If a patient has piles which prolapse while he walks, or during such activities as digging in his fields, they are too advanced for Lord's operation. Such patients are rare, and form only about 10% of those who present with piles. The alternatives are injection, which is only palliative, and difficult to do well; the application of rubber bands, which needs special equipment, or tying and excision. Tie and excise each of his three piles, together with a triangle of his perianal skin. This is not difficult, but be sure to leave bridges of mucosa between each pile. If you don't, a stricture may form.
Fig. 22-11 TYING AND EXCISING PILES. A, inject adrenalin in saline to control bleeding. B, apply forceps to the skin of each primary pile. C, apply a second pair of forceps to the mucosa- covered part of each pile. D, make the skin cuts for the 3 o'clock pile. E, nick the mucocutaneous junction at the neck of each pile and tie it. F, pull strongly as you tie a pile, release the forceps as you do so, and allow the ligature to sink into the tissues. G, after you have tied all three piles, excise the 7 o'clock and then the 3 o'clock pile, taking care to leave adequate stumps. H, the final skin wounds have been trimmed. After Goligher JC, from ''Surgery of the Anus Rectum and Colon', (4th edn 1980) Figs. 80 to 87, Bailli[gr]ere Tindall, with kind permission.
MILLIGAN'S HAEMORRHOIDECTOMY INDICATIONS. Piles which are unsuitable for Lord's procedure on the indications given in Section 22.5. These are: (1) Piles which prolapse while a patient is walking, sneezing, coughing, exercising vigorously, or passing wind. (2) Piles which are prolapsed most of the time, or are permanently prolapsed (third degree). (3) Patients with second degree piles, but with a loose sphincter, which makes them unsuitable for Lord's operation, particularly older patients.
CONTRAINDICATIONS. (1) Septic piles. (2) Acutely thrombosed piles, because it is easy to remove too much mucosa.
ANAESTHESIA. (1) General anaesthesia, ether (A 11.3). Relaxation is useful. (2) Caudal block (A 7.6). (3) Ketamine may be adequate (A 8.2).
POSITION AND PREPARATION. Put him into the lithotomy position, with his buttocks well beyond the end of the table. A sandbag under his sacrum helps exposure. Clean his anal region, and arrange the instruments and towels as in Fig. 22-4.
Do a careful digital examination to make sure that he really does have no other pathology. Sigmoidoscope him if you have not already done so.
Some surgeons infiltrate the subcutaneous tissues round his anus with 1:100 000 adrenalin in saline or lignocaine (A, in Fig. 22-11). The adrenalin reduces bleeding, and the lignocaine reduces postoperative pain. Others prefer not to use it, saying that it increases the incidence of reactionary bleeding afterwards. It you decide to use it, insert the needle in the midline, and deposit 15[nd]20 ml in the subcutaneous tissues on either side of his anus.
Push some dry gauze into his rectum, and slowly pull it out. His piles will prolapse with it.
Grasp the skin at the mucocutaneous junction of each pile with haemostats, and pull them outwards (B). This will make their mucosa covered parts protrude.
Take the purple mucosa covered part of each pile in other larger haemostats, and draw them downwards and outwards. This will bring all three piles well out of his anus, so that you see his pink rectal mucosa at their upper ends (C).
Pull on all three piles until you see the rectal mucosa, not only at the upper end of each pile, but also between them. The piles have now been drawn down as far as they will go, which will allow you to tie them at their upper poles, rather than around their middles.
The 3 o'clock or left lateral pile. Grasp the two haemostats attached to this pile in your left hand. Draw them down towards the opposite side, while your index finger rests in his anal canal, and presses downwards and outwards on the pile. Using blunt scissors in your right hand, make a V-shaped cut in his anal and perianal skin opposite this pile (D). The ends of the V should reach the mucocutaneous junction, but not extend into the mucosa beyond it. The point of the V should lie 2.5 to 3 cm from the junction.
If you press your index finger firmly against the end of the scissors as you cut, you will see the lower edge of his internal sphincter laid bare. This is a firm, whitish ring which should be clearly visible. If you hold the pile aside (E), you will see it quite clearly.
Make a slight nick in the mucosa above and below the narrow mucosal pedicle.
Transfix the pedicle of each pile using a 30 cm strand of No. 16 braided silk. Alternatively, use No. 3 chromic catgut, but transfix the pile, because it will be more likely to slip off. As you tie the pile, remove the haemostat grasping its mucosa, and use it to hold the ends of the ligature. Hand both pairs of haemostats to your assistant, and ask him to retract them laterally (F).
CAUTION ! A slipped ligature can cause fearsome bleeding!
The 7 o'clock or right posterior pile. Treat this in the same way. Hold the pile forceps with your right hand and make the scissor cuts with your left hand. When you make your cut, note the position of the cut you made for the 3 o'clock pile, and make sure you leave a good skin bridge and a bridge of intact mucosa running into his anal canal.
The 11 o'clock pile. Treat this similarly, being sure to preserve bridges of skin and mucosa between it and his other piles.
Excision. Now excise all three piles, leaving at least 1 cm of tissue beyond the ligatures (G). As you cut the ligatures short, the stumps of the piles will disappear inside his anal canal.
Pass your finger into his anus to assess the tightness of his anal canal. If it is tight, stretch it to four fingers, which may lessen postoperative pain.
Push some dry gauze into his anus, while you examine his skin wounds. Trim any loose edges with scissors, to leave three flat pear-shaped raw areas. The end result should look like a clover leaf (''If it looks like a dahlia it's a failure!'')
Pass a lubricated speculum and look at the ligatures. Control all bleeding, either with more ligatures, or with diathermy. Don't allow blood to pool in his rectum. Oozing will stop spontaneously, but all spurting vessels must be picked up and tied, however small.
Apply a hypochlorite or saline dressing, or vaseline gauze, to his anus, and cover this with plenty of dry gauze and cotton wool. Hold it in place with a T-bandage. Start salt baths (22.1) on the first or second day. Let him remove his own dressing in the bath.
If he has passed no stool by the third day, do a rectal examination, and if he has faeces in his rectum, give him a glycerine suppository.
CAUTION ! (1) Always leave mucosal bridges between the excised piles. (2) Do a rectal examination before discharging him to make sure that: (a) His faeces are not impacted, and (b) that he is not developing a stricture. If he is, he must pass a dilator every day. Many surgeons postpone this examination until the second week.
DIFFICULTIES [s7]WITH HAEMORRHOIDECTOMY If he has has ACCESSORY PILES, only excise the main ones, so that that you only make three skin wounds.
CAUTION ! Be careful not to take too much anal mucosa: it is better to leave secondary piles alone.
If he has an associated ANAL FISSURE, treat it by by stretching it with your fingers (Lord's procedure). There is no need to excise it. Large piles and fissures are seldom seen in the same patient.
If he has postoperative PAIN, give him pethidine. If severe pain follows defaecation, a hot bath will soothe it.
If he has DIFFICULTY PASSING URINE postoperatively, try giving him pethidine, or ask him to stand while he passes it. If this fails, give him subcutaneous carbachol 0.5 mg, and ask him to try again in 15 minutes. Only if his fails, catheterize him, and remove the catheter after 48 hours. Or, do a suprapubic aspiration.
If he BLEEDS WITHIN 12 HOURS (reactionary haemorrhage), you may be able to secure the vessel with artery forceps in the ward. If this fails, return him to the theatre, reanaesthetize him, and tie it there.
If he BLEEDS BETWEEN 7 AND 10 DAYS (secondary haemorrhage), he may bleed into his rectum and pass clotted blood with his next stool. Bleeding may stop spontaneously; if it does not, try pushing a lubricated, adrenalin-soaked pack into his anus and lower rectum. If this is inadequate or impractical, insert a large Foley catheter, inflate it, tie a weight to it, and exert traction on the bleeding site. Maintain traction for 3 days. Thereafter, keep his stools soft. Return him to the theatre only as a last resort.
If you FORGOT TO LEAVE BRIDGES OF SKIN AND MUCOSA between his piles, so that his rectal mucosa has retracted up his anus, pull it down and suture it to his perianal skin. He will probably recover uneventfully, but watch for a stricture.
If he develops a STRICTURE (unusual), you probably did not leave adequate bridges of tissue between his excised piles. Provide him with an anal dilator. If you don't have one, he can use a banana, but he must use it with a lubricant.