By

MAHMOUD ZAGHLOUL RASLAN, MD

CONSULTANT SURGEON, MGH

MEDINA

ANAL FISSURE & ANAL HEMORRHOIDS PR & proctoscopy should be done for patients with any

perianal complaint.

Acute anal fissure: Treated by WASH regimen:

Warm water

Analgesics

Stool softeners

High fiber diet

Chronic anal fissure:

WASH regimen should be tried first.

Non responders need to be treated by internal sphinctrotomy and excision of the fisure.

2. Anal hemorrhoids:

2.1. Thrombosed external hemorrhoids:

2.1.1. Seen within 3 days: Do excision

2.1.2. Seen after 3 days: WASH regimen

2.2. Internal hemorrhoids:

2.2.1. Try WASH regimen first

2.2.2. It may be enough in 1st degree

2.2.3. 2nd and 3rd degrees may improve. But complete resolution may require hemorrhoidectomy

2.2.4. Acute gangrenous or thrombosed 4th

degree need urgent hemorroidectomy

PILONIDAL DISEASE1. Thorough anorectal examination: is required to detect any associated fistula-in-ano, Crohn’s disease or any anorectal pathology.

2. Nonoperative treatment: (if no found abscess)

2.1. Hair shaving or depilation.

2.2. Avoid sedentary life, weight reduction.

2.3. Phenol (not used due to its toxicity)

2.4. Fibrin glue (not to be used bec. It did not prove to be effective)

3. Operative treatment:3.1. Asymptomatic patients should not undergo any surgical treatment.

3.2. Acute PN abscess: Incision & drainage.

3.3. Chronic PN disease:3.3.1. Pit picking3.3.2. Sinusectomy3.3.3. Excision with open wound healing3.3.4. Excision with midline closure3.3.5. Flap-based off-midline procedures

4. Antibiotics:

4.1. Not required in acute PN abscess except if there is surrounding cellulitis.

4.2. A single dose of antibiotic prophylaxis is used empirically in chronic cases.

5.Wound drainge:

5.1. Needed in off-midline flap procedures.

6.Postoperative shaving or depilation:

6.1. Is not be recommended.

INGUINAL HERNIA IN ADULTS

1. Diagnosis:

1.1. Physical examination

1.2. Dynamic US in doubtful cases

1.3. Herniography: an alternative to dynamic US if local expertise is available

1.4. MRI: In case of persistent inguinal pain & negative dynamic US.

2. Who requires surgery:

2.1. Asymptomatic hernias can be treated by “watch and wait” policy. They may require surgery in the future.

2.2. Symptomtic hernias: surgical repair should be offered.

2.3. Inform the pt about the possibility of chronic postoperative groin pain. This can be lessened by laparoscopic repair.

3. Open vs laparoscopic repair:

3.1. Laparoscopic repair in:

3.1.1. Patients at risk of chronic pain e.g. young pt, and in case of marked pain with small hernia.

3.1.2. Female patients

3.1.3. Bilateral inguinal hernias

3.1.4. Recurrent hernia after open repair

3.2. Open repair in:

3.2.1. Patients at low risk of chronic pain e.g. older pt and patients with mild groin pain.

3.2.2. Recurent cases after laparoscopic repair.

4. Surgical treatment of inguinal hernia:

4.1. Tension free open mesh repair (Lichtenchtein)

4.2. Laparoscopic TAPP or TEP

4.3. Choice of treatment option should be based on:

4.3.1. Surgeon’s expertise

4.3.2. Local resources

4.3.3. Patient- and hernia-related factors

ANORECTAL ABSCESS & FITULA-IN-ANO1. Diagnosis:

1.1. MRI: may be needed for occult anorectalabscess, recurrent fistula-in-ano and perianal Crohn’s disease.

1.2. Fistulography: useful alternative if MRI is not available

2. Treatment:

2.1. Anorectal abscess:

2.1.1. Intersphincteric: drain via internal sphinctrotomy

2.1.2. Supraelevator:

2.1.2.1. As extension of ischiorectalabscess: drain through perianal skin

2.1.2.2. As extension of intersphincteric abscesss: drain transanally with drain insertion

2.1.3. Horseshoe abscess: drained by internal sphinctrotomy and seton insertion

2.1.4. With fistula formation: drain with seton insertion

2.1.5. Antibiotics:

2.1.5.1. Only with cellulitis, systemic illness or immmunocompromized

2.1.5.2. Should cover MRSA

2.2. Fistula-in-ano:2.2.1. Fistulotomy: For simple fistulas2.2.2. Fistulectomy: may be followed by incontenance2.2.3. Endoanal advancement flap2.2.4. Ligation of intersphincteric fistula tract (LIFT): with prior seton2.2.5. Seton insertion:

2.2.5.1. followed by definitive surgery2.2.5.2. with gradual tightening

2.2.6. Fistula plug & fibrin glue: not proved to be effective

DIABETIC FOOT ULCERS

DIABETIC FOOT ASSESSMENT:

1. Assessment of the ulcer

2. Assessment for sensory loss

3. Assessment for the vascular status

4. Identifying infection

5. Assessment of bone involvement

6. Inspection for foot deformities

DFU MANAGEMENT:

1. Treatment of the underlying disease2. Ensuring adequate blood supply3. TIME optimum wound care (recommended by EWMA)

3.1. Tissue debridement3.2 Inflammation & infection control3.3. Moisture balance (optimum dressing selection)3.4. Edge of the wound

4. Advanced therapy: 4.1. Negative pressure wound therapy NPWT4.2. Hyperbaric oxygen therapy4.3. Bioengineered skin equivalents & growth factors

5. Offloading6. Amputation

PrecautionsIndicationsActionsType

_Not used in dry necrotic

wounds

_Not used in friable

tissues

_Do not pack the wound

tightly

_Moderate to high exudative

wounds

_Special cavity presentations

e.g. ribbon

_May be silver impregnated

_Absorb exudate

_Promote autolytic

debridement

_Moisture control

Alginates

e.g. Silvercel

_Not used in dry necrotic

wounds

_Not used in wounds with

minimal exudate

_Moderate to high exudative

wounds

_Special cavity presentations

e.g. ribbon

_ Absorb exudate

_Moisture control

_Antimicrobial if is silver

impregnated

Foams

e.g. Mepilex Ag

_Known sensitivity_Low to moderate exudative

wounds

_Infected sloughy wounds

_Rehydrate the wound bed

_Promote autolytic

debridement

_Antimicrobial action

Honey

e.g. Apinate Medihoney

_Not used in highly

exudative wounds

_Not used if anaerobic

infection is suspected

_May cause maceration

_ Dry/low to moderate

exudative wounds

_Rehydrate the wound bed

_Promote autolytic

debridement

_Moisture control

Hydrogel

e.g. NU-gel and Purilon

gel

PrecautionsIndicationsActionsType

_Not used on dry/necrotic

tissue

_Known sensitivity to iodine

_Not used for long term

(risk of systemic absorption)

_Low to high exudative wounds

_Clinical signs of infection

_Antimicrobial actionIodine

e.g. Iodosorb

_Not used in dry wounds_Malodorous wounds due to

excess exudate or increased

bioburden

_Odour absorptionOdour control

e.g. Activated charcoal

with silver (Actisorb

silver 220)

_Not used in dry wounds_Not improving clean wounds

despite correction of underlying

cause, exclusion of infection and

optimum wound care

_Active or passive control of

wound protease level

Protease modulating

e.g. Colactive plus

and Colactive plus Ag

_Not used in case of gross

slough

_Wound thin slough_ Debridement of thin slough

_Cleansing of the peri-lesional

area

Wound debridement

e.g. UCS debridement

wipe

_Known sensitivity_Moderate to high exudative

wounds

_Protect the peri-wound skinPeri-wound skin

barrier e.g. Cavilon

cream