Makarov Nikolay Viktorovich

SI “Crimea State Medical University named after S. I. Georgievsky”

New methods in proctoplasty in case of chronic and acute paraproctitis

The target of the investigation is improving of acute and chronic paraproctitis treatment results.

The most common method of proctoplasty is based on staining of fistulous canal with methylene blue stain and disjunction of fistulous canal from external fistula foramen placed on perianal skin, by doing so the disjunction is made till the wall of rectum in the air of internal fistula foramen, and then we perform semilunar incision along the anal canal and perianal skin mucobuccal fold, after this the hydraulic dissection is performed with the dioxidine and normal saline solution which is injected under the anal canal epithelial lepidic tissue till the level of anal canal upper fimbria switching to lower ampullar part of rectum. After this the anal canal epithelial lepidic tissue is dissected till the level of internal fistulous foramen over the entire width of semilunar incision, the mobilization of transplantate is performed together with internal fistulous foramen switching to lower ampullar part of rectum, besides the mobilization is performed 3-3 cm. higher of dentate line, the transplantate of 2-3 c. width is formed by two lineal incisions, movable piece of tissue is captured for the distal part by fenestrated forceps and two separate directive interrupted sutures are overlapped which fix the base of tissue piece to proximal part of anal canal in the place of attenuating incisions end, then it is fixed by separate interrupted sutures which are placed between directive sutures, which fix wound surface of mobilized segment to proximal part of anal canal wound surface and form the first layer of stay sutures (3-4 sutures), before the suturing of stay sutures second layer the excess of removed transplantate which contain internal fistulous foramen is dissected away on the level of perianal skin then the suturing of separate interrupted sutures second layer is performed for fixing of transplantate lips to perianal skin.

The skin incision and skin preparation are two main distinctive features of this method.

The main reasons that inhibit an achievement of positive result are: the hydraulic dissection is performed only under the anal canal epithelial lepidic tissue, which increases traumatization of mucous-muscular fragment and leads to increase of tissue hemorrhage and appearing of submucous hematomas which complicate survival rate of mobilized fragment, intramural part of fistula canal and internal foramen are not sealed so the risk of relapse is increased, bringing down of a fragment is performed in craniocaudal direction which determines stronger level of tissues’ tension than in case of translocational proctoplasty. This tension may lead to retraction or necrotizing of tissue fragment which may cause such complications as the relapse of fistula or anal canal stenosis. Also this type of surgical operation cannot be performed in case of active inflammatory process in pararectal cellular tissue.

Surgical operation by our method is performed by the following technique.

The revision of rectum is performed with the help of rectal mirror. Then we perform fistula canal intubation for final reconnaissance of its dislocation towards sphincter fibers. Then fistula canal is stained with solution of brilliant green and under vision control the separation of fistula canal from external fistula foramen to rectum wall level, where it is dissected and sutured. Epulosis of perineal wound is performed by secondary tension. Then we make posterior wall of anal canal hydraulic dissection by the frontal or back semicircle, depending on the location of internal foramen, 0,5% solution of novocain and ceftriaxone are used. Solution is injected in submucous layer to the upper frontier of anal canal.

The affected anal crypt is dissected as a rhomb-shaped fragment together with cicatrical tissues. Herewith the inner foramen and intramural area of fistula canal are opened, after the treatment with small curet and sanitation with 1% dioxidine solution it is sutured by Albert’s suture.

After this left or right edge of rhomb is continued as the incision cranially to the level of top and down in order the lines of these incisions create an angle equal to the rhomb’s upper angle. These two mucous-muscular fragments are fixed with each other and with the anal canal mucous-muscular layer by interrupted suture, 2-3 sutures with the interval about 0,3-0,4 cm. In such a way internal foramen of fistula canal is separated from rectum lumen by unchanged full-layer segment of anal canal wall.

During the suturing of internal foramen and fragments fixation we use long absorbable suture material, such as vicryl and the atraumatic needle.

The examples of this manipulation are given below.

Sample 1. Patient B., 63 years old, chronic extrasphincteral paraproctitis, 4^th degree of complexity. Surgery by the proposed method was performed. Postsurgical period in hospital – 21 days. In a three month after the control revision no relapse was found.

Sample 2. Patient C., 31 years old, acute ischiorectal paraproctitis. Surgery by the proposed method was performed. Postsurgical period in hospital – 17 days. In a three month after the control revision no relapse was found.

The declared method of proctoplasty in case of acute and chronic paraproctitis decreases the chance of disease relapse and its usage allows to reduce chance of postsurgical incontinence. Also it reduces the time of postsurgical staying in hospital.