By R. Emet. Bradley University.

However cheap generic citalopram canada, in females order citalopram 10 mg with visa, masses in the cul-de-sac order on line citalopram, such as an acute salpingitis discount citalopram 40 mg on line, ectopic pregnancy, or endometriosis, will cause rectal pain. In males, prostatic abscess, foreign bodies, and seminal vesiculitis may cause rectal pain. Fistula-in-ano, perirectal abscess, ischiorectal abscess, and submucous abscess may cause a purulent discharge. Unilateral redness of the eye is more likely bacterial conjunctivitis, a foreign body, herpes corneal ulcer, corneal abrasion but be sure to look for herpes zoster, or cluster headache. If there is only unilateral redness but the redness is circumcorneal or focal, is the pupil dilated or constricted? A dilated pupil suggests glaucoma, while a constricted or irregular pupil is more likely iritis. If the pupil is normal and reacts to light and accommodation, look for episcleritis, herpes simplex, or a corneal abrasion. Diffuse bilateral redness makes viral or allergic conjunctivitis more likely than bacterial conjunctivitis. If the palpebral conjunctiva are not involved, consider the possibility of scleritis. This finding would suggest iritis, glaucoma, or keratitis which can again be differentiated by the appearance of the pupil. If the visual acuity is affected or the pupil is dilated or constricted, immediately referral to an ophthalmologist is indicated. Many emergency rooms are equipped with a slit lamp and a tonometer, but these examinations are best performed by an eye specialist. Patients with scleritis or episcleritis need a workup for systemic disease such as rheumatoid arthritis and various collagen diseases. The presence of difficulty swallowing should suggest carcinoma of the esophagus, esophageal strictures, esophageal diverticulum, achalasia, aortic aneurysm, and other mediastinal masses. The presence of significant weight loss suggests carcinoma of the esophagus and esophageal stricture. Several of the conditions associated with esophageal regurgitation may be accompanied by heartburn, but reflux esophagitis and gastric ulcer are the most common. A Bernstein test, esophageal pH monitoring, and esophageal manometry may be useful in diagnosing reflux esophagitis. The presence of rapid respiration indicates dyspnea (page 155), and may be caused by shock, congestive heart failure, asthma, emphysema, and other disorders. The presence of slow respiration should suggest diabetes mellitus, alcoholic stupor, uremia, opium poisoning, cerebral concussion, and metabolic acidosis from other causes. This would suggest Cheyne–Stokes respiration or Biot’s breathing, and the causes to consider are coma, congestive heart failure, uremia, tuberculosis, bacterial meningitis, typhoid fever, chorea, and many other conditions. The presence of deep respiration should suggest metabolic acidosis due to diabetes mellitus, renal failure, alcoholic stupor, or respiratory alkalosis from salicylate intoxication. The presence of shallow respiration would suggest uremia, opium poisoning, and concussion. If there is fever, blood cultures, febrile agglutinins, and tuberculin and other skin tests may be ordered. Many drugs, including barbiturates and benzodiazepines, may cause a restless leg syndrome. Various forms of peripheral neuropathy and multiple sclerosis may be associated with restless leg syndrome. A therapeutic trial of a combination of dopa and carbidopa or pramipexole may be useful. A careful search for a puncture wound or evidence of frequent intravenous injections should be done and cultures of any exudate obtained. The tenderness is more subtle in temporal arteritis unless there is associated homolateral blindness or obvious enlargement of the superficial temporal artery. Tenderness in the occipital area is usually due to occipital major or minor entrapment by the posterior cervical muscles. This is common after flexion–extension injuries of the cervical spine or cervical spondylosis. Referred tenderness from trigeminal neuralgia, sinusitis, otitis media, mastoiditis, and disorders of the teeth may occur. When a patient presents with scalp tenderness, especially at the top of the head, and the physical examination is normal, the diagnosis of psychoneurosis should be entertained. A skull x-ray should be done to exclude fracture, rickets, syphilitic periostitis, and primary and secondary tumors of the cranium. A sedimentation rate should be done to exclude temporal arteritis, especially in the elderly. If the physical examination and diagnostic workup are normal and the patient persists with the complaint, a referral to a psychiatrist is in order. Patients with scoliosis and a history of trauma should be suspected of having a thoracic or lumbosacral sprain, fracture, or herniated disk. Abnormal neurologic findings should suggest poliomyelitis, muscular dystrophy, multiple sclerosis, syringomyelia, Friedreich’s ataxia, and many other disorders. If the neurologic examination is abnormal, are there motor findings only or both sensory and motor findings? Abnormal motor findings would suggest poliomyelitis or muscular dystrophy, whereas abnormal sensory and motor findings would suggest multiple sclerosis, syringomyelia, and Friedreich’s ataxia, among other disorders. Diseases of the bone that may cause scoliosis are Paget’s disease, osteoporosis, destructive disease of the vertebrae, such as tuberculosis, osteogenesis imperfecta, rickets, congenital hemivertebra, and Klippel–Feil syndrome. Children with scoliosis and bone disease may have rickets, osteogenesis imperfecta, congenital hemivertebra, and Klippel–Feil syndrome. Adults with x-ray changes of bone diseases may have Paget’s disease, osteoporosis, destructive disease of the vertebrae, and other disorders. In this position, there will be asymmetry in the height of the scapulae (Adam’s test). The vast majority of mild cases of scoliosis require only x-ray and watchful expectancy or referral to an orthopedic surgeon. If these tests are negative, the patient should be referred to an orthopedic surgeon. Remember, scoliosis is rarely the cause of back pain unless the spinal angulation exceeds 40 degrees. If the scotomas are transient, then migraine, transient ischemic attacks, and retrobulbar neuritis should be suspected. On a careful eye examination, the clinician may find corneal opacities, muscae volitantes, cataracts, choroiditis, glaucoma, retinitis, retinal hemorrhage, and detached retina. The presence of other neurologic signs may suggest multiple sclerosis, carotid artery thrombosis or insufficiency, basilar artery thrombosis or insufficiency, and pseudotumor cerebri, among other disorders. If the initial findings suggest an ocular disorder, referral to an ophthalmologist should be made. Following the algorithm, you note that it is only his left scrotum, so systemic diseases, such as congestive heart failure, cirrhosis and nephrosis can be ruled out. It is painless, so it is unlikely that he has torsion of the testicle, or an incarcerated, or strangulated inguinal hernia. On examination, you find that the mass fails to transilluminate ruling out a hydrocele. Diffuse scrotal swelling would suggest congestive heart failure, nephrosis, uremia, and cirrhosis, as well as focal diseases such as filariasis or bilateral hydrocele. Focal scrotal swelling would suggest a hernia, hydrocele, torsion of the testicle, abscesses, epididymitis, orchitis, varicoceles, and testicular tumors. The presence of diffuse edema of the scrotum with ascites or generalized edema would suggest congestive heart failure, nephrosis, uremia, or cirrhosis. The presence of painful scrotal swelling would suggest an incarcerated or strangulated inguinal hernia, torsion of the testicle, a hematoma, orchitis, epididymitis, furuncle, or abscess. If the mass transilluminates, it is very likely a hydrocele of the testicle or a spermatocele. If intestinal obstruction is suspected, a flat plate of the abdomen and lateral decubitus should be ordered. Ultrasonography or a radionuclide testicular scan with technetium-99m are useful in differentiating between testicular torsion and epididymitis. Scrotal ultrasound may be done to evaluate any kind of testicular or scrotal mass. This would suggest a viral, bacterial or autoimmune disorder somewhere in the body.

Even prolapsed intervertebral disc has been seen to involve more than one member in a family discount 20 mg citalopram with amex. In case of secondary carcinoma of the spine 10mg citalopram mastercard, patients often give history of quick loss of weight in near past order citalopram amex. In ankylosing spondylitis malaise order citalopram 20 mg mastercard, fatigue and loss of weight are often complained of. Fever or rise of temperature is mainly come across in inflammatory conditions of the spine. Starting from above note :— (i) Position of the head, whether bent or twisted to one side; (ii) the level of the shoulders; (iii) the position of the scapulae, whether one is elevated or displaced forward, backward, laterally or medially; (iv) the lateral margins of the body from axilla to the crest of the ilium — whether the affected side is flatter or more curved than the other; (v) the relative prominence of the iliac crest, e. It should be remembered that the bodies of the vertebrae are rotated towards the convexity of the curve and the spinous processes are rotated towards the concavity. Differentiation should immediately be made between mobile scoliosis (transient) and fixed scoliosis (structural). In case of scoliosis if the patient is asked to lean forward, postural scoliosis will Fig. In I 1 scoliosis, the chest diagonally opposite to posterior convexity I " is more prominent. In advanced kyphosis, the sternum also A becomes convex anteriorly to compensate for the diminished ^ ^ v „ vertebral measurement of the thorax. In caries of the spine the patient walks with short step and often on the toes to avoid jerking on the spine. In case of to rotate the vertebra by pressing on the sacro-iliac arthritis the Fig. This will elicit patient may limp and either side of the spine to elicit tender­ tenderness in pathologies of the spinal if this condition is ness. In spina bifida occulta, there may be a swelling, a tuft of hair, dilated vessels, a fibrofatty tumour or even a dimple to show the point of attach­ ment of membrana reuniens to the skin. Congenital sacrococcygeal teratoma is occasionally seen in the sacrococcygeal region. Tenderness may be elici­ ted by press­ ing upon the side of the spinous pro­ cess in an attempt to rotate the vertebra (Fig. Tenderness can also be elicited by percussing on the spinous processes with a finger (See Fig. In such cases pinch up the skin to differentiate whether the pain is in the skin or in the spine. This is to perform the anvil test always to elicit tenderness being determined by eliciting cross fluctuation. In this test sudden jerk is applied over the head or the patient is asked to jump down from a chair. In case children the meningocele may be pressed with one hand keeP* 8n other hand on the anterior fontanelle to feel for the 3. Extension is free in the lumbar and lumbo- while the meningocele is being dorsal regions. Nodding movement of the head takes place at the atlanto-occipital joint whereas rotation of the head occurs mainly at the atlanto-axial joint. Movements of the cervical spine should be examined with great caution as sudden death may occur from dislocation of the atlanto-axial joint. Mobility of the costovertebral joints is judged from the range of chest expansion. The normal difference of the chest girth between full expiration and full inspiration is about 2Vi inches. In the early stage it is due to reflex muscular spasm — a natural attempt to immobilize the painful part. Presence of rigidity is determined by testing the different movements of the spine as follows: (i) Flexion. The clinician the dorso-lumbar region is picking up places his hands over the spine to note the movements of a coin from the floor by bending the the spinous processes. It may be possible to touch the toes by excessive flexion of the hips while the spine remains stiff. When the spine is rigid the child will stoop bending his knees and hips keeping the spine straight. While raising the body he puts his hands successively on the legs, knees and thighs as if he is climbing up his own legs. This movement mainly occurs in the lumbar region and will not be affected until this region of the spine is involved (Fig. The clinician lifts up his legs in an attempt to bend the lumbar spine whilst the other hand fixes the dorsal spine. If the lumbar spine is affected it cannot be bent but will be lifted as one piece (Fig:19. The other hand of the clinician is placed on the thoracic spine to detect the movement of the spine (Fig. He should continue ^ to raise the leg till he experiences pain as r evidenced by watching his face. To be sure the test is repeated and as the angle j is approached additional cate is exercised to ^ note when the pain started. In a child this is possible to the extent of 30° to If the pain is evoked at an angle above 40° it 40° from the median line. At the angle when the patient experiences first twinge of pain, the ankle is passively dorsiflexed (Fig. It suggests irritation of one or more nerve roots either by disc protrusion or from some other space occupying lesion. Note that the pelvis is being steadied sciatica from diseases of the by the clinician. This indicate that probably the protruding disc is L2-3 which is irritating the femoral nerve. The patient is asked to lie on his abdo­ men and flex the knee of the affected side. This is important to differentiate the sacro-iliac lesion protrusion of cervical intervertebral disc or an from sciatica. Now the head of the patient is bent down passively (flexing the cervical spine) and simultaneously the lower limbs are lifted (flexing the hip joints) keeping the knees straight. Neck and hip are simultaneously position of the sacro-iliac joint is flexed keeping the knees in full extension. Sharp pain is experienced determined by presence of a dimple down the spine into the upper or lower extremity due to irritation situated just medial to the posterior of the spinal dura either by tumour or by protruded intervertebral superior iliac spine. In standing position the patient is asked to point out the site of pain and the direction in which it radiates. In recumbent position it should be noted whether the hip and knee joints are slightly flexed or not. A search \ --------- for presence of a cold abscess should be made over the (_------ ca ) buttock, iliac fossa and pelvis (by rectal examination). This will exert a rotational strain on the sacro-iliac joint and will cause sharp pain. A sharp pain is felt by the patient when the concerned sacro-iliac joint is diseased. The patient is steadied on the table by grasping the shoulder of the side to be tested. The knee and hip of that side are flexed and brought up towards the shoulder of the opposite side. But when this test is performed on the affected side a severe pain is complained of in the affected sacro-iliac joint. This will cause pain at the pathological sacro-iliac joint due to the rotational strain imposed on this joint. Rectal or Vaginal examination is sometimes required to exclude presence of pelvic abscess. This examination is also required if pathological condition of the prostate, seminal vesicles or uterine appendages is suspected.

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Te duration of beneft lasted 3–6 months; adequately counseled on the risks of weakness order genuine citalopram line, which is usually mild however generic citalopram 20 mg without prescription, 20% of patients reported the treatment had no efect on and transient discount 20 mg citalopram with mastercard. Likewise purchase citalopram with a visa, Almeida uses an adapter In the published literature, one patient reported weakness of plantar to shorten her 7 mm 30 G needle to measure 2. Gustatory sweating (Frey’s syndrome) is a relatively common complication afer surgery or injury in the region of the parotid gland and will be discussed later in the chapter. Five of 10 patients had partial disabil- ity in frowning of the forehead, but this was limited to a maximum of 8 weeks. Tere was no ptosis noted and satisfaction was good or excellent in 90% of the subjects. Similarly, Tan and Solish report that injections, particularly on the forehead or over any facial muscles, should be placed as superfcially as possible in order to attempt to minimize difusion into under- symptoms return on average of 4–12 months afer treatment of the 15 ling muscles. Böger treated 12 men sufering from bilateral craniofacial (Courtesy of Albert Ganss, International Hyperhidrosis Society. Decreased sweating was seen within 1–7 days afer injection and lasted a minimum of 3 months, but one patient experienced anhidrosis for 27 months. Side efects were limited to temporary weakness of the frontalis muscle (100%) and brow asymmetry that lasted 1–12 months in 17% of subjects. It is the observation of the authors that patients typically present with forehead sweating that may be combined with scalp sweating in a difuse pattern or in an ophiasis pattern. Te forehead can be treated more inferiorly if the response is not sufcient and if the patient is willing to accept the possibility of brow ptosis. Identifying the surface areas that need injection by the iodine-starch test can be technically challenging due to the body location, but is valuable. Using technique much the same for axillary injections, the treatment area is identifed with the starch-iodine technique and range from 60 to 100 U per side depending on the extent of the injections of 2. Te injections were well-toler- 5–72 U) and no recurrence of sweating was observed during the fol- ated, but the authors noted incomplete resolution of the sweating low-up period of 6 months. A marked long-lasting beneft of 11–36 due to insufcient dosing, and the duration lasted only 4 months. In clinical practice, the Minor’s iodine-starch test should be per- Chromhidrosis formed before injection to visualize the afected area that needs to be Chromhidrosis is a rare disorder characterized by the excretion of injected. Afer the iodine and starch have been applied to the area, the colored or pigmented sweat. It is most commonly confned to the face patient should chew on a piece of candy or food to stimulate the facial or axilla but has been noted elsewhere on the body. This patient had a dermatomal band of hyperhidrosis as identifed here with starch-iodine testing. Neurologic evaluation failed to detect a cause and he was successfully treated with botulinum toxin afer which he was lost to follow-up. Multiple neuropathies of the autonomic nervous sys- a band of sweating which clearly extended beyond the segmental tem or a failure in the synthesis or release of neurotransmitters have level of injury. Tere Residual Limb Hyperhidrosis Following Amputation is no therapy for the segmental progressive anhidrosis. Te dilution and injection technique and dos- a patient sufering from Ross syndrome with a defned area of anhi- ing is similar to that for other anatomic areas. Afer identifying the drosis in the right hand, the right axilla, and the right side of the face. Arch Dermatol were equally efective in blocking axillary sweating when studying 19 2002; 138: 539–41. A comprehensive starting 1 week afer injection, lasting 5 weeks, as well as accommo- approach to the recognition, diagnosis, and severity-based treat- dation difculties and conjunctival irritation that lasted 3 weeks. Dermatol Surg 2007; achieved excellent reduction in sweating, but the incidence of side 33: 908–23. Treatment Adverse events were common: dry mouth or throat (90%), indiges- of granulosis rubra nasi with botulinum toxin type A. Dermatol tion (60%), excessively dry hands (60%), muscle weakness (60%), and Surg 2009; 35: 1298–9. An epidermiological study Lower dosing may be the key to reducing the high incidence of side of hyperhidrosis. Efect of botulinum toxin type other secretory disorders and signifcantly improved the quality of A on quality of life measures in patients with excessive axillary life for the many patients who have been treated with it. Long-term efcacy and quality of life in the treat- safe, and efective pain control is needed for the treatment of more ment of focal hyperhidrosis with botulinum toxin A. Another area risk factors for superfcial fungal infections among Italian Navy of potential research is with combination therapy. Freedberg I, Eisen A, Wolf K, Goldsmith L, Katz S, Fitzpatrick T Treatment of Frey syndrome with botulinum toxin type F. A randomized, double-blind, hyperhidrosis: Best practice recommendations and special con- placebo-controlled trial of botulinum A toxin for severe axillary siderations. Botulinum toxin type A in treatment of hyperhidrosis treated with aluminum chloride in a salicylic acid bilateral primary axillary hyperhidrosis: Randomised, parallel gel base. Use of oral glycopyrronium bromide in the treatment of primary axillary hyperhidrosis: A 52-week hyperhidrosis. J Vasc Surg 2012; 55(6): with repeated botulinum toxin type A treatment of primary 1696–1700. Treatment of excess sweating of the palms by ionto- American Academy of Dermatology, San Francisco, 2006. Microinvasive video-assisted thoraco- toxin type A therapy for axillary hyperhidrosis markedly pro- scopic sympathicotomy for primary palmar hyperhidrosis. Predicting changes in the distribution of axillary hyperhidrosis: A study in 83 patients. Endoscopic sympathectomy toxin a (Botox) versus abobotulinum toxin a (Dysport) using a treatment for craniofacial hyperhidrosis. Clinical evalu- with and without preservative: A double-blind, randomized con- ation of a microwave device for treating axillary hyperhidrosis. Te efcacy of a microwave containing saline solution on pain perception during botulinum device for treating axillary hyperhidrosis and osmidrosis in toxin type-A injections at diferent locations: A prospective, sin- Asians: A preliminary study. Treatment of axillary hyperhidrosis by chemodener- cal evaluation of a novel microwave device for treating axillary vation of sweat glands using botulinum toxin type A. Treatment of axillary hyperhidro- with the repetition of botulinum toxin A injections in primary sis with botulinum toxin type A reconstituted in lidocaine or in axillary hyperhidrosis: A study in 83 patients. A review of peripheral nerve double-blind, randomized, comparative study of Dysport vs. Botulinum neural block at the wrist for treatment of palmar hyperhidro- toxin type A in primary palmar hyperhidrosis: Randomized, sin- sis with botulinum toxin: Technical improvements. Brief overview of methodol- Intravenous regional anaesthesia for treatment of palmar hyper- ogy and 2 years’ experience. Botulinum toxin type A in efcacy of two anaesthetic techniques for botulinum toxin ther- the treatment of palmar hyperhidrosis: the efect of dilution and apy. Te efect with dichlorotetrafuoroethane lessens the pain of botulinum of two sites of high frequency vibration on cutaneous pain thresh- toxin injections for the treatment of palmar hyperhidrosis. Botulinum toxin A for palmar hyperhi- botulinum toxin-A injections for hyperhidrosis: A case report drosis. Sao Paulo: Know-how Editorial Ltd, 2004; Treatment of palmar hyperhidrosis with botulinum toxin type A: 155–62. Palmar hyperhidrosis: Long-term follow-up of nine children Dermatologic Clinics 2004; 22: 177–85. Kontochristopoulos G, Gregoriou S, Zakopoulou N, Rigopoulos Dermatol 2009; 26(4): 439–44. Focal hyperhidrosis: ice packs in patients treated with botulinum toxin A for palmar Efective treatment with intracutaneous botulinum toxin. Ice minimizes discomfort asso- anesthesia (Bier’s block) is superior to a peripheral nerve block for ciated with injection of botulinum toxin type A for the treatment painless treatment of plantar hyperhidrosis with botulinum toxin. Botulinum toxin in the management of focal hyper- idiopathic hyperhidrosis and botulinum toxin: A pilot study.

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The loop of the seton encircles the fistula The internal opening should be located in a crypt near the loosely purchase citalopram american express. They are replaced when the sutures break or become dentate line purchase cheap citalopram on line, most often in the posterior commissure cheap 40 mg citalopram visa. Then insert a probe into the external orifice of opening of the fistula and gently guide it to exit through the the fistula purchase citalopram 40 mg with mastercard. With a simple fistula, in which the probe goes internal opening by palpation or direct observation using an directly into the internal orifice, simply make a scalpel inci- anoscope. A completely traversed the fistula, deliver the end of the probe grooved directional probe is helpful for this maneuver. With complex fistulas the probe may not pass through the Then use the probe to pull the seton through the tract. If these maneuvers are not successful, Goldberg and associates sug- gested injecting a dilute (1:10) solution of methylene blue dye into the external orifice of the fistula. Then incise the tissues over a grooved director along that portion of the track the probe enters easily. At this point it is generally easy to identify the probable location of the fistula’s internal open- ing. For fistulas in the posterior half of the anal canal, this opening is located in the posterior commissure at the dentate line. If a patient has multiple fistulas, including a horseshoe fistula, the multiple tracks generally enter into a single poste- rior track that leads to an internal opening at the usual loca- tion in the posterior commissure of the anal canal. In patients with multiple complicated fistulas, fistulograms obtained by radiography or magnetic resonance imaging help delineate the pathology. Marsupialization When fistulotomy results in a large gaping wound, Goldberg and associates suggested marsupializing the wound to speed Fig. Chassin Postoperative Care Complications Administer a bulk laxative such as Metamucil daily. For the Urinary retention first bowel movement, an additional stimulant, such as Postoperative hemorrhage Senokot-S (two tablets) may be necessary. Sepsis including cellulitis and recurrent abscess For patients who have had operations for fairly simple fistu- Recurrent fistula las, warm sitz baths two or three times daily may be initi- Thrombosis of external hemorrhoids ated beginning on the first postoperative day, after which Anal stenosis no gauze packing may be necessary. For patients who have complex fistulas, light general anes- thesia may be required for removal of the first gauze pack- Further Reading ing on the second or third postoperative day. During the early postoperative period, check the wound American Medical Association. Endorectal advancement flap divided, warn the patient that for the first week or so there repair of rectovaginal and other complicated anorectal fistulas. Benign anorectal: abscess and Perform a weekly anal digital examination and dilatation, fistula. Optionally, the surgeon may make a Painful chronic anal fissure not responsive to medical therapy radial incision through the mucosa directly over this area to identify visually the lower border of the internal sphincter (we have not found this step necessary). Preoperative Preparation Many patients with anal fissure cannot tolerate a preopera- Documentation Basics tive enema because of excessive pain. Consequently, a mild cathartic the night before operation constitutes the Coding for anorectal procedures is complex. In general, it is important to document: Pitfalls and Danger Points • Findings • Extent of sphincterotomy Injury to external sphincter • Open or closed? Inducing fecal incontinence by overly extensive • Excision of hypertrophied papilla or not? Feel for a distinct groove between the subcutaneous external sphincter and the lower border of the tense internal Place the patient in the lithotomy position. There is a gritty sensation while the internal sphinc- ter is being transected, followed by a sudden “give” when the blade has reached the mucosa adjacent to the surgeon’s left index finger. Remove the knife and palpate the area of the sphincterotomy with the left index finger. Any remain- ing muscle fibers are ruptured by lateral pressure exerted by this finger. It is rarely necessary to make an incision in the mucosa to identify and coagulate a bleeding point. An alternative method of performing the subcutaneous sphincterotomy is to insert a No. Then turn the cutting edge of the blade so it faces laterally; cut the sphincter in this fashion. This approach has the disadvantage of possibly lacerating the external sphincter if excessive pressure is applied to the blade. Then the lower border of the internal sphincter and intersphincteric groove are identified. Divide the lower portion of the internal sphincter up to a point level with the dentate line. Removal of the Sentinel Pile If the patient has a sentinel pile more than a few millimeters in size, simply excise it with a scissors. If in addition to the chronic anal fissure the patient has symptomatic internal hemorrhoids that require surgery, hem- orrhoidectomy may be performed simultaneously with the lateral internal sphincterotomy. If the patient has large inter- nal hemorrhoids, and hemorrhoidectomy is not performed Fig. During this insertion keep the flat portion of the blade paral- lel to the internal sphincter. Insert the left index finger into the anal canal Apply a simple gauze dressing to the anus and remove it the opposite the scalpel blade. Generally, there is dramatic Further Reading relief of the patient’s pain promptly after sphincterotomy. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs fissurectomy—midline sphincterotomy. Segmental internal sphincterotomy – a Complications new technique for treatment of chronic anal fissure. Cochrane Database Syst Some patients complain that they have less control over the Rev. The treatment of anal fissure by lateral subcutaneous internal sphincterotomy: a technique and results. Efficacy of management algorithm for reducing porary, and the problems rarely last more than a few need for sphincterotomy in chronic anal fissures. Patients with mild forms of anal stenosis may respond to a simple Symptomatic fibrotic constriction of the anal canal not internal sphincterotomy if there is no loss of anoderm. In general, it is important to document: Pitfalls and Danger Points • Findings • Nature of flap Fecal incontinence • Sphincterotomy or not? Slough of flap Inappropriate selection of patients Operative Technique Operative Strategy Sliding Mucosal Flap Some patients have a tubular stricture with fibrosis involving Incision mucosa, anal sphincters, and anoderm. This condition, fre- With the patient under local or general anesthesia, in the prone quently associated with inflammatory bowel disease, is not position, and with the buttocks retracted laterally by means of susceptible to local surgery. This incision elevating the anoderm and mucosa in the proper plane frees should extend from the dentate line outward into the anoderm for these tissues from the underlying muscle and permits forma- about 1. This should permit dila- tation of the anus to a width of two or three fingerbreadths. Then advance the mucosa so it can be sutured circumferentially to the sphincter muscle (Fig. This suture line should fix the rectal mucosa near the normal location of the dentate line. Advancing the mucosa too far results in an ectropion with annoying chronic mucus secretion in the perianal region. In a few cases of severe stenosis, it may be necessary to repeat this process and create a mucosal flap at 6 o’clock (Figs. Hemostasis should be complete following the use of accurate electrocautery and fine ligatures. Sliding Anoderm Flap Incision After gently dilating the anus so a small Hill-Ferguson spec- ulum can be inserted into the anal canal, make a vertical inci- sion at the posterior commissure, beginning at the dentate line and extending upward in the rectal mucosa for a distance Fig. Then make a Y extension of this incision on 73 Anoplasty for Anal Stenosis 673 to the anoderm as in Fig. Be certain the two limbs of the incision in the anoderm are separated by an angle of at least 90° (angle A in Fig.

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