1. What aspect of the initial patient encounter is most important in the diagnosis of anorectal disease?

Show answer
Clinical history, including duration of complaints, exacerbating or alleviating issues, precipitating events, dietary and bowel habits, and current or previous treatments. This may not sound glamorous, but you will never encounter a more grateful patient than one whose rectal problem you have solved.

2. What is the most common cause of painless, bright red blood per rectum? Show answer
Internal hemorrhoids.

3. What are the proximal and distal anatomic landmarks of the anal canal? What is its average length?

Show answer
The anal canal starts at the anorectal junction (which is the upper border of the internal sphincter muscle or puborectalis muscle) and ends at the anal verge. The average length is only 3-4 cm. The midpoint of the anal canal is called the dentate line.

4. What is the anatomic and surgical significance of the dentate line?

Show answer
The dentate line is the location of the anal crypts that drain the intramuscular and intersphincteric anal glands, which are the site of anorectal abscesses and fistulas in ano. Above the dentate line, the anal canal receives visceral innervation (involuntary control), is covered by columnar epithelium, and is the origin of internal hemorrhoids. Below the dentate line, the anal canal receives somatic innervation (voluntary control), is lined with squamous epithelium, and is the location of external hemorrhoids.

5. What is the most common cause of anorectal abscess?

Show answer
Ninety percent result from cryptoglandular infection.

6. What are the four potential anorectal spaces used to classify anorectal abscesses?

Show answer

1. Perianal (area of the anal verge)
2. Ischiorectal (area lateral to the external sphincter muscles, extending from the levator ani muscles to the perineum)
3. Intersphincteric (area between the internal and external sphincter muscles, continuous inferiorly with the perianal space and superiorly with the rectal wall)
4. Supralevator (area superior to the levator ani muscles, inferior to the peritoneum, and lateral to the rectal wall)

7. Define fistula in ano.

Show answer
A fistula is an abnormal communication between any two epithelial-lined surfaces. The internal opening of the fistula in ano involves the anoderm at the dentate line, whereas the external orifice is located at the anal margin.

8. What is the incidence of fistula in ano after appropriate surgical incision and drainage of acute anorectal abscesses?

Show answer
50%.

9. What is the most important factor leading to the successful surgical eradication of anorectal abscesses or fistulas?

Show answer
You must know anorectal anatomy, including the potential spaces (just memorize the answers to questions 4 and 6).

10. What is Goodsall’s rule?

Show answer
The location of the internal opening of an anorectal fistula is based on the position of the external opening. An external opening posterior to a line drawn transversely across the perineum originates from an internal opening in the posterior midline. An external opening, anterior to this line, originates from the nearest anal crypt in a radial direction.

11. What is the most important determinant of successful surgical treatment of fistula in ano?

Show answer
Identification of the internal openings.

12. What is a seton?

Show answer
A seton is a heavy suture placed through the fistulous tract that is then serially tightened, allowing slow, controlled transection of the sphincter. The associated fibrous reaction maintains sphincter integrity. Although associated pain is a limiting factor in its use, the technique can effectively change a high fistula into a low fistula with minimal risk of incontinence.

13. What is the role of fibrin glue in the management of anal fistula?

Show answer
Theoretically, the use of fibrin sealant represents an attractive alternative to the morbidity of operative treatment. However, although preliminary results support a marked decrease in postoperative pain and discomfort, 1-year recurrence rates are often > 50%.

14. What is the most common location for idiopathic anal fissure?

Show answer
90% are posterior, and 10% are anterior.

15. What are the most common symptoms of anal fissure?

Show answer
Tearing anal pain and bleeding with bowel movements.

16. What is the underlying pathophysiology of fissure in ano?

Show answer
Local trauma to the anal canal, internal anal sphincter dysfunction, and ischemia.

17. What is the differential diagnosis for anal fissure, especially if atypical in location?

Show answer
Anorectal abscess, thrombosed hemorrhoid, inflammatory bowel disease, or malignancy.

18. How do you best diagnose anal fissure?

Show answer
By clinical history and visual inspection-not by digital examination or anoscopy (which serves only to turn a friendly patient into an irate one).

19. What are the nonoperative treatment options?

Show answer
High-fiber diet; stool-bulking agents; increased hydration; frequent, warm sitz baths; and topical agents containing anti-inflammatory agents, local anesthetics, and vasodilators (nitroglycerin).

20. What is the most common operation performed to treat intractable fissure in ano?

Show answer
Fissurotomy with lateral internal anal sphincterotomy.
KEY POINTS: ANAL FISSURE

1. Ninety percent of idiopathic anal fissures are posterior and 10% are anterior.
2. The most common symptoms are tearing anal pain and bleeding with bowel movements.
3. The diagnosis involves visual inspection-not by digital exam or anoscopy.
4. Nonoperative treatment includes high-fiber diet, warm sitz baths, and topical agents containing anti-inflammatory agents, local anesthetics, and vasodilators.
5. The most common operation is a fissurotomy with lateral internal anal sphincterotomy.

7. How many anatomic lobes are present in the liver? What is their topographic boundary?

Show answer
The liver is divided into two anatomic lobes, the right and the left. Their boundary lies in an oblique plane extending from the gallbladder fossa anteriorly to the inferior vena cava posteriorly. The three hepatic veins define the division between the lobar segments and the planes of surgical resection. Lobar segments are numbered I-VIII, according to Couinaud’s nomenclature. (See Figure 25-1.)

Figure 25-1 The functional division of the liver and the segments according to Couinaud’s nomenclature. (From Bismuth H: Surgical anatomy and anatomical surgery of the liver. World J Surg 6:6, 1982, with permission.)

8. What is the blood supply to the liver and the relative contribution of each structure to hepatic oxygenation?

Show answer
The hepatic artery supplies approximately 30% of the blood flow to the liver and 50% of its oxygen supply. The portal vein provides 70% of the liver’s blood flow and 50% of its oxygen. The relative significance of arterial flow in cirrhotic patients is greater; therefore, hepatic artery ligation is not recommended in patients with cirrhosis.

9. What are the most common variations in hepatic arterial supply to the right and left lobes of the liver?

Show answer
In most people, the common hepatic artery originates from the celiac axis and divides into right and left hepatic arterial branches within the porta hepatis. Approximately 15% of people have a replaced right hepatic artery (sole arterial supply to the right lobe) that originates from the superior mesenteric artery (SMA). A replaced right hepatic artery always supplies a cystic artery; thus, ligation should be followed by cholecystectomy. A replaced left hepatic artery (approximately 15% of people) arises from the left gastric artery; it may be the sole blood supply to the left lobe or may contribute to blood supply in conjunction with a normal left hepatic artery. In 5% of people, the hepatic arterial supply does not arise from the celiac axis. In these people, either the right and left hepatic arteries are replaced or a single main hepatic trunk derives from the SMA.

10. What is the venous drainage of the liver?

Show answer
The right, middle, and left hepatic veins are the major venous tributaries and enter the inferior vena cava below the right hemidiaphragm.

KEY POINTS: BLOOD SUPPLY AND DRAINAGE OF THE LIVER

29. What is the most common clinical presentation of a pilonidal sinus?

Show answer
Pain and swelling in the sacrococcygeal region, which typically are associated with a (sometimes several) chronic draining sinus tract.

30. Is pilonidal disease acquired or congenital?

Show answer
Acquired. Hair follicles in the midline sacrococcygeal area enlarge and become infected, resulting in an abscess.

31. How is acute pilonidal abscess treated?

Show answer
Incision and drainage (like a fistula in ano, it is necessary to excise the whole tract).

32. What is the definitive therapy for pilonidal disease?

Show answer
Excision of the entire pilonidal cavity and associated sinus tracts down to the fascia with primary or delayed closure.

33. What theory explains the rarity of pilonidal disease after age 40 years?

Show answer
Changes in body habitus.

References
BIBLIOGRAPHY
1. Beck DE, Wexner SD (eds): Fundamentals of Anorectal Surgery. Philadelphia, W.B. Saunders, 1998.
2. Cho DV: Endosonographic criteria for an internal opening of fistula-in-ano. Dis Colon Rectum 42:515-518, 1999.
3. Cintron JR, Park JJ, Orsay CP, et al: Repair of fistulas-in ano using fibrin adhesive: Long-term follow-up. Dis Colon Rectum 43:944-949, 2000. Medline Similar articles
4. Corman ML: Anal fistula. In Corman ML: Colon and Rectal Surgery, 4th ed. Philadelphia, Lippincott-Raven, 1998, pp 238-271.
5. Hodgkin W: Pilonidal sinus disease. J Wound Care 7:481-483, 1998. Medline Similar articles
6. Law WL, Chu KW: Triple rubber band ligation for hemorrhoids: Prospective randomized trial of local anesthetic injection. Dis Colon Rectum 42:363-366, 1999. Medline Similar articles
7. Park JJ, Cintron JR, Orsay CP, et al: Repair of chronic anorectal fistulae using commercial fibrin sealant. Arch Surg 135:166-169, 2000.
8. Sentovich SM: Fibrin glue for all anal fistulas. J Gastrointest Surg 5:158-161, 2001. Medline Similar articles Full article

1. “Groin” hernia refers to which three hernias?

Show answer
Direct and indirect inguinal hernias and femoral hernias.

2. Francois Poupart, a French surgeon and anatomist (1616-1708), described a ligament that bears his name. What is the anatomic name of the Poupart ligament?

Show answer
Inguinal ligament, which is a key element in most groin hernia repair.

3. Franz K. Hesselbach, a German surgeon and anatomist (1759-1816), described a triangle that is the common site of direct hernias. What are the anatomic margins of Hesselbach’s triangle?

Show answer
The triangle is defined inferiorly by the inguinal ligament, superiorly by the inferior epigastric vessels, and medially by the rectus fascia. The transversalis fascia forms the floor of the triangle. The original description used Cooper’s ligament as the inferior limit but because of the common use of the anterior approach to hernias, the more apparent inguinal ligament was substituted as the inferior limit of the triangle. With the increasing use of preperitoneal approaches to hernia repair, Cooper’s ligament is again much more apparent and useful as an anatomic touchstone.

4. Sir Astley Paston Cooper, an English surgeon and anatomist (1768-1841), described a ligament bearing his name. What is the anatomic name for the ligament and the proper name of Cooper’s ligament repair?

Show answer
The anatomic name of Cooper’s ligament is iliopectineal ligament. The Cooper’s ligament repair or McVay repair was popularized by Chester McVay (1911-1987). With Barry Aston, professor of anatomy at Northwestern University, McVay provided the modern description of the groin anatomy.

5. Antonio de Gimbernat, a Spanish surgeon and anatomist (1734-1816), had his interesting name attached to the lacunar ligament, which marks the medial margin of a groin area opening. What is the opening? What hernia protrudes into this opening?

Show answer
The opening is the femoral canal, which is defined medially by the lacunar ligament, anteriorly by the inguinal ligament, posteriorly by the pectineal fascia, and laterally by the femoral vein. A femoral hernia protrudes into the femoral canal.

6. Indirect inguinal hernia (particularly in children) and hydrocele are associated with which congenital abnormality?

Show answer
Persistence of an open processus vaginalis, in the case of a hernia, allows descent of bowel into the inguinal canal. With fluid accumulation, partial obstruction presents as a hydrocele of the spermatic cord.

7. What are the diagnostic criteria for hernia in an infant or child?

Show answer

* Inguinal, scrotal, or labial lump that may or may not be reducible
* History of a lump seen by a health care provider
* History of a lump seen by the mother
* The “silk sign” (the feeling of rubbing together two surfaces of silk cloth when gently rubbing together the two surfaces of a hernia sac)
* An incarceration sometimes felt on rectal examination

8. What can be done to reduce an incarcerated hernia in an infant or child?

Show answer
The four-point program is easier said than done, but it is worth the effort:

1. Sedate the patient.
2. Place the patient in the Trendelenburg position.
3. Apply a cold pack (over petroleum gauze to avoid skin injury) in inguinal area.
4. In the absence of spontaneous reduction-and if the patient is quiet-use gentle manipulation.

9. How often can incarceration be successfully reduced? What should be done next?

Show answer
About 80% of incarcerated hernias can be reduced in children; in adults, the percentage is lower. Despite the fact that 80-90% of inguinal hernias occur in boys, most incarcerations occur in girls. The hernia should be repaired electively within a few days after incarceration. The 20% of hernias that are still incarcerated are operated immediately.

10. What is a Bassini repair?

Show answer
The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring (Figure 56-1). This classic procedure, introduced in 1887 at the Italian Society of Surgery in Genoa, revolutionized hernia repair. Until recently, it has been the standard of repair. After graduation from medical school and while fighting for Italian independence, Eduardo Bassini (1844-1924) was bayoneted in the groin and, as a prisoner, was hospitalized for months with a fecal fistula.

Figure 56-1 The standard right inguinal hernia repair using the conjoined tendon and inguinal ligament.

11. What is the recurrence rate with indirect and direct hernias that have been repaired with classic Bassini repair technique?

Show answer
Over a follow-up period of 50 years, the recurrence rate of adult indirect hernias is 5-10%; of direct hernias, 15-30%.

12. Describe a McVay hernia repair.

Show answer
The line of interrupted sutures starts at a the pubic tubercle and joins the tendinous arch of the transversus abdominis muscle to Cooper’s ligament up to the femoral canal. At this point, two or three transitional sutures are placed from Cooper’s ligament to the anterior femoral fascia, effectively closing the medial extreme of the femoral canal. The final set of sutures joins the transversus abdominis arch and the anterior femoral fascia. The stitches usually incorporate the inguinal ligament at the upper limit of the repair, the site of the new internal inguinal ring and cord structures. About 15 years ago, McVay described laying in a mesh patch and stitching it, at its periphery, to the same anatomic structures. This application of mesh closely resembles the Lichtenstein repair (see question 17), except that it uses Cooper’s ligament.

13. For what type of hernias is the McVay Cooper’s ligament repair most useful?

Show answer
Femoral and direct hernias.

14. What is the Shouldice repair?

Show answer
The Shouldice repair, popularized at the Shouldice Clinic near Toronto, imbricates or overlays the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures. The suture tract runs from the pubic tubercle to a new internal ring. Care is taken with the inferior epigastric vessels. The result is layered approximation of the conjoined tendon to the inguinal ligament tract.

15. What is the reported recurrence rate for the Shouldice repair?

Show answer
The recurrence rate is 1%, the lowest reported rate for nonmesh repairs of inguinal hernias in adults.

16. For what type of groin hernia is the Shouldice repair not appropriate?

Show answer
Femoral hernia.

17. Describe the Lichtenstein repair.

Show answer
The Lichtenstein repair consists of a sutured patch of polypropylene mesh (Marlex, C.R. Bard, Inc., Covington, GA) that covers Hesselbach’s triangle and the indirect hernia area. It is considered a tension-free repair because the mesh is sutured in place without pulling ligaments or tissues together as in all other repairs. The mesh is divided at its upper end to wrap closely around the spermatic cord and its associated structures in the normal position of the internal inguinal canal. The Lichtenstein procedure is rapidly becoming the most widely used repair of adult inguinal hernia. The reported recurrence rate is < 1%.

18. What are the advantages of using the Marlex mesh?

Show answer
Central to acceptance and success of the Lichtenstein hernia repair has been the development of and experience with the Marlex mesh. The monofilament mesh is strong, inert, and resistant to infection. The interstices are rapidly and completely infiltrated with fibroblasts, and the mesh is not subject to deterioration, rejection, or fragmentation. (See Figure 56-2.)

19. For what groin area is the Lichtenstein repair not appropriate?

Figure 56-2 The Marlex mesh repair of a right inguinal hernia. Note that the same structures are used but not brought together; thus, the name of the “tension-free” repair.

20. Which type of repair is acceptable for the femoral hernia?

Show answer
Several different repairs can be used. Mesh in the form of a plug can be inserted into the femoral canal and fixed in place. A McVay Cooper’s ligament repair can be done. A preperitoneal approach to the hernia can be used to suture or plug the defect. A suture repair or a sartorius facial flap applied from below the inguinal ligament in a femoral approach also may be used. The preperitoneal approach is increasingly used for complicated inguinal and femoral hernias.

21. What is the preperitoneal or Stoppa procedure?

Show answer
The preperitoneal or Stoppa procedure is a groin hernia repair on the internal side of the abdominal wall between the peritoneum and fascial surfaces that do not open into the peritoneal cavity. The anatomic landmarks are very different and initially quite challenging to surgeons accustomed to the external abdominal wall approach. The technique is suited for recurrent hernias in which scarring and obliterated anatomy increase the risk of cord injury and recurrence. Other problems such as large hernias and femoral hernias are corrected with this approach. Conceptually, the laparoscopic hernia repair uses the same approach. (See Figure 56-3.)

22. Where are the spaces of Retzius and Bogros? Why are they increasingly important?

Show answer
Retzius’ space is between the pubis and the urinary bladder. Bogros’ space is between the peritoneum and the fascia and muscle planes on the posterior aspect of the abdominal wall below the umbilicus and down to Cooper’s ligament. Laterally, the space goes to the iliac spines. In either the open Stoppa procedure or the laparoscopic preperitoneal repair, the spaces of Retzius and Bogros are developed for mesh placement and surgical exposure.

23. How tight around the spermatic cord should a surgically fashioned, internal inguinal ring be?

Show answer
About 5 mm, which http://surgeryprocedure.info/wp-admin/media-upload.php?post_id=285&type=image&TB_iframe=true&width=640&height=525
Add an Imageis less than a fingertip and more than a forceps tip.

Figure 56-3 The different appearance and landmarks are seen in the anterior view (above) and the posterior view (below) of the inguinal-femoral area. In the posterior view the importance of the inferior epigastric vessels, bladder, and Cooper’s ligament as anatomic landmarks is apparent.

24. What is the common fascial defect of larger indirect and all direct inguinal hernias?

Show answer
Weakness or attenuation of the transversalis fascia.

25. On examination, the femoral hernia may be confused with what other inguinal hernia?

Show answer
The femoral hernia may be confused with a direct inguinal hernia because of the tendency of the femoral hernia to present at the lateral edge of the inguinal ligament.

KEY POINTS: TYPES OF INGUINAL HERNIA REPAIR

1. The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring.
2. The McVay repair is most useful for femoral and direct hernias.
3. The Shouldice repair imbricates the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures (not appropriate for femoral hernias).
4. The Lichtenstein repair consists of a sutured patch of polyprolene mesh that covers Hesselbach’s triangle and the indirect hernia sac.

26. What is the difference between an incarcerated and a strangulated hernia?

Show answer
Incarcerated: structures in the hernia sac still have a good blood supply but are stuck in the sac because of adhesions or a narrow neck of the hernia sac.
Strangulated: herniated structures, such as bowel or omentum, have lost their blood supply because of anatomic constriction at the neck of the hernia. The herniated, ischemic tissue is, therefore, in various stages of gangrenous changes. Strangulated hernias are surgical emergencies.

27. What operation is done for an uncomplicated indirect infant hernia?

Show answer
High ligation of the hernia sac.

28. What operation is done for an uncomplicated indirect hernia in young adults?

Show answer
The appropriate operation consists of high ligation and possibly one or two stitches in the transversalis fascia to tighten the internal ring. This is the basic Marcy technique, developed by Henry Orlando Marcy (1837-1924); it is smaller and more anatomically focused than the Bassini repair.

29. What operation is done for an uncomplicated but sizable direct hernia in elderly adults?

Show answer
Traditionally, the Bassini or McVay repair was chosen. More recently, because of the low recurrence rate, the Shouldice or Lichtenstein repair is favored.

30. What organ systems should be reviewed with particular care in the work-up of patients with hernia (especially elderly patients with recent onset of hernia)?

Show answer
The gastrointestinal, urinary, and pulmonary systems should be reviewed with particular care. One is looking for causes of chronic strain or sudden forces that may have induced the hernia. Straining during defecation or urination, unusual coughing, or difficulty with breathing, if corrected, may be of great value to the patient and reduce the chance of recurrent hernia.

31. What is a sliding hernia?

Show answer
A sliding hernia is formed when a retroperitoneal organ protrudes (herniates) outside the abdominal cavity in such a manner that the organ itself and the overlying peritoneal surface constitute a side of the hernia sac.

32. What organs can be found in sliding hernias?

Show answer

* Colon
* Cecum
* Appendix
* Ovary
* Bladder
* Fallopian tubes
* Uterus (rare)

33. What are common operative and postoperative complications of hernia repairs?

Show answer
Intraoperative complications

* Injury to the spermatic cord, especially in children
* Injury to the spermatic vessels, resulting in atrophy or acute necrosis of testes
* Injury to the ilioinguinal nerve, genitofemoral nerve, and lateral femoral cutaneous nerve (the lateral femoral cutaneous nerve is uniquely vulnerable in laparoscopic and properitoneal procedures)
* Injury to the femoral vessels

Postoperative complications

* Infection-high risk in children with diaper rash and patients with bowel injury or necrosis
* Hematoma-should resolve in time
* Nerve injury-the nerve is not always divided and, with time, may improve. If pain persists, try lidocaine block for both diagnosis and treatment. If a nerve block is not successful, one may consider reexploration to free the nerve from scar or to excise a postsurgical neuroma.

34. What are the common sites of hernia recurrence?

Show answer
Direct hernias often recur at the pubic tubercle. Indirect hernias recur at the internal ring. The cause is usually related to poorly placed or insufficient stitches. Other possible causes include infection, poor tissue, poor collagen formation, or too much tension at the surgical suture line. A single line of repair under moderate tension fails in a significant number of patients, regardless of adequacy of repair or healing process. Tension is almost always bad in surgery.

35. How long should the patient avoid heavy lifting after a hernia repair?

Show answer
The standard advice for decades has been 6 weeks. The current advice varies from no limitation with the Lichtenstein or preperitoneal repairs to 6 weeks for a Bassini repair. The self-limitation of pain is an excellent guide.

36. What are some of the anatomic issues related to inguinal hernias?

Show answer
At issue is the iliopubic tract, which is central to the Anson/McVay anatomic description of the inguinal area and featured in the McVay Cooper’s ligament repair. Although the McVay repair is used in England, the iliopubic tract is not referred to or described in English anatomic texts.

The term conjoined tendon, although commonly used, is considered by many to be anatomically inaccurate and misleading. The internal oblique and transversus abdominis muscles that make up the conjoined tendon are obvious and can be used surgically either alone or together. The tendinous edge of the transversus abdominis muscle and the tendinous edge of the internal oblique muscle start at their insertion on the pubic tubercle and course laterally and superiorly to the medial edge of the internal ring. At this point, the tendinous elements diminish, leaving only muscle tissues, and continue laterally and superiorly to their origins.
Whether the lacunar ligament or the iliopubic tract defines the medial border of the femoral canal is controversial. The compromise position is that the iliopubic tract is the border whereas in the normal unstretched state, the lacunar ligament (Gimbernat’s ligament) is the border in the presence of hernia (stretched state). At surgery it is enough to say that a palpable, visible curved ligament is present and used in some femoral repairs.

37. What are some surgical issues in the repair of inguinal hernias?

Show answer

The controversy over implanting mesh, as in the Lichtenstein repair, has been resolved in favor of mesh. Another controversy concerns the use of the laparoscope for hernia repair. A further issue is intra-abdominal or preperitoneal placement of mesh. At present, most surgeons accept laparoscopic repair as an alternative for preperitoneal hernia repair. The indications for a preperitoneal approach to hernia repair are still being defined, although the preperitoneal approach is acceptable for repair of recurrent hernia and unusually large or difficult hernias. The preperitoneal approach is used with increasing frequency for repair of femoral hernias. The repair should be appropriate to the circumstance of the hernia. Thus, hernia location and size as well as the patient’s age, general condition, and recurrence status should be factored into the strategy of repair.

References
BIBLIOGRAPHY
1. Avisse C, Delattre JF, Flament JB: The inguinal rings. Surg Clin North Am 80:49-69, 2000. Medline Similar articles
2. Avisse C, Delattre JF, Flament JB: The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications. Surg Clin North Am 80:35-48, 2000. Medline Similar articles
3. Bendavid R, Howarth D: Transversalis fascia rediscovered. Surg Clin North Am 80:25-33, 2000. Medline Similar articles
4. Collaboration EH: Laparoscopic compared with open methods of groin hernia repair: Systematic review of randomized controlled trials. Br J Surg 87:860-867, 2000. Medline Similar articles Full article
5. Collaboration EH: Mesh compared with non-mesh methods of open groin hernia repair. Systematic review of randomized controlled trials. Br J Surg 87:854-859, 2000. Medline Similar articles Full article

21. What are hemorrhoidal tissues, and what are their normal functions?

Show answer
Hemorrhoids are cushions of vascular tissue that contribute to anal continence and protect the sphincter mechanism during defecation. Hemorrhoids are not veins, but sinusoids. Bleeding originates from presinusoidal arterioles, thus explaining the bright red arterial color.

22. What are the most common causes of pathologic hemorrhoids?

Show answer
Constipation, prolonged straining, pregnancy, and internal sphincter dysfunction.

23. What is the most important difference between internal and external hemorrhoids?

Show answer
Whereas internal hemorrhoids are located above the dentate line with visceral innervation, external hemorrhoids are located below the dentate line with somatic innervation. Ablation of internal hemorrhoids causes a pressure sensation with an urge to defecate, but a similar approach to external hemorrhoids causes excruciating pain.

24. What are the most common complaints associated with pathologic internal hemorrhoids?

Show answer
Bleeding, mucus discharge, and prolapsing tissue.

25. What are the most common complaints associated with external hemorrhoids?

Show answer
Pain, inflammation, thrombosis, and difficulty with anal hygiene.

26. Are there any treatment options for symptomatic internal hemorrhoids based on identifiable physical characteristics?

Show answer
Yes. Treatment is based on the degree of prolapse:

Grade 1: None
Grade 2: Spontaneous reduction
Grade 3: Manual reduction
Grade 4: Unreducible

27. How are patients with symptomatic grades 2 and 3 and occasionally grade 4 internal hemorrhoids treated?

Show answer
Diet and stool bulking, rubber band ligation, injection sclerotherapy, cryotherapy, infrared photocoagulation, anal dilatation, or electrocautery.

28. What is the last-resort treatment for recalcitrant symptomatic internal hemorrhoids or combined internal and external hemorrhoids?

Show answer
Operative hemorrhoidectomy.

1. What signs or symptoms suggest intestinal obstruction in the neonate?

Show answer
Signs and symptoms vary according to the level of obstruction. Proximal intestinal obstruction leads to the early onset of bilious emesis, generally with minimal abdominal distention. In contrast, neonates with distal intestinal obstruction present after the first day of life with bilious vomiting and pronounced abdominal distention. Bilious emesis should always be interrogated further in infants and children.

2. What is the differential diagnosis of intestinal obstruction in neonates?

Show answer
Look for an anal opening, which eliminates the diagnosis of imperforate anus. Next obtain an abdominal radiograph. The extent of gaseous distention of the bowel implicates a proximal or distal bowel obstruction. No attempts should be made to distinguish small from large bowel obstruction.

3. When are contrast studies of the gastrointestinal (GI) tract indicated? Show answer
If peritonitis or pneumoperitoneum is present, proceed to exploratory laparotomy without delay. Malrotation with volvulus must be distinguished from the other cause of congenital duodenal obstruction (duodenal atresia). In this setting, upper GI is the study of choice. In volvulus, the upper GI demonstrates distention of the proximal duodenum, corkscrewing of the distal duodenum, and limited or no progression of contrast into the distal bowel. Conversely, duodenal atresia appears as a blind ending pouch in the first or second portion of the duodenum. Contrast enema is generally the preferred study in all other forms of neonatal intestinal obstruction.

4. Describe intestinal atresia.

Show answer
Atresia can occur anywhere in the GI tract: duodenal (50%), jejunoileal (45%), or colonic (5%). Duodenal atresia arises from a failure of recanalization during the 8th-10th week of gestation; jejunoileal and colonic atresia are caused by an in utero mesenteric vascular accident.

5. Distinguish duodenal atresia from other forms of intestinal atresia.

Show answer
Duodenal atresia is characterized by the onset of bilious vomiting (85% of atresia distal to the ampulla of Vater) within the first day of life; significant abdominal distention is absent. Approximately 25% of affected infants have trisomy 21. The abdominal radiograph demonstates a “double bubble” caused by the distended stomach and first or second portions of duodenum. Surgical correction is performed by duodenoduodenostomy.
Jejunoileal atresia produces bilious vomiting at 2-3 days of life with moderate to severe abdominal distention. The abdominal radiograph shows dilated loops of bowel with air-fluid levels. Barium enema reveals a microcolon and no reflux of contrast into the dilated bowel. Associated anomalies are uncommon. Surgical correction involves end-to-end anastomosis with or without limited intestinal resection.
Colonic atresia, similar to jejunalileal atresia, is associated with the late onset of bilious vomiting, no passage of meconium, and moderate to severe abdominal distention. The abdominal radiograph reveals dilated loops of bowel with air-fluid levels suggesting distal intestinal obstruction. Barium enema demonstrates a microcolon with a cutoff observed in a proximal colonic segment. Twenty percent of affected infants suffer an associated anomaly of the heart, musculoskeletal system, abdominal wall, or GI tract. Surgical management includes limited colonic resection with primary anastomosis.

6. Describe malrotation with midgut volvulus.

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During the 6th-12th week of gestation, the intestine undergoes evisceration, growth, return to the abdominal cavity, and counterclockwise rotation with fixation. Malrotation is an error in both rotation and fixation. Abnormal fixation and a narrow-based mesentery predispose to twisting of the midgut on its blood supply (superior mesenteric artery), vascular occlusion (strangulation), and obstruction (malrotation with midgut volvulus). Typically, a previously well neonate or child without a history of surgery presents with bilious vomiting, abdominal distention, and variable degrees of shock. If the infant is acutely ill, no further studies are needed and surgical exploration is indicated. If the diagnosis is in question and the infant is stable, an upper GI study, not a barium enema, is performed. Surgical treatment entails four parts: (1) division of abnormal peritoneal bands, (2) correction of malrotation, (3) restoration of a broad-based mesentery, and (4) appendectomy because of the location of the cecum in the right upper quadrant.

7. Is midgut volvulus a surgical emergency?

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Yes! The risk of strangulation caused by the rotational anomaly and abnormal peritoneal bands implies a surgical emergency. Delay places the infant at risk of losing the entire midgut and potentially dying.

8. What is meconium ileus (MI)?

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MI is the obstruction of the terminal ileum by highly viscid, tenacious meconium. MI is a complication of cystic fibrosis (CF). Fifteen percent of neonates with CF present with MI. The combination of hyperviscous mucus secreted by the abnormal intestinal glands and pancreatic insufficiency leads to abnormal meconium and obstructs the lumen of the terminal ileum. Symptoms of feeding intolerance, bilious emesis, and abdominal distention begin in the second to third days of life. Unlike most forms of neonatal intestinal obstruction, surgery is reserved for patients refractory to nonoperative treatment or complex MI (atresia, volvulus, perforation). Sixty percent of infants with simple MI can be treated successfully with Gastrografin enemas and rectal irrigation. If an operation is indicated, the objective is to remove the obstructing meconium by limited resection or enterostomy with evacuation of the meconium and irrigation of the distal bowel.

9. What is Hirschsprung’s disease?

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In this disease, the intestine is innervated by cells originating in the neural crest. During the 5th-12th week of gestation, neural crest cells migrate in a craniocaudal direction and disperse within the wall of the intestine (intermuscular, to Auerbach’s plexus; submucosal, to Meissner’s plexus). Hirschsprung’s disease arises from the failure of normal enteric innervation. The bowel remains in a contracted, spastic state and produces a functional rather than a true mechanical obstruction. Abdominal distention, feeding intolerance, and delayed or absent meconium within the first 48 hours of life are the presenting findings in infants. Older patients suffer chronic constipation, abdominal distention, and failure to thrive. Because the disease always affects the most distal bowel (80-85% rectosigmoid) with a variable involvement of proximal bowel, barium enema demonstrates the characteristic radiographic appearance of a spastic, contracted rectum with dilated proximal bowel. Suction rectal biopsy documenting the absence of ganglion cells and presence of nerve hypertrophy confirms the diagnosis. Surgical correction is performed by excision of the aganglionic (distal colorectal) segment and coloanal anastomosis.

10. What is intussusception? What are the therapeutic options?

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Intussusception is the invagination of proximal bowel (intussusceptum) into the distal bowel (intussuscipien). Swelling, vascular compromise, and obstruction follow. Nearly two thirds of cases occur in the first 2 years of life. The cause is thought to be a result of lymphoid hyperplasia in the terminal ileum after viral infection. The diagnosis should be suspected in previously well infants, 6-9 months of age, with vomiting, crampy abdominal pain, and bloody stools. Barium or air enema is both diagnostic and therapeutic. Injection of contrast demonstrates colonic obstruction with no reflux into the proximal bowel. Controlled hydrostatic reduction with barium or air is successful in 90% of cases. If hydrostatic reduction is unsuccessful or in children with peritonitis, operative reduction is indicated. The risk of recurrent intussusception is 5% for either radiographic or surgical reduction.

11. What examples of neonatal obstruction can escape early detection and present later in life?

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Although most conditions are identified within the first week to month of life, lesions other than atresia may be identified in children and even adults.
Duodenal stenosis. Unlike duodenal atresia, stenosis results in narrowing but not complete obstruction of the duodenum. Thus, infants fed formula or pureed foods may not become symptomatic until childhood. Children with intermittent abdominal pain and symptoms of gastric outlet obstruction require an upper GI study, particularly if they have trisomy 21.
Malrotation. One third of patients with malrotation are identified after the first month of life. Children present with bilious emesis and intermittent abdominal pain, and malrotation is generally identified by an upper GI series. Malrotation with midgut volvulus should be suspected in any ill child with signs of intestinal obstruction and no history of abdominal surgery.
Hirschsprung’s disease. One third of patients are diagnosed after the first year of life. A long history of constipation refractory to therapy mandates rectal biopsy, particularly in patients with trisomy 21.
Intussusception. One third of cases occur after age 2 years. A pathologic lead point (i.e., polyp, tumor, hematoma, Meckel’s diverticulum) is present in one third of older patients.

References
BIBLIOGRAPHY
1. Aquino A, Domini M, Rossi C, et al: Correlation between Down’s syndrome and malformation of pediatric surgical interest. J Pediatr Surg 33:1380-1382, 1998. Medline Similar articles
2. Daneman A, Alton DJ, Ein S, et al: Perforation during attempted intussusception reduction in children-a comparison of perforation with barium and air. Pediatr Radiol 25:81-88, 1995. Medline Similar articles
3. Godbole P, Stringer MD: Bilious vomiting in the newborn: How often is it pathologic? J Pediatr Surg 37:909-911, 2002.
4. Long FR, Kramer SS, Markowitz RI, Taylor GE: Radiographic patterns of intestinal malrotation in children. Radiographics 16:547-560, 1996. Medline Similar articles
5. Maxson RT, Franklin PA, Wagner CW: Malrotation in the older child: Surgical management, treatment, and outcome. Am Surg 61:135-138, 1995. Medline Similar articles
6. Reding R, de Ville de Goyet J, Gosseye S, et al: Hirschsprung’s disease: A 20 year experience. J Pediatr Surg 32:1221-1225, 1997. Full article

1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?

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1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home

2. Which is the most dangerous course?

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To send the patient home.

3. Is it important to make the diagnosis in the emergency department?

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No. Frequently time spent confirming a diagnosis in the emergency department is lost to inhospital resuscitation or treatment in the operating room. The only patient who needs a relatively firm diagnosis is a patient who is to be sent home.

4. If the essential goal is not to make the diagnosis, what should the surgeon do?

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1. Resuscitate the patient. Most patients do not eat or drink when they are getting sick. Most patients are depleted of at least several liters of fluid. Fluid depletion is worse in patients with diarrhea or vomiting.
2. Start a big IV line.
3. Replace lost electrolytes (see Chapter 7).
4. Insert a Foley catheter.
5. Examine the patient (frequently).

5. Are symptoms and signs uniquely misleading in any groups of patients?

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Yes. Watch out for the following groups:

* The very young, who cannot talk.
* Diabetics, because of visceral neuropathy.
* The very old, in whom, much as in diabetics, abdominal innervation is dulled.
* Patients taking steroids, which depress inflammation and mask everything.
* Patients with immunosuppression (a heart or kidney transplant patient may act cheerful even with dead or gangrenous bowel).

6. Summarize the history needed.

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1. The patient’s age. Neonates present with intussusception; young women present with ectopic pregnancy, pelvic inflammatory disease, and appendicitis; the elderly present with colon cancer, diverticulitis, and appendicitis.
2. Associated problems. Previous hospitalizations, prior abdominal surgery, medications, heart and lung disease? An extensive gynecologic history is valuable; however, it is probably safer to assume that all women between 12 and 40 years old are pregnant.
3. Location of abdominal pain. Right upper quadrant: gallbladder or biliary disease, duodenal ulcer. Right flank: pyelonephritis, hepatitis. Midepigastrium: duodenal or gastric ulcer, pancreatitis, gastritis. Left upper quadrant: ruptured spleen, subdiaphragmatic abscess. Right lower quadrant: appendicitis (see Chapter 37), ectopic pregnancy, incarcerated hernia, rectus hematoma. Left lower quadrant: diverticulitis, incarcerated hernia, rectus hematoma. Note: Cancer, unless it obstructs (colon cancer), and bleeding (diverticulosis) typically do not hurt.
4. Duration of pain. The pain of a perforated duodenal ulcer or perforated sigmoid diverticulum is sudden, whereas the pain of pyelonephritis is gradual and persistent. The pain of intestinal obstruction is intermittent and crampy. Note: Although the surgeon is rotating through a gastrointestinal service, the patient may not know this and may present with urologic, gynecologic, or vascular pathology.