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Complications of Anorectal Surgery
Complications of Anorectal Surgery NEIL W. SWINTON JOSEPH R. VAN HORNE
MOST patients approach examinations for and the treatment of hemorrhoids and other anorectal pathologic conditions with considerable apprehension. This is understandable because of the pain, embarrassment, disability and frequent postoperative complications that have been so often associated with these troubles in the past. .i \t the clinic a large number of patients are seen with various pathologic conditions of the terminal bowel and are treated with a minimum of discomfort. It is gratifying that these patients are among the most grateful treated by us. It is not necessary that these patients should suffer unduly during treatment of their rectal difficulties and it is the paramount obligation of all surgeons treating them to reassure them and to obtain their confidence before proceeding with examinations and treatment.
PAIN
Patients with anorectal disease will usually have experienced some degree of rectal discomfort. The pain associated with an acute thrombosed hemorrhoid, an anorectal fissure or a perianal abscess can be an agonizing experience. Yet the majority can be adequately examined without undue physical or emotional trauma. The acute thrombosed hemorrhoid can be visualized with gentle retraction of the buttocks, and in most instances this is adequate for a preoperative diagnosis. The majority of acute and chronic fissures can be detected by close scrutiny of the involved area. Some submucosal abscesses cannot be detected on inspection but any localized tenderness or signs of inflammation apparent in the perianal area are usually adequate evidence for the preliminary diagnosis of a surgical condition. Definitive surgery must not be done in these acute conditions until complete diagnostic methods have been performed. The ruthless insertion without anesthesia of a large sized proctoscope through an anal canal in spasm from a chronic fissure borders on the barbaric. When sigmoidoscopic examinations are necessary in acute conditions and prior to definitive treatment, local anesthesia can usually be obtained which 757
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Neil W. Swinton, Joseph R. Van Horne
will allow the passage of the sigmoidoscope without undue discomfort. At the clinic we can obtain local anesthesia for ordinary sigmoidoscopic examination by the topical application of either 5 per cent Xylcaine ointment or a 3 to 5 per cent Metycaine solution. A cotton pledget soaked in the ointment or solution is placed in the anal canal and changed at three to five minute intervals for a total time of twenty to thirty minutes. This will usually produce adequate local anesthesia. For patients who can be hospitalized immediately for definitive treatment sigmoidoscopic examinations need not be done until an adequate local or general anesthetic has been given. A patient submitted to a hemorrhoidectomy, excision of an anal fissure or even the drainage of a perianal abscess should undergo sigmoidoscopic examination at the time of the operation if this has not previously been performed. It has been stated that there may be some danger in performing this examination under general anesthesia but the surgeon who has learned never to pass a sigmoidoscope except under direct vision and with adequate lighting will not have trouble with a. proctoscopic examination under these conditions. . In preventing postoperative pain it should not be necessary to emphasize the avoidance of unnecessary trauma at operation, the excessive crushing of tissues so common in the days of the clamp and cautery type of hemorrhoidectomy, the avoidance of unnecessary or too heavy suture material, or both, and excessive dilatations of the rectum. At the completion of anorectal operations a Vaseline gauze strip soaked with a liberal amount of Diothane ointment is applied over the raw surfaces of the wound. This is used primarily for hemostasis and to eliminate the discomfort in removing the dry gauze dressings. Also, the tight strapping of the buttocks with adhesive over a gauze pack placed over the wound area, immobilizing the buttocks for the first few postoperative hours, is of help in lessening the immediate postoperative discomfort. As anesthesia wears off and with the first twinges of postoperative pain, it is our custom to give a narcotic; usually 16 mg. (>i' grain) of morphine is adequate. As soon as sensation to the area has returned and there is no danger of burns, massive hot wet saline dressings are applied and continued for the first 18 to 24 hours. It is important that these dressings be massive. We use several inches of thickness of wet saline gauze dressings, usually a hot, "vet Turkish towel over the dressings and, if necessary, a piece of rubber sheeting and one or two hot water bottles. Patients should be turned from side to side at one hour intervals during this initial phase, at which time dressings can be reapplied. The anus, perianal skin and external anal sphincter receive their cerebrospinal nerve supply from the inferior hemorrhoidal and pudic nerves which anastomose with the branches of the lower cutaneous femoral nerve in the perineum. This area is one of the most sensitive in
! I
Complications of Anorectal Surgery
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the body. The rectum receives an autonomic nerve supply and is usually sensitive only to distention. If these patients can be kept reasonably comfortable during the first eighteen hours after operation so that the sphincter, levator and perineal muscles do not go into spasm, their postoperative convalescence will be relatively uneventful. If hot packs and adequate sedation are not used in the first postoperative hours, spasm will result which may take several days to eradicate. Spasm in this area results not only in distress to the patient but in ischemia of the tissues, lowered resistance to infection, edema, delayed wound healing and urinary complications. After the first 18 to 24 hours, sitz baths can be substituted for the hot packs. Climbing in and out of the ordinary bathtub may be difficult for elderly patients. In our hospitals, portable, stainless steel, comfortable chairs with a built-in, easily cleaned basin are available; they can be moved from room to room and used by these patients as often as is necessary. Other methods have been used for the control of postoperative pain. Probably the most common has been the instillation of one of the procaine-in-oil preparations into the sphincters at the time of operation. This has been used successfully by some experienced proctologic surgeons, with excellent results. On two occasions in the past we have treated a small series of patients by injecting one of these preparations into the sphincter muscles at the time of operation. There can be no question but that the postoperative discomfort experienced by these patients was minimal but sooner or later in both our series of cases we encountered abscesses. They have not been too serious but they have required drainage, and have added to the patient's morbidity and to the embarrassment of the surgeon. Having treated patients with both methods, we do not believe that the added comfort with the use of the procaine-in-oil preparations rather than the use of moist heat is sufficient to warrant this occasional complication. A variety of other medications, usually applied topically, have been employed by many surgeons during this postoperative period. The majority have for their effectiveness the "caine" element. We have seen so many instances of sensitivity to these drugs and the frequency of this complication has been so emphasized by our dermatologists that we use them in anorectal conditions only as an emergency measure. We do not advocate the continued use of any of the "caine" drugs. BLADDER DYSFUNCTION
Probably the second most common and disabling complication that may follow anorectal surgery is bladder dysfunction. We must admit in all frankness that this postoperative complication is too common and we do not have all the answers to its prevention. The control of postoperative muscle spasm by adequate medication,
760
Neil W. Swinton, Joseph. R. Van Horne
hot packs, and sitz baths is most important in the prevention of bladder dysfunction. The overdistended bladder is the most important single postoperative urinary complication that must be avoided. A bladder distended up to 300 to 400 cc. may require several days of treatment. If this distention becomes 700 to 1000 cc., prolonged treatment will always be necessary before the bladder regains normal tone and function. These patients must be encouraged to empty their bladder immediately before operation. This may be difficult because frequently considerable sedation may be given one to two hours before an operative procedure when caudal or spinal anesthetics are being used. It is paramount that there are not several hours of urinary excretion in the bladder at the time of operation. Our patients are not routinely catheterized after operation and it is frequently difficult to determine the exact time that should elapse before a catheter should be inserted after an anorectal operation. This must be correlated with the fluid intake, the presence or absence of prostatic hypertrophy and other disease that may be apparent. We usually leave orders that such patients be catheterized seven or eight hours after operation although there will be occasions when twelve hours may elapse without difficulty and we have seen an overdistended bladder occur less than six hours following a hemorrhoidectomy. Palpation of the. lower abdomen and a feeling of bladder discomfort are signs that must be carefully evaluated. We do not believe in repeated catheterizations in most cases. If more than one catheterization is necessary before a female patient can void satisfactorily she is placed on inlying catheter drainage for two or three day periods as necessary. Patients with prostatic hypertrophy present a special problem. For this group it is the belief of our urologists that constant inlying catheter drainage should be avoided if possible and catheterizations are repeated with maximal sterile precautions for a longer period than in females. In both groups, however, careful urinary antisepsis must be maintained. We depend upon Gantrisin in doses of 0.5 grams three or four times a day. For the rare cases of prostatitis, more energetic chemotherapy may be required and the assistance of an experienced urologist is of the utmost help in their treatment. With the prevention of early bladder overdistention and perineal spasm, bladder complications should be minimal and late genitourinary complications after anorectal surgery are rare. Emmett and Christol* pointed out that the pudic nerve supplies both the external anal sphincter and the external urethral sphincter which are semivoluntary muscles. They believe that these muscles and their
* Emmett, J. L. and Christel, D. S.: Urinary retention following surgical operation on rectum and sigmoid: treatment by transurethral resection. J.A.M.A. 126: 10771079 (Dec. 23) 1944.
Complications of Anorectal Surgery
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nerve supply are important factors in reflex urinary retention and are more important than the internal urethral sphincter which has its nerve supply through the nervi erigentes made up of the second, third and fourth sacral segments. Therefore, it is apparent that spasm of the external anal sphincter through this pathway is important in producing reflex spasm of the external urethral sphincter and subsequent bladder dysfunction. POSTOPERATIVE HEMORRHAGE
Postoperative hemorrhage following anorectal surgery is uncommon but can be distressing and even serious. It can occur immediately after operation or several days later. The usual hemorrhages following hemorrhoidectomy, the excision of an anal fissure or the more extensive operations for fistulas occur within the immediate postoperative period. They may originate from two sources: from the perianal tissues where an external hemorrhoidal tab has been removed or from the hemorrhoidal pedicle itself, the superior hemorrhoidal vessels. In the case of the former the bleeding is usually minimal but hemorrhage from a primary hemorrhoidal pedicle can be serious and even exsanguinating. When a patient has bleeding immediately after operation the area should first be carefully inspected. Frequently a small pumping vessel will be visualized at the skin edge that can be controlled with adequate local pressure or a single catgut suture. Very light local or Pentothal anesthesia may be, but is not always, indicated. If, however, the source of the bleeding is not obvious from such an inspection an anoscope should be introduced into the anal canal so that adequate visualization of the entire operative site can be obtained. Some type of anesthesia will be necessary for many of these situations. It is almost unknown in our experience to have a postoperative hemorrhage from a primary hemorrhoidal pedicle. This is due to the careful preliminary ligation of the hemorrhoidal pedicle that we have employed routinely for years in the removal of hemorrhoids, and the anchoring of this pedicle to the lower border of the internal sphincter muscle. Distressing hemorrhages, however, have occurred in a few instances following the slough resulting from a hemorrhoidal injection or when adequate hemostasis has not been obtained after the removal of a hypertrophied anal papilla. It is common for such bleeding originating above the sphincters to assume considerable proportions before becoming apparent. Such bleeding requires immediate treatment. Anesthesia should be given, the patient moved to the operating room, a large sized proctoscope with adequate illumination passed its full length, well above the area of bleeding, and the blood that has accumulated in the colon removed with suction. This will allow, when the scope is brought down, adequate visualization of the source of the hemorrhage without the blood clot obscuring the field.
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Neil W. Swinton, Joseph R. Van Horne
In some cases the hemorrhage has stopped spontaneously when the bleeding point is finally visualized. The best method of stopping such a hemorrhage is with local pressure. The application of a cotton swab to the area, continued for several minutes if necessary,' the use of gelfoam or one of the other types of anticoagulant dressings will almost invariably stop bleeding of this type. Fulguration may be required when there is a brisk hemorrhage from the central artery of the pedicle of a polyp after its removal. A ballpoint type of fulgurating unit is not the most satisfactory for hemorrhage of this nature because if it is continued, particularly with much pressure, there is the possibility of perforation of the bowel. The type of fulgurating tip that is ideal for this purpose is a hollow tube with built-in suction, which can be applied to such a pedicle and by means of the suction pressure the polyp pedicle can be drawn away from the bowel wall before the current is applied. There is one other type of hemorrhage that must be considered and, although uncommon, it has on occasion assumed serious. proportions. Ten or twelve days following the fulguration or the snare removal and cauterization of a polyp there may be a slough of the eschar and a delayed or late hemorrhage. It is our policy to explain to patients that this may occur following the treatment of polyps. Ordinarily such a hemorrhage is inconsequential but unless these patients have been warned in advance of the possibility of its occurrence, it may result in anxiety and apprehension. On at least two occasions a serious delayed hemorrhage has occurred at a time when the patients have been a considerable distance from the clinic. Again, if this possibility is recognized, such areas can be reached with a sigmoidoscope and if accumulated blood is removed so that the area can be adequately visualized, continued local pressure will control the bleeding. Only once has it been necessary for us to perform a laparotomy for hemorrhage following the removal of a polyp. STRICTURE OR STENOSIS OF ANAL CANAL
Stricture or stenosis of the anal canal has followed anorectal surgery at the clinic. Almost invariably it has occurred in patients whom we have not been able to keep under observation after operation as long as we would have liked and the complication has resulted from inadequate care and attention during the healing period. Whenever possible, patients who have had operations for hemorrhoids, strictures or fistulas should be kept under observation for a minimum of six weeks. This is frequently difficult for patients who come to us from some distance and many times it is totally impracticaL If the physicians responsible for this postoperative care understand the principles involved and follow them, narrowing and stenosis of the anal canal should not occur. We have never utilized the closed hemorrhoidal techniques to any
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extent. Operative wounds are left open. With techniques of this type the care given these patients during their postoperative period is as important or more so than the technical details of the operation itself. Wounds must be kept clean. Sitz baths are usually adequate for this purpose. Bowel function should be regulated so that there is not the excessive trauma of loose stools nor the difficulties encountered with hard stools or impactions. The wounds must be kept open and skin edges separated at intervals so that they will not heal over and prevent solid granulations developing from the base of these wounds. The purpose of the gentle' insertion of a well lubricated gloved finger into these wounds at three to five day intervals during this postoperative period is not to dilate the rectum but primarily to prevent the bridging over of such wounds, the prevention of excessive scar, narrowing and stricture. It is our custom in the hospital to do the first digital check on these patients on the third postoperative day. It is repeated on the fifth day, at which time the majority will be ready to leave the hospital. We see them again some five days later at the clinic or arrange for a careful follow-up by their home physician. In very recent years we have been impressed with the fact that many of these patients are capable and willing to do these digital checks themselves. These patients are instructed to insert a well lubricated glove or finger cot into the anal canal, after sitting in a sitz bath for five minutes, and gently massage -the anal canal up to the point of tolerance. We explain to them that it is almost impossible to hurt themselves. This may result in the loss of a drop or two of blood but that is necessary in order to prevent excessive scar and contracture of these wounds. That this principle is not appreciated by the profession is demonstrated by the fact that each year we see a large number of patients with postoperative strictures who have had hemorrhoidectomies or operations for other anorectal conditions. So far as the operation of hemorrhoidectomy itself is concerned, the maintenance of intact bridges of tissue between the skin and mucosa, the avoidance of excessive removal of skin and of excessive dilatations are, of course, of the utmost importance in the prevention of postoperative strictures and stenosis. RECURRENT HEMORRHOIDS
The injection of hemorrhoids, which is indicated and justified for patients with small internal hemorrhoids, whose chief complaint is bleeding and not pain or discomfort and in whom the prolapse is not extensive, will give relief to many. As we point out individually to patients with hemorrhoids for whom we elect a series of injections, however, an appreciable percentage will have a recurrence. Injections do not Temove hemorrhoids; the sclerosing solution shrinks them down and the same factors which led to the occurrence of the hemorrhoids in the first
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Neillll . Sunnion, Joseph R. Van Horne
place perhaps are responsible for their recurrence. Approximately 25 to 30 per cent of patients who have injections will require subsequent injections at some time in the future and of this group a small number, perhaps 10 per cent, ultimately will require operation. This latter group probably should have been operated on in the first place and are the result of an error in judgment in the original selection of patients for injection. External hemorrhoids must never be injected and we believe injections are contraindicated in the presence of any degree of infection in the crypts, large papillae, any degree of stenosis or scar, or other anorectal disease. Following the operative treatment of hemorrhoids the necessity for subsequent surgery has, with our technique of hemorrhoidectomy, been almost nonexistent. Principles of the high ligation of the pedicle and the removal of all hemorrhoidal tissue at the time of operation almost insure against any possible recurrence. Occasionally, however, a patient returns several years after hemorrhoidectomy with a complaint of painless rectal bleeding and on endoscopic visualization does exhibit some recurrence, rather high up, of internal hemorrhoids. Almost without exception these hemorrhoids can be managed with a few injections without further trouble. There is one other situation that is occasionally found in the recurrence of hemorrhoids. Many patients submitted to hemorrhoidectomy because of rectal complaints and the finding of obvious hemorrhoids have a shortened anal canal caused by partial or complete loss of the supporting structures of the anal canal. It is not uncommon to examine a patient whose chief complaint is hemorrhoids whose findings indicate large internal and external hemorrhoids but whose basic pathologic condition is a large, bulging rectocele. This is a situation in which, if primary attention is not given to correction of the rectocele and the hemorrhoids alone are treated, recurrences will be common. Such patients should first have a repair of the rectocele and re-establishment of lacerated sphincters and levators before the hemorrhoids are removed. As to whether hemorrhoidectomy should be performed at the same time as a perineal repair is done is a matter best left to the judgment and experience of the operating surgeon. We frequently do both procedures at the same sitting but feel that usually it is best to correct perineal and levator lacerations first. In such cases it is not uncommon to find several months after the perineal repair that the hemorrhoids have practically disappeared and all rectal symptoms have been relieved. One principle of anorectal surgery that is important is that of restoring or not disturbing the length of the anal canal. This is one objection to the so-called plastic amputative type of hemorrhoidectomy with which we had some experience many years ago and, although it is true that the results so far as the removal of all hemorrhoidal tissue and the nonrecurrence of hemorrhoids are good, the frequently resulting shortened
Complications of Anorectal Surgery
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anal canal may cause some moisture, eversion of mucosa and other distressing late sequelae. RECTAL INCONTINENCE AND BOWEL PERFORATION
It should be almost unnecessary to mention rectal incontinence following anorectal surgery, although after extensive operations for fistula, incontinence may result. If the levator sling is left intact in all anorectal operations in cases in which other obvious disease is not present, rectal incontinence will not develop. In women who have borne several children and in whom there is obvious separation of the levator muscles, however, there will be occasions when mild degrees of incontinence may occur even after a routine hemorrhoidectomy. It is in these situations that repair of pelvic lacerations should not only be considered but done before definitive hemorrhoidal surgery. Patients with diarrheas and, most emphatically, patients with chronic ulcerative colitis present special problems that should be carefully evaluated before anorectal surgery is done. We do not believe that elective anorectal surgery is indicated in patients with chronic nonspecific ulcerative colitis. Bowel perforation from the introduction and passage of examining instruments has occurred. The passage of the examining sigmoidoscope only under direct vision, with particular care being given to patients with ulcerative colitis, patients with obstructing cancers or other tumors, patients under anesthesia and elderly patients in whom the supporting structures of the lower bowel have atrophied, should prevent this complication. Brief mention should be made of our attitude on the treatment of rectal incontinence. We do not believe that surgery is always indicated for patients with rectal incontinence with the exception, perhaps, of women in whom pelvic lacerations resulting from childbirth or previous surgery are the cause. There are many such patients who have an associated irritable colon syndrome, perhaps accentuated by their anxiety of the bowel difficulty in whom correction of dietary habits will be adequate to control bowel leakage. One factor that has always seemed to us to be important and frequently neglected is restoration of bowel control by various physiotherapy measures. The restoration of normal tone of the sphincters, transverse perineal and levator muscles which can be accomplished over a period of months by regular muscle exercises designed to strengthen and restore these components is almost invariably gratifying. We have seen patients with very extensive tears of the supporting mechanism of the lower bowel resulting from trauma or very extensive surgery who have been able, over a period of months, to obtain adequate bowel control which at first may have seemed almost impossible.
MOST patients approach examinations for and the treatment of hemorrhoids and other anorectal pathologic conditions with considerable apprehension. This is understandable because of the pain, embarrassment, disability and frequent postoperative complications that have been so often associated with these troubles in the past. .i \t the clinic a large number of patients are seen with various pathologic conditions of the terminal bowel and are treated with a minimum of discomfort. It is gratifying that these patients are among the most grateful treated by us. It is not necessary that these patients should suffer unduly during treatment of their rectal difficulties and it is the paramount obligation of all surgeons treating them to reassure them and to obtain their confidence before proceeding with examinations and treatment.
PAIN
Patients with anorectal disease will usually have experienced some degree of rectal discomfort. The pain associated with an acute thrombosed hemorrhoid, an anorectal fissure or a perianal abscess can be an agonizing experience. Yet the majority can be adequately examined without undue physical or emotional trauma. The acute thrombosed hemorrhoid can be visualized with gentle retraction of the buttocks, and in most instances this is adequate for a preoperative diagnosis. The majority of acute and chronic fissures can be detected by close scrutiny of the involved area. Some submucosal abscesses cannot be detected on inspection but any localized tenderness or signs of inflammation apparent in the perianal area are usually adequate evidence for the preliminary diagnosis of a surgical condition. Definitive surgery must not be done in these acute conditions until complete diagnostic methods have been performed. The ruthless insertion without anesthesia of a large sized proctoscope through an anal canal in spasm from a chronic fissure borders on the barbaric. When sigmoidoscopic examinations are necessary in acute conditions and prior to definitive treatment, local anesthesia can usually be obtained which 757
758
Neil W. Swinton, Joseph R. Van Horne
will allow the passage of the sigmoidoscope without undue discomfort. At the clinic we can obtain local anesthesia for ordinary sigmoidoscopic examination by the topical application of either 5 per cent Xylcaine ointment or a 3 to 5 per cent Metycaine solution. A cotton pledget soaked in the ointment or solution is placed in the anal canal and changed at three to five minute intervals for a total time of twenty to thirty minutes. This will usually produce adequate local anesthesia. For patients who can be hospitalized immediately for definitive treatment sigmoidoscopic examinations need not be done until an adequate local or general anesthetic has been given. A patient submitted to a hemorrhoidectomy, excision of an anal fissure or even the drainage of a perianal abscess should undergo sigmoidoscopic examination at the time of the operation if this has not previously been performed. It has been stated that there may be some danger in performing this examination under general anesthesia but the surgeon who has learned never to pass a sigmoidoscope except under direct vision and with adequate lighting will not have trouble with a. proctoscopic examination under these conditions. . In preventing postoperative pain it should not be necessary to emphasize the avoidance of unnecessary trauma at operation, the excessive crushing of tissues so common in the days of the clamp and cautery type of hemorrhoidectomy, the avoidance of unnecessary or too heavy suture material, or both, and excessive dilatations of the rectum. At the completion of anorectal operations a Vaseline gauze strip soaked with a liberal amount of Diothane ointment is applied over the raw surfaces of the wound. This is used primarily for hemostasis and to eliminate the discomfort in removing the dry gauze dressings. Also, the tight strapping of the buttocks with adhesive over a gauze pack placed over the wound area, immobilizing the buttocks for the first few postoperative hours, is of help in lessening the immediate postoperative discomfort. As anesthesia wears off and with the first twinges of postoperative pain, it is our custom to give a narcotic; usually 16 mg. (>i' grain) of morphine is adequate. As soon as sensation to the area has returned and there is no danger of burns, massive hot wet saline dressings are applied and continued for the first 18 to 24 hours. It is important that these dressings be massive. We use several inches of thickness of wet saline gauze dressings, usually a hot, "vet Turkish towel over the dressings and, if necessary, a piece of rubber sheeting and one or two hot water bottles. Patients should be turned from side to side at one hour intervals during this initial phase, at which time dressings can be reapplied. The anus, perianal skin and external anal sphincter receive their cerebrospinal nerve supply from the inferior hemorrhoidal and pudic nerves which anastomose with the branches of the lower cutaneous femoral nerve in the perineum. This area is one of the most sensitive in
! I
Complications of Anorectal Surgery
759
the body. The rectum receives an autonomic nerve supply and is usually sensitive only to distention. If these patients can be kept reasonably comfortable during the first eighteen hours after operation so that the sphincter, levator and perineal muscles do not go into spasm, their postoperative convalescence will be relatively uneventful. If hot packs and adequate sedation are not used in the first postoperative hours, spasm will result which may take several days to eradicate. Spasm in this area results not only in distress to the patient but in ischemia of the tissues, lowered resistance to infection, edema, delayed wound healing and urinary complications. After the first 18 to 24 hours, sitz baths can be substituted for the hot packs. Climbing in and out of the ordinary bathtub may be difficult for elderly patients. In our hospitals, portable, stainless steel, comfortable chairs with a built-in, easily cleaned basin are available; they can be moved from room to room and used by these patients as often as is necessary. Other methods have been used for the control of postoperative pain. Probably the most common has been the instillation of one of the procaine-in-oil preparations into the sphincters at the time of operation. This has been used successfully by some experienced proctologic surgeons, with excellent results. On two occasions in the past we have treated a small series of patients by injecting one of these preparations into the sphincter muscles at the time of operation. There can be no question but that the postoperative discomfort experienced by these patients was minimal but sooner or later in both our series of cases we encountered abscesses. They have not been too serious but they have required drainage, and have added to the patient's morbidity and to the embarrassment of the surgeon. Having treated patients with both methods, we do not believe that the added comfort with the use of the procaine-in-oil preparations rather than the use of moist heat is sufficient to warrant this occasional complication. A variety of other medications, usually applied topically, have been employed by many surgeons during this postoperative period. The majority have for their effectiveness the "caine" element. We have seen so many instances of sensitivity to these drugs and the frequency of this complication has been so emphasized by our dermatologists that we use them in anorectal conditions only as an emergency measure. We do not advocate the continued use of any of the "caine" drugs. BLADDER DYSFUNCTION
Probably the second most common and disabling complication that may follow anorectal surgery is bladder dysfunction. We must admit in all frankness that this postoperative complication is too common and we do not have all the answers to its prevention. The control of postoperative muscle spasm by adequate medication,
760
Neil W. Swinton, Joseph. R. Van Horne
hot packs, and sitz baths is most important in the prevention of bladder dysfunction. The overdistended bladder is the most important single postoperative urinary complication that must be avoided. A bladder distended up to 300 to 400 cc. may require several days of treatment. If this distention becomes 700 to 1000 cc., prolonged treatment will always be necessary before the bladder regains normal tone and function. These patients must be encouraged to empty their bladder immediately before operation. This may be difficult because frequently considerable sedation may be given one to two hours before an operative procedure when caudal or spinal anesthetics are being used. It is paramount that there are not several hours of urinary excretion in the bladder at the time of operation. Our patients are not routinely catheterized after operation and it is frequently difficult to determine the exact time that should elapse before a catheter should be inserted after an anorectal operation. This must be correlated with the fluid intake, the presence or absence of prostatic hypertrophy and other disease that may be apparent. We usually leave orders that such patients be catheterized seven or eight hours after operation although there will be occasions when twelve hours may elapse without difficulty and we have seen an overdistended bladder occur less than six hours following a hemorrhoidectomy. Palpation of the. lower abdomen and a feeling of bladder discomfort are signs that must be carefully evaluated. We do not believe in repeated catheterizations in most cases. If more than one catheterization is necessary before a female patient can void satisfactorily she is placed on inlying catheter drainage for two or three day periods as necessary. Patients with prostatic hypertrophy present a special problem. For this group it is the belief of our urologists that constant inlying catheter drainage should be avoided if possible and catheterizations are repeated with maximal sterile precautions for a longer period than in females. In both groups, however, careful urinary antisepsis must be maintained. We depend upon Gantrisin in doses of 0.5 grams three or four times a day. For the rare cases of prostatitis, more energetic chemotherapy may be required and the assistance of an experienced urologist is of the utmost help in their treatment. With the prevention of early bladder overdistention and perineal spasm, bladder complications should be minimal and late genitourinary complications after anorectal surgery are rare. Emmett and Christol* pointed out that the pudic nerve supplies both the external anal sphincter and the external urethral sphincter which are semivoluntary muscles. They believe that these muscles and their
* Emmett, J. L. and Christel, D. S.: Urinary retention following surgical operation on rectum and sigmoid: treatment by transurethral resection. J.A.M.A. 126: 10771079 (Dec. 23) 1944.
Complications of Anorectal Surgery
761
nerve supply are important factors in reflex urinary retention and are more important than the internal urethral sphincter which has its nerve supply through the nervi erigentes made up of the second, third and fourth sacral segments. Therefore, it is apparent that spasm of the external anal sphincter through this pathway is important in producing reflex spasm of the external urethral sphincter and subsequent bladder dysfunction. POSTOPERATIVE HEMORRHAGE
Postoperative hemorrhage following anorectal surgery is uncommon but can be distressing and even serious. It can occur immediately after operation or several days later. The usual hemorrhages following hemorrhoidectomy, the excision of an anal fissure or the more extensive operations for fistulas occur within the immediate postoperative period. They may originate from two sources: from the perianal tissues where an external hemorrhoidal tab has been removed or from the hemorrhoidal pedicle itself, the superior hemorrhoidal vessels. In the case of the former the bleeding is usually minimal but hemorrhage from a primary hemorrhoidal pedicle can be serious and even exsanguinating. When a patient has bleeding immediately after operation the area should first be carefully inspected. Frequently a small pumping vessel will be visualized at the skin edge that can be controlled with adequate local pressure or a single catgut suture. Very light local or Pentothal anesthesia may be, but is not always, indicated. If, however, the source of the bleeding is not obvious from such an inspection an anoscope should be introduced into the anal canal so that adequate visualization of the entire operative site can be obtained. Some type of anesthesia will be necessary for many of these situations. It is almost unknown in our experience to have a postoperative hemorrhage from a primary hemorrhoidal pedicle. This is due to the careful preliminary ligation of the hemorrhoidal pedicle that we have employed routinely for years in the removal of hemorrhoids, and the anchoring of this pedicle to the lower border of the internal sphincter muscle. Distressing hemorrhages, however, have occurred in a few instances following the slough resulting from a hemorrhoidal injection or when adequate hemostasis has not been obtained after the removal of a hypertrophied anal papilla. It is common for such bleeding originating above the sphincters to assume considerable proportions before becoming apparent. Such bleeding requires immediate treatment. Anesthesia should be given, the patient moved to the operating room, a large sized proctoscope with adequate illumination passed its full length, well above the area of bleeding, and the blood that has accumulated in the colon removed with suction. This will allow, when the scope is brought down, adequate visualization of the source of the hemorrhage without the blood clot obscuring the field.
762
Neil W. Swinton, Joseph R. Van Horne
In some cases the hemorrhage has stopped spontaneously when the bleeding point is finally visualized. The best method of stopping such a hemorrhage is with local pressure. The application of a cotton swab to the area, continued for several minutes if necessary,' the use of gelfoam or one of the other types of anticoagulant dressings will almost invariably stop bleeding of this type. Fulguration may be required when there is a brisk hemorrhage from the central artery of the pedicle of a polyp after its removal. A ballpoint type of fulgurating unit is not the most satisfactory for hemorrhage of this nature because if it is continued, particularly with much pressure, there is the possibility of perforation of the bowel. The type of fulgurating tip that is ideal for this purpose is a hollow tube with built-in suction, which can be applied to such a pedicle and by means of the suction pressure the polyp pedicle can be drawn away from the bowel wall before the current is applied. There is one other type of hemorrhage that must be considered and, although uncommon, it has on occasion assumed serious. proportions. Ten or twelve days following the fulguration or the snare removal and cauterization of a polyp there may be a slough of the eschar and a delayed or late hemorrhage. It is our policy to explain to patients that this may occur following the treatment of polyps. Ordinarily such a hemorrhage is inconsequential but unless these patients have been warned in advance of the possibility of its occurrence, it may result in anxiety and apprehension. On at least two occasions a serious delayed hemorrhage has occurred at a time when the patients have been a considerable distance from the clinic. Again, if this possibility is recognized, such areas can be reached with a sigmoidoscope and if accumulated blood is removed so that the area can be adequately visualized, continued local pressure will control the bleeding. Only once has it been necessary for us to perform a laparotomy for hemorrhage following the removal of a polyp. STRICTURE OR STENOSIS OF ANAL CANAL
Stricture or stenosis of the anal canal has followed anorectal surgery at the clinic. Almost invariably it has occurred in patients whom we have not been able to keep under observation after operation as long as we would have liked and the complication has resulted from inadequate care and attention during the healing period. Whenever possible, patients who have had operations for hemorrhoids, strictures or fistulas should be kept under observation for a minimum of six weeks. This is frequently difficult for patients who come to us from some distance and many times it is totally impracticaL If the physicians responsible for this postoperative care understand the principles involved and follow them, narrowing and stenosis of the anal canal should not occur. We have never utilized the closed hemorrhoidal techniques to any
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extent. Operative wounds are left open. With techniques of this type the care given these patients during their postoperative period is as important or more so than the technical details of the operation itself. Wounds must be kept clean. Sitz baths are usually adequate for this purpose. Bowel function should be regulated so that there is not the excessive trauma of loose stools nor the difficulties encountered with hard stools or impactions. The wounds must be kept open and skin edges separated at intervals so that they will not heal over and prevent solid granulations developing from the base of these wounds. The purpose of the gentle' insertion of a well lubricated gloved finger into these wounds at three to five day intervals during this postoperative period is not to dilate the rectum but primarily to prevent the bridging over of such wounds, the prevention of excessive scar, narrowing and stricture. It is our custom in the hospital to do the first digital check on these patients on the third postoperative day. It is repeated on the fifth day, at which time the majority will be ready to leave the hospital. We see them again some five days later at the clinic or arrange for a careful follow-up by their home physician. In very recent years we have been impressed with the fact that many of these patients are capable and willing to do these digital checks themselves. These patients are instructed to insert a well lubricated glove or finger cot into the anal canal, after sitting in a sitz bath for five minutes, and gently massage -the anal canal up to the point of tolerance. We explain to them that it is almost impossible to hurt themselves. This may result in the loss of a drop or two of blood but that is necessary in order to prevent excessive scar and contracture of these wounds. That this principle is not appreciated by the profession is demonstrated by the fact that each year we see a large number of patients with postoperative strictures who have had hemorrhoidectomies or operations for other anorectal conditions. So far as the operation of hemorrhoidectomy itself is concerned, the maintenance of intact bridges of tissue between the skin and mucosa, the avoidance of excessive removal of skin and of excessive dilatations are, of course, of the utmost importance in the prevention of postoperative strictures and stenosis. RECURRENT HEMORRHOIDS
The injection of hemorrhoids, which is indicated and justified for patients with small internal hemorrhoids, whose chief complaint is bleeding and not pain or discomfort and in whom the prolapse is not extensive, will give relief to many. As we point out individually to patients with hemorrhoids for whom we elect a series of injections, however, an appreciable percentage will have a recurrence. Injections do not Temove hemorrhoids; the sclerosing solution shrinks them down and the same factors which led to the occurrence of the hemorrhoids in the first
764
Neillll . Sunnion, Joseph R. Van Horne
place perhaps are responsible for their recurrence. Approximately 25 to 30 per cent of patients who have injections will require subsequent injections at some time in the future and of this group a small number, perhaps 10 per cent, ultimately will require operation. This latter group probably should have been operated on in the first place and are the result of an error in judgment in the original selection of patients for injection. External hemorrhoids must never be injected and we believe injections are contraindicated in the presence of any degree of infection in the crypts, large papillae, any degree of stenosis or scar, or other anorectal disease. Following the operative treatment of hemorrhoids the necessity for subsequent surgery has, with our technique of hemorrhoidectomy, been almost nonexistent. Principles of the high ligation of the pedicle and the removal of all hemorrhoidal tissue at the time of operation almost insure against any possible recurrence. Occasionally, however, a patient returns several years after hemorrhoidectomy with a complaint of painless rectal bleeding and on endoscopic visualization does exhibit some recurrence, rather high up, of internal hemorrhoids. Almost without exception these hemorrhoids can be managed with a few injections without further trouble. There is one other situation that is occasionally found in the recurrence of hemorrhoids. Many patients submitted to hemorrhoidectomy because of rectal complaints and the finding of obvious hemorrhoids have a shortened anal canal caused by partial or complete loss of the supporting structures of the anal canal. It is not uncommon to examine a patient whose chief complaint is hemorrhoids whose findings indicate large internal and external hemorrhoids but whose basic pathologic condition is a large, bulging rectocele. This is a situation in which, if primary attention is not given to correction of the rectocele and the hemorrhoids alone are treated, recurrences will be common. Such patients should first have a repair of the rectocele and re-establishment of lacerated sphincters and levators before the hemorrhoids are removed. As to whether hemorrhoidectomy should be performed at the same time as a perineal repair is done is a matter best left to the judgment and experience of the operating surgeon. We frequently do both procedures at the same sitting but feel that usually it is best to correct perineal and levator lacerations first. In such cases it is not uncommon to find several months after the perineal repair that the hemorrhoids have practically disappeared and all rectal symptoms have been relieved. One principle of anorectal surgery that is important is that of restoring or not disturbing the length of the anal canal. This is one objection to the so-called plastic amputative type of hemorrhoidectomy with which we had some experience many years ago and, although it is true that the results so far as the removal of all hemorrhoidal tissue and the nonrecurrence of hemorrhoids are good, the frequently resulting shortened
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anal canal may cause some moisture, eversion of mucosa and other distressing late sequelae. RECTAL INCONTINENCE AND BOWEL PERFORATION
It should be almost unnecessary to mention rectal incontinence following anorectal surgery, although after extensive operations for fistula, incontinence may result. If the levator sling is left intact in all anorectal operations in cases in which other obvious disease is not present, rectal incontinence will not develop. In women who have borne several children and in whom there is obvious separation of the levator muscles, however, there will be occasions when mild degrees of incontinence may occur even after a routine hemorrhoidectomy. It is in these situations that repair of pelvic lacerations should not only be considered but done before definitive hemorrhoidal surgery. Patients with diarrheas and, most emphatically, patients with chronic ulcerative colitis present special problems that should be carefully evaluated before anorectal surgery is done. We do not believe that elective anorectal surgery is indicated in patients with chronic nonspecific ulcerative colitis. Bowel perforation from the introduction and passage of examining instruments has occurred. The passage of the examining sigmoidoscope only under direct vision, with particular care being given to patients with ulcerative colitis, patients with obstructing cancers or other tumors, patients under anesthesia and elderly patients in whom the supporting structures of the lower bowel have atrophied, should prevent this complication. Brief mention should be made of our attitude on the treatment of rectal incontinence. We do not believe that surgery is always indicated for patients with rectal incontinence with the exception, perhaps, of women in whom pelvic lacerations resulting from childbirth or previous surgery are the cause. There are many such patients who have an associated irritable colon syndrome, perhaps accentuated by their anxiety of the bowel difficulty in whom correction of dietary habits will be adequate to control bowel leakage. One factor that has always seemed to us to be important and frequently neglected is restoration of bowel control by various physiotherapy measures. The restoration of normal tone of the sphincters, transverse perineal and levator muscles which can be accomplished over a period of months by regular muscle exercises designed to strengthen and restore these components is almost invariably gratifying. We have seen patients with very extensive tears of the supporting mechanism of the lower bowel resulting from trauma or very extensive surgery who have been able, over a period of months, to obtain adequate bowel control which at first may have seemed almost impossible.