½  Circle     
needle
Stitch length 0.5 -1 Cm. 
First ligated & later on All stitches double locked

 

 

 

 

All around the rectal wall.                                          

2 circum. lines of stitches
1st  2cm. Above dentate line
2nd 4 Cm. above dentate line

 

 

 

Centers            Ladukar Hospital Bramhpuri.
Jeevan Jyot Hospital Thane.
Sanjivani Hospital Virar.
Balaji Hospital Virar.
Shobha Hospital Ambernath.

Design             Meta analysis, Longitudinal
prospective study.

Period              January 2006 --- December 2008

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trans Anal Suture Rectopexy For Piles – Dr. Chivate’s procedure

 

GRADE I Con.,flavanoides, phenols, IRC,Injections 30 - 70 % Rec
GRADE II Injections, IRC, Banding, Cryo 40 - 60 %  Rec.
GRADE III & IV Longo’s 18 - 20 %  Rec.

Morinaga 12 - 40 %  Rec.

Milligan Morgan 15 - 20 %  Rec.

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