HPREOPERATIVE DIAGNOSES: Lower gastrointestinal (GI) bleeding and mixed hemorrhoids.
POSTOPERATIVE DIAGNOSES: Lower gastrointestinal (GI) bleeding and mixed hemorrhoids with posterior midline anal fissure.
SURGICAL PROCEDURES PERFORMED:
TECHNIQUE: The patient was taken to the operating room for the procedure. Per patient request, general anesthesia was induced. She was then placed in the lithotomy position.
The fiberoptic endoscope was lubricated, gently inserted into the rectum, and advanced to the cecum. Bowel preparation was excellent. Appendiceal orifice was clearly identified and photographed. The scope was slowly withdrawn through the bowel. No polyps were identified. No diverticular disease was noted. Several passes were made through the sigmoid without finding any areas of inflammation. There did not appear to be any sign of bleeding. The scope was retroflexed in the rectum. The patient had very large mixed hemorrhoids without active bleeding. The bowel was deflated and the scope withdrawn. Marcaine 0.5% with epinephrine, 25 mL, was infiltrated in the perineal tissues and the anal speculum was introduced. The patient was noted to have very large posterior column hemorrhoids on both sides. As these were separated the patient was found to have an approximately 3 x 4 mm midline anal fissure with exposed sphincter fibers. The posterior hemorrhoids were excised. The wounds appeared to be hemostatic. We did not remove any anterior hemorrhoids, electing rather to leave normal tissue there, minimal amount, for some stretch as the posterior half of the anal canal sclerosis and with healing. A right lateral sphincterotomy was performed using the cautery through perhaps a third to a half of the internal sphincter. This one appeared to be hemostatic. Further local anesthetic was infiltrated in the tissues. Dressings were applied.
The patient was then awakened and returned to the recovery room.
ESTIMATED BLOOD LOSS: Minimal.
POSTOPERATIVE CONDITION: Satisfactory.