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Control of hemorrhage following anorectal surgery
CONTROL
OF HEMORRHAGE FOLLOWING ANORECTAL SURGERY M. E.
ROLENS, M.D.
Springfield,
Illinois due to fauIty operative technic such as insecure Iigation of the pedicIe with hemorrhage from the superior hemorrhoidal vesse1. Secondary postoperative hemorrhages, those occurring on or about the tenth day postoperativeIy, are usuahy due to infection or to hgation of too thick a pedicIe. The fohowing cases wiII ihustrate some of the common causes of postoperative hemorrhage:
ECTAL bIeeding seems ofIittIe importance unti1 we are confronted with a massive postoperative hemorrhage in the earIy hours of the morning. This paper wiII describe a simpIe and effective method of controI of those hemorrhages which constitute a serious emergency. SIight anaI bIeeding and bIoodstained stooIs fohowing surgery wiII not be discussed. Many textbooks pubhshed within the Iast fifteen years dismiss the subject of postoperative hemorrhage in a short paragraph with recommendations to grasp and ligate the bIeeder or to pack the rectum with gauze. Gant’ describes severa methods. One consists of packing the rectum with gauze to which two stirngs have been attached and tying them to an externa pack. In another method gauze is packed into a tent previousIy pIaced in the rectum. Yeomans2 described a simiIar method but spiraIed the cord around the gauze. Gabrie13 describes a pack consisting of a hohow tube around which dry gauze has been wrapped. Buie4 describes a method which wiII be described with minor modifications. Dr. Buie credits this method to Drs. E. C. and F. W. Burrows. Before describing this method Iet us brieffy review the symptoms and causes of postoperative hemorrhage. The symptoms of massive rectaI hemorrhage are the IocaI manifestations plus the cIassica1 symptoms of conceaIed hemorrhage anywhere in the body, i.e., as in genera1 shock, faintness, sweating, pahor, air hunger and a rapid, thready p&e. The IocaI symptoms are an urgent desire to defecate and a serosanguineous discharge from the rectum. The patient usuahy gives a history of a desire to defecate fohowed with the passage of a Iarge amount of bIood and dizziness or syncope. Upon examination the buttocks wiI1 be found soiled with fresh and cIotted bIood. When a recta1 specuhrm is inserted, there wiI1 be a ffow of bIood resembhng a miscarriage. Primary postoperative recta1 hemorrhages, those occurring soon after surgery, are usuahy
R
CASE
REPORTS
F. L., a femaIe aged thirty-three, was operated upon ApriI 21, 1945, for interna and externat hemorrhoids by the suture over cIamp method. She was dismissed from the hospita1 on ApriI 25th after an uneventful recovery. About midnight, ApriI soth, her mother caIIed stating that the patient had fainted whiIe on the toiIet after passing a Iarge amount of bIood. The patient was sent to the hospita1 at once. Recta1 examination reveaIed a thick, greyish stump at the site of the upper poIe of the right posterior hemorrhoid. The stump was bIeeding but showed no evidence of a spurting vesse1. The rectum was packed in the manner to be described Iater. The pack was removed after fifty-two hours. Recovery was uneventfu1. CASE II. W. J. a maIe aged forty-one, was first seen in the offrce on October 20, 1947. He had Iarge interna hemorrhoids which bIed with stooIs and proIapsed upon straining. Surgery was advised but the patient chose injections. The Ieft IateraI hemorrhoid was injected with 6 cc. of 5 per cent phenoI-in-oi1. The same afternoon the patient requested surgery. He entered the hospita1 and was operated upon the folIowing morning, using the dissection and Iigation method. At the time of operation the injected hemorrhoid was inffamed and indurated which made it impossibIe to dissect the hemorrhoid to a narrow pedicle. The patient Ieft the hospita1 on the fourth postoperative day. On October 28th he came to the of&e compIaining of a sense of fuIIness and warmth in the rectum. DigitaI examination reveaIed an indurated mass that was hot to the touch at the site of the stump of the Ieft IateraI hemorrhoid. On the ninth day postoperativeIy the patient entered the hospita1 foIIowing a severe recta1 hemorrhage. Recta1 examination reveaIed that the sIoughing, greyish stump of the Ieft IateraI hemorrhoid was bIeeding CASE
28
I.
American Journal of Surgery
RoIens-Hemorrhage profuseIy. The stump was sutured but the suture cut through the inflamed tissue. The rectum was packed with gauze which was removed after forty-eight hours. Recovery was uneventfu1. This case is cited to caIl attention that injection of the hemorrhoid
FIG. I. A, straight needle; B, gauze z-inch squares; C, heavy Iinen suture.
to the fact creates in-
I 95 I
AnorectaI
Surgery
29
needed: a strong suction apparatus, one bivaIve or medium-sized tubuIar specuIum, a few smaII surgica1 sponges and a recta1 pack. The recta1 pack shouId be made in the folIowing manner: Beginning at one end one-half of an ordinary vagina1 pack is foIded back and forth
pack folded to
duration and inflammatron of the area which contraindicate surgery. Operative procedures shouId be postponed unti1 a11 induration and inflammation has subsided, which is usuaIIy about three weeks. It shouId be reaIized at this point that each case of recta1 hemorrhage, if treated at aI1, shouId be considered serious or potentiaIIy serious. No haIf measures shouId be permitted. It is far better to do too much than too Iittle. A suggested routine is as foIIows: Nurses and house physicians shouId be instructed as to the symptoms. Patients being dismissed from the hospita1 shouId be instructed to report any excessive amount of bIood noticed in the stools. If the physician cannot be reached, the patient shouId return to the hospita1 at once. When hemorrhage is diagnosed, the patient is put to bed and 42 gr. of morphine is given. The physician is notified. The patient is typed for bIood transfusion and is then sent to the dressing room. For treatment the foIlowing equipment is
January,
after
FIG. 2. A, lower recta1 valve; B, internal portion of gauze pack in rectum; c, single strip of gauze in anal canaI; D, external portion of gauze pack against the ana margin.
on itseIf in an accordion-Iike fashion so that it forms a piIe about 2 inches square. This vagina1 pack is made of absorbent gauze 3 yards Iong and I yard wide foIded to make a pack 2 inches wide and 3 yards Iong. SurgicaI suppIy houses suppIy this in 5-yard steriIized packages folded to 435 inches in width. A 3-foot strip of this may be foIded once Iengthwise making a very satisfactory pack. After the gauze has been foIded, a Iarge straight needIe is threaded with a heavy Iinen retention suture about 5 feet Iong. This suture is passed through the pack and then passed
30
RoIens-Hemorrhage
back in the opposite direction, returniqg the suture to the starting point. The Ioose ends are tied together to prevent unthreading of the pack. (Fig. I.) With the preceding equipment at hand the patient is pIaced in the Iithotomy position. At this point it is important to note that if an anesthetic is used it shouId be carried as IightIy as possibIe. An anesthetic is usuaIIy unnecessary. The ana cana is first gently diIated manuaIIy and the specuIum is inserted. Suction is used to cIean the rectum and irrigation with a warm saIine soIution may be used if necessary. If an activeIy bIeeding vesse1 can be seen, it may be sutured; but too much time shouId not be wasted in searching. The surgeon shouId not depend on the Iigation of the bIeeder to contro1 the hemorrhage. Very often the Iigature wiI1 erode through the tissue and a repetition of the hemorrhage wiI1 occur. After the rectum has been cIeaned, the pack is inserted. This is done by threading the pack through the specuIum, pIacing the gauze as far up as possibIe without undue force. When the rectum is fiIIed, the specuIum is removed whiIe the pack is heId in pIace with the forceps. The externa1 part of the pack is then pushed against the ana margin with one hand whiIe the other hand puIIs on the free ends of the suture. When the tension is snug, the suture is tied. This creates a dumbbeII-shaped pack. The inner sphere of the dumbbe exerts a firm pressure on the Iower part of the rectum and the upper part of the ana cana1. The outer sphere exerts firm pressure on the externa1 margin. The handIe of the dumbbe Iies in the ana cana1. Since there is onIy one strip of gauze in the ana cana1, the pack causes very IittIe discomfort. (Fig. 2.) After the pack is in pIace a bIood transfusion is started as soon as possibIe, the amount de-
after AnorectaI Surgery pending on the condition of the patient. A soft diet with Iow residue is aIIowed. MineraI oi1 is given morning and night. Opiates are aIIowed for pain if needed aIthough the discomfort is not as great as that foIIowing anorectal surgery. The pack is removed after forty-eight hours. It is advisabIe to give 46 gr. of morphine one-haIf hour before remova1. The pack wiI1 be found saturated with serum and remova is not as painfu1 as one might expect. If the boweIs have not moved within twenty-four hours after the pack has been removed, an oi1 enema shouId be given foIIowed with a saline enema if necessary. Attention shouId be caIIed to the fact that this method is appIicabIe onIy to those hemorrhages having their origin in the Iower portion of the rectum, i.e., those beIow the Iqwer recta1 vaIve. This pack appIied for hemorrhages above this area wouId act as an ana pIug conceaIing the severity of the bIeeding which couId Iead to fata termination. SUMMARY I.
Attention is caIIed to the potentia1 severity of postoperative anorecta1 hemorrhages. 2. The diagnosis and causes are brieff y noted. 3. A simpIe and effective method of contro1 is described in detai1. 4. Contraindications of the method described is noted. REFERENCES I. GANT, S. G. Diseases of Rectum,
Anus and CoIon, 1923. W. B. pp. 10-21, vol. 2. PhiIadelphia, Saunders Co. 2. YEOMANS, F. ProctoIogy, p. 172, 2nd ed. D. Appleton-century Co. New York, 1936. 3. GABRIEL, W. B. Principles and Practices of Rectal Surgery, pp. 95-6. SpringfieId, III., 1938. CharIes C Thomas Co. 4. BUIE, L. A. PracticaI ProctoIogy, pp. 93-4. PhiIadeIphia, 1937. W. B. Saunders Co.
American Journal of Surgery
OF HEMORRHAGE FOLLOWING ANORECTAL SURGERY M. E.
ROLENS, M.D.
Springfield,
Illinois due to fauIty operative technic such as insecure Iigation of the pedicIe with hemorrhage from the superior hemorrhoidal vesse1. Secondary postoperative hemorrhages, those occurring on or about the tenth day postoperativeIy, are usuahy due to infection or to hgation of too thick a pedicIe. The fohowing cases wiII ihustrate some of the common causes of postoperative hemorrhage:
ECTAL bIeeding seems ofIittIe importance unti1 we are confronted with a massive postoperative hemorrhage in the earIy hours of the morning. This paper wiII describe a simpIe and effective method of controI of those hemorrhages which constitute a serious emergency. SIight anaI bIeeding and bIoodstained stooIs fohowing surgery wiII not be discussed. Many textbooks pubhshed within the Iast fifteen years dismiss the subject of postoperative hemorrhage in a short paragraph with recommendations to grasp and ligate the bIeeder or to pack the rectum with gauze. Gant’ describes severa methods. One consists of packing the rectum with gauze to which two stirngs have been attached and tying them to an externa pack. In another method gauze is packed into a tent previousIy pIaced in the rectum. Yeomans2 described a simiIar method but spiraIed the cord around the gauze. Gabrie13 describes a pack consisting of a hohow tube around which dry gauze has been wrapped. Buie4 describes a method which wiII be described with minor modifications. Dr. Buie credits this method to Drs. E. C. and F. W. Burrows. Before describing this method Iet us brieffy review the symptoms and causes of postoperative hemorrhage. The symptoms of massive rectaI hemorrhage are the IocaI manifestations plus the cIassica1 symptoms of conceaIed hemorrhage anywhere in the body, i.e., as in genera1 shock, faintness, sweating, pahor, air hunger and a rapid, thready p&e. The IocaI symptoms are an urgent desire to defecate and a serosanguineous discharge from the rectum. The patient usuahy gives a history of a desire to defecate fohowed with the passage of a Iarge amount of bIood and dizziness or syncope. Upon examination the buttocks wiI1 be found soiled with fresh and cIotted bIood. When a recta1 specuhrm is inserted, there wiI1 be a ffow of bIood resembhng a miscarriage. Primary postoperative recta1 hemorrhages, those occurring soon after surgery, are usuahy
R
CASE
REPORTS
F. L., a femaIe aged thirty-three, was operated upon ApriI 21, 1945, for interna and externat hemorrhoids by the suture over cIamp method. She was dismissed from the hospita1 on ApriI 25th after an uneventful recovery. About midnight, ApriI soth, her mother caIIed stating that the patient had fainted whiIe on the toiIet after passing a Iarge amount of bIood. The patient was sent to the hospita1 at once. Recta1 examination reveaIed a thick, greyish stump at the site of the upper poIe of the right posterior hemorrhoid. The stump was bIeeding but showed no evidence of a spurting vesse1. The rectum was packed in the manner to be described Iater. The pack was removed after fifty-two hours. Recovery was uneventfu1. CASE II. W. J. a maIe aged forty-one, was first seen in the offrce on October 20, 1947. He had Iarge interna hemorrhoids which bIed with stooIs and proIapsed upon straining. Surgery was advised but the patient chose injections. The Ieft IateraI hemorrhoid was injected with 6 cc. of 5 per cent phenoI-in-oi1. The same afternoon the patient requested surgery. He entered the hospita1 and was operated upon the folIowing morning, using the dissection and Iigation method. At the time of operation the injected hemorrhoid was inffamed and indurated which made it impossibIe to dissect the hemorrhoid to a narrow pedicle. The patient Ieft the hospita1 on the fourth postoperative day. On October 28th he came to the of&e compIaining of a sense of fuIIness and warmth in the rectum. DigitaI examination reveaIed an indurated mass that was hot to the touch at the site of the stump of the Ieft IateraI hemorrhoid. On the ninth day postoperativeIy the patient entered the hospita1 foIIowing a severe recta1 hemorrhage. Recta1 examination reveaIed that the sIoughing, greyish stump of the Ieft IateraI hemorrhoid was bIeeding CASE
28
I.
American Journal of Surgery
RoIens-Hemorrhage profuseIy. The stump was sutured but the suture cut through the inflamed tissue. The rectum was packed with gauze which was removed after forty-eight hours. Recovery was uneventfu1. This case is cited to caIl attention that injection of the hemorrhoid
FIG. I. A, straight needle; B, gauze z-inch squares; C, heavy Iinen suture.
to the fact creates in-
I 95 I
AnorectaI
Surgery
29
needed: a strong suction apparatus, one bivaIve or medium-sized tubuIar specuIum, a few smaII surgica1 sponges and a recta1 pack. The recta1 pack shouId be made in the folIowing manner: Beginning at one end one-half of an ordinary vagina1 pack is foIded back and forth
pack folded to
duration and inflammatron of the area which contraindicate surgery. Operative procedures shouId be postponed unti1 a11 induration and inflammation has subsided, which is usuaIIy about three weeks. It shouId be reaIized at this point that each case of recta1 hemorrhage, if treated at aI1, shouId be considered serious or potentiaIIy serious. No haIf measures shouId be permitted. It is far better to do too much than too Iittle. A suggested routine is as foIIows: Nurses and house physicians shouId be instructed as to the symptoms. Patients being dismissed from the hospita1 shouId be instructed to report any excessive amount of bIood noticed in the stools. If the physician cannot be reached, the patient shouId return to the hospita1 at once. When hemorrhage is diagnosed, the patient is put to bed and 42 gr. of morphine is given. The physician is notified. The patient is typed for bIood transfusion and is then sent to the dressing room. For treatment the foIlowing equipment is
January,
after
FIG. 2. A, lower recta1 valve; B, internal portion of gauze pack in rectum; c, single strip of gauze in anal canaI; D, external portion of gauze pack against the ana margin.
on itseIf in an accordion-Iike fashion so that it forms a piIe about 2 inches square. This vagina1 pack is made of absorbent gauze 3 yards Iong and I yard wide foIded to make a pack 2 inches wide and 3 yards Iong. SurgicaI suppIy houses suppIy this in 5-yard steriIized packages folded to 435 inches in width. A 3-foot strip of this may be foIded once Iengthwise making a very satisfactory pack. After the gauze has been foIded, a Iarge straight needIe is threaded with a heavy Iinen retention suture about 5 feet Iong. This suture is passed through the pack and then passed
30
RoIens-Hemorrhage
back in the opposite direction, returniqg the suture to the starting point. The Ioose ends are tied together to prevent unthreading of the pack. (Fig. I.) With the preceding equipment at hand the patient is pIaced in the Iithotomy position. At this point it is important to note that if an anesthetic is used it shouId be carried as IightIy as possibIe. An anesthetic is usuaIIy unnecessary. The ana cana is first gently diIated manuaIIy and the specuIum is inserted. Suction is used to cIean the rectum and irrigation with a warm saIine soIution may be used if necessary. If an activeIy bIeeding vesse1 can be seen, it may be sutured; but too much time shouId not be wasted in searching. The surgeon shouId not depend on the Iigation of the bIeeder to contro1 the hemorrhage. Very often the Iigature wiI1 erode through the tissue and a repetition of the hemorrhage wiI1 occur. After the rectum has been cIeaned, the pack is inserted. This is done by threading the pack through the specuIum, pIacing the gauze as far up as possibIe without undue force. When the rectum is fiIIed, the specuIum is removed whiIe the pack is heId in pIace with the forceps. The externa1 part of the pack is then pushed against the ana margin with one hand whiIe the other hand puIIs on the free ends of the suture. When the tension is snug, the suture is tied. This creates a dumbbeII-shaped pack. The inner sphere of the dumbbe exerts a firm pressure on the Iower part of the rectum and the upper part of the ana cana1. The outer sphere exerts firm pressure on the externa1 margin. The handIe of the dumbbe Iies in the ana cana1. Since there is onIy one strip of gauze in the ana cana1, the pack causes very IittIe discomfort. (Fig. 2.) After the pack is in pIace a bIood transfusion is started as soon as possibIe, the amount de-
after AnorectaI Surgery pending on the condition of the patient. A soft diet with Iow residue is aIIowed. MineraI oi1 is given morning and night. Opiates are aIIowed for pain if needed aIthough the discomfort is not as great as that foIIowing anorectal surgery. The pack is removed after forty-eight hours. It is advisabIe to give 46 gr. of morphine one-haIf hour before remova1. The pack wiI1 be found saturated with serum and remova is not as painfu1 as one might expect. If the boweIs have not moved within twenty-four hours after the pack has been removed, an oi1 enema shouId be given foIIowed with a saline enema if necessary. Attention shouId be caIIed to the fact that this method is appIicabIe onIy to those hemorrhages having their origin in the Iower portion of the rectum, i.e., those beIow the Iqwer recta1 vaIve. This pack appIied for hemorrhages above this area wouId act as an ana pIug conceaIing the severity of the bIeeding which couId Iead to fata termination. SUMMARY I.
Attention is caIIed to the potentia1 severity of postoperative anorecta1 hemorrhages. 2. The diagnosis and causes are brieff y noted. 3. A simpIe and effective method of contro1 is described in detai1. 4. Contraindications of the method described is noted. REFERENCES I. GANT, S. G. Diseases of Rectum,
Anus and CoIon, 1923. W. B. pp. 10-21, vol. 2. PhiIadelphia, Saunders Co. 2. YEOMANS, F. ProctoIogy, p. 172, 2nd ed. D. Appleton-century Co. New York, 1936. 3. GABRIEL, W. B. Principles and Practices of Rectal Surgery, pp. 95-6. SpringfieId, III., 1938. CharIes C Thomas Co. 4. BUIE, L. A. PracticaI ProctoIogy, pp. 93-4. PhiIadeIphia, 1937. W. B. Saunders Co.
American Journal of Surgery