If a patient has second degree piles, you have a choice of two procedures: (1) Lord's anal stretch, and (2) excision and ligation. Piles are probably the result of an unduly tight anal sphincter, which may be associated with bands of rigid tissue in his anus. Lord's operation dilates his sphincter and breaks these bands. The indications for it, and for those tying and excising piles are important, and are given below, so follow them with the greatest care. They include the readiness of his piles to prolapse, his age, and the tightness of his anal sphincter. Lord's operation is one of the simplest in surgery. Anaesthetize him, put your fingers into his anus, gradually stretch it, and his piles will be cured. He need only be in hospital for a few hours, so that you can treat him as an outpatient. Tying and excising his piles will keep him in hospital for up to ten days.
Fig. 22-10 LORD'S ANAL STRETCH[md]TWO. A, identifying the constriction. B, the direction of dilatation. Pull laterally and avoid the weak 12 and 6 o'clock positions. After Peter Lord in Rob C and Smith R, ''Operative Surgery: Part 1: Abdomen, Rectum and anus; (2nd edn 1969), (Butterworth) with kind the permission of Hugh Dudley.
LORD'S ANAL DILATATION INDICATIONS. (1)Piles which prolapse when a patient defecates, after which they either return spontaneously, or he has to push them back. The operation is particularly likely to be successful if he is under 50, and has a tight sphincter, and a history of painful defecation. (2) Acutely prolapsed and strangulated piles. (3) First or second degree piles which are bleeding heavily, especially if he has a tight sphincter. (4) Anal fissure, including an associated anal tag. (5) Constipation caused by a tight anal sphincter. (6) Always dilate his anus after you have have done a colostomy for obstruction, or a resection and anastomosis.
CONTRAINDICATIONS. (1) Piles which prolapse when he walks, sneezes, coughs, exercises vigorously, or passes wind. (2) Piles which are prolapsed most of the time (third degree). (3) A loose sphincter[md]never stretch his sphincter, unless you can feel some tightness in his anal canal[md]there is no point in doing so otherwise, and it may impair his continence. (4) Chronic diarrhoea.
The operation is less likely to be successful if he is over 50, and he is more likely to suffer from incontinence of wind, or occasionally faeces. Bleeding piles are not a contraindication.
ANAESTHESIA. (1) General anaesthesia, preferably but not necessarily with relaxants is best. (2) Ketamine (A 8.2). (3) Caudal block (A 7.6).
POSITION. If you are using subarachnoid anaesthesia his position immediately after its injection is important[md]see A 7.6. As soon as the anaesthetic solution has been fixed (about 10 minutes), lay him on his back with his legs up in stirrups, and give the table a slight head-down tilt.
Alternatively, if your anaesthetist is more skilled, lay him on his left side.
SIGMOIDOSCOPY OR PROCTOSCOPY should always follow a careful digital examination. If you don't do this, you may fail to diagnose carcinoma of his rectum.
FEEL FOR THE CONSTRICTING BAND. First, do a digital examination with your right index finger. Insert two fingers of your left hand and pull upwards, and one finger of your right hand and pull downwards, if he is in the lateral position, as in A, Fig. 22-10. Feel for the constricting band, which is usually at the level of his anorectal line (22-1). If his anus feels tight, dilatation is likely to be successful. If it feels loose, proceed to haemorrhoidectomy (22.6).
DILATATION must be gentle and controlled. Start by introducing the index fingers of each hand, then gradually insert more fingers as you overcome the constriction. Put the strain on the constricting bands in the right and left lateral positions, in the 3 and 9 o'clock positions. Try to avoid damaging his sphincter at 12 o'clock, and especially at 6 o'clock, where it is weaker. Stretch hard and then put four fingers in. Dilate his anus gradually over 3 or 4 minutes, so that the fibres of his sphincter are stretched, and not torn. Usually, you can insert six or eight of your fingers. The tighter his anus, the more you should stretch it. You may feel constrictions in his lower rectum, as high as your fingers can reach. Make these give way laterally. You should be able to see well up his rectum between your two hands. He may bleed a little, but he will not bleed severely.
CAUTION ! (1) The necessary degree of dilatation varies, and it is better to dilate too little rather than too much. (2) The more severe degrees of dilatation are not indicated for anal fissures (22.7). For a fissure ''four fingers for four minutes' is enough.
Some surgeons put a pack in his anus to minimize haematoma formation, some give him a dilator, others do nothing. If his piles prolapse after the stretch, apply a pad and T-bandage to keep them in place.
Give him 20 ml of liquid paraffin daily for 10 days to soften his stools. There is no need for him to use a dilator. You can usually send him home on the same day.
If you have operated for piles, advise him to eat a high- residue diet.
DIFFICULTIES [s7]WITH LORD'S PROCEDURE If he is INCONTINENT OF FLATUS, reassure him that this will pass off in for a few days to a few weeks.
If he FEELS UNSURE OF HIS SPHINCTER MECHANISM, reassure him. If his outlet was previously very tight, he will need to get used to its new condition. Encourage him, and ask him to do sphincter exercises for a few weeks.
If FAECES STAINED MUCUS escapes from his anus at the 6 o'clock position, causing soiling and soreness (keyhole deformity of the anus, rare), avoid producing it in future by making sure that the strain of dilatation is thrown on the lateral aspects of the anus.
If there is BRUISING, reassure him. It may be extensive.
If his PILES THROMBOSE postoperatively, with much swelling and soreness, reassure him. His symptoms will settle and the result will be excellent.
If his rectal mucosa or a LARGE PILE PROLAPSES postoperatively, and is troublesome, anaesthetize him, clamp the redundant mucosa, and cut it off distal to the clamp. Tape the clamp to his buttocks. Return him to the ward. Remove the clamp an hour later. Or, do nothing, except wait for a few weeks, and then do a haemorrhoidectomy if his piles are still troublesome.
If his PILES RECUR, excise them, do another maximal dilatation of his anus, and excise any skin tags. There is about a 25% chance of recurrence on the first occasion.