Surgical diseases
Videos of Surgical Procedures
This page provides links to prerecorded webcasts of surgical procedures. These are actual operations performed at medical centers in the United States since January 2004. The videos last an hour. Please note that you cannot send in questions by email, though the webcast may say that you can, because you are not seeing these videos live.
Most videos dated after July 15, 2007 are in Flash format. You will need Flash to view the programs. You can download the flash players atwww.adobe.com/products/flashplayer.
For videos dated before July 15, 2007, you will need RealPlayer to view the programs. If you do not have Real Player, you will be prompted to obtain a free download of the software before you view the presentation. You can download the RealPlayer media player at www.real.com.
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Hemorrhoids-
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Hemorrhoids
Hemorrhoids are the swelling and inflammation of veins in the rectum and anus.
Prevalence
Hemorrhoids are very common. It is estimated that approximately half of all Americans have this condition by the age of 50. However, only a small number seek medical treatment. Annually, only about 500,000 people are medically treated for hemorrhoids, with 10 to 20% of them requiring surgeries.
Causes and risk factors
Some people are more prone to developing hemorrhoids due to inherent problems with their bodies' collagen and elastic fibers due to a genetic predisposition. This leads to weak rectal vein walls or week venous valves. These people may have other related defects such as 'flat feet', herniae. Others develop hemorrhoids due to problems in their intestinal tract.
The causes of hemorrhoids include genetic predisposition (weak rectal vein walls and/or valves, excessive time (over 1 minute daily) and straining during bowel movements, and chronic bowel straining or pressure due to poor posture or muscle tone. Constipation, bouts of diarrhea, poor bathroom habits (reading on the toilet or multiple cleaning attempts), pregnancy, excessive coughing, constant sitting and fiber-deprived Western diet can all foster the conditions that cause hemorrhoids.
Hemorrhoids is particularly common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.
Types of hemorrhoids
Hemorrhoids can present as internal or external hemorrhoids or both. External hemorrhoids are those that occur outside of the anal opening. Internal hemorrhoids are those that occur inside the rectum.
Clinical Picture
External hemorrhoids
External hemorrhoids are asymptomatic except when secondary thrombosis occurs. However, some patients with non-thrombosed hemorrhoids may complain of pruritus ani or itching, swelling, and burning sensation. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.
If the vein ruptures and a blood clot develops, the hemorrhoids become a thrombosed hemorrhoid. Thrombosis may result from defecatory straining or extreme physical activity, or it may be a random event. Patients often report feeling the sensation of sitting on a tender marble. Physical examination identifies the external thrombosis as a purple mass at the anal verge.
If infected this can lead to inguinal lymph node enlargement. The inguinal lymph nodes are situated in the crease between the leg and pelvis (more on the outside of that crease, ie, laterally). They drain the penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal.
Internal hemorrhoids
As this area lack sensitive nerve endings, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl.
Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed hemorrhoid is an internal hemorrhoid that are so distended that it is pushed outside of the anus. If the anal sphincter muscle goes into spasm and trap the prolapsed hemorrhoid outside of the anal opening, the supply of blood is cut off, and the hemorrhoids become a strangulated hemorrhoid.
Differential Diagnosis
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms. The differential diagnosis of anal mass includes many benign diseases. hemorrhoids, rectal prolapse, perianal haematomas, anal tags, polyps, warts or condylomas, anal abscesses can all present as an anal mass. Non-proctological lumps can also be present from time to time. These include sebaceous cysts and lipomas. On the other hand, a palpable mass and/or bleeding is the presenting symptom in 50% of patients that are later found to have anal cancer. Other potential causes include inflammatory bowel disease or bowel infection.
Diagnosis
A thorough evaluation and proper diagnosis are important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.
Examination of the anus and rectum to includes inspection to look for swollen blood vessels that indicate hemorrhoids and a digital rectal exam with a gloved, lubricated finger to feel for abnormalities. Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.
To rule out other causes of gastrointestinal bleeding, examination of the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy may be necessary. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.
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Prevention
Prevention of hemorrhoids includes drinking more fluids, eating more fiber, exercising, practicing better posture, and reducing bowel movement strain and time. Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining at stool to well under 1 minute (ideally 10 seconds) daily.
Treatments
For many people, hemorrhoids are temporary conditions that are healed either serendipitously or by the same measures recommended for prevention. In these cases, warm sitz bath, cold compress, or topical analgesic (such as Preparation H), is sufficient to provide temporary relief.
The first step is to eliminate the factors causing hemorrhoids. After eliminating the risk factors and possible causes the goal is to achieve symptomatic relief as well as shrinkage of the hemorrhoids. This can be accomplished by Sitz baths as well as pain meds.
Treatment of chronic or complicated hemorrhoids
Chronic hemorrhoids or those that flare up from time to time can be medically treated by:
- dilation: stretching of the anal sphincter muscle. Although no longer popular, this treatment can be successfully applied to select cases of strangulated hemorrhoids.
- rubber band ligation: elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. Within several weeks, withered hemorrhoid is sloughed off during normal bowel movement.
- sclerotherapy (injection therapy): sclerosant or hardening agent is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up.
- cryosurgery: a frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues.
- laser, infared or BICAP coagulation: laser, infrared beam, or electricity is used to cauterize the affected tissues.
- hemorrhoidectomy: a true surgical procedure to excise and remove hemorrhoids.
For severe cases of hemorrhoids, such as prolapsed, thrombosed, or strangulated hemorrhoids, surgery may be the only treatment option. The pain in thrombosed external hemorrhoid, which is better known as a perianal haematoma, is usually severe and instantly relieved by incision and evacuation of the clot.
General measures to decrease flare ups and aggravation are increase dietary fiber found in fruits, vegetables, grains and cereals. A fiber supplement may also be used. Increase water intake. These measure may soften the bowel movements and prevent straining and trauma.
Natural astringents and soothing agents, such as witch hazel, cranesbill and aloe vera, may also be used topically. Lastly, fiber-rich bulking agents such as plantain and psyllium can be used to help create soft stool that is easy to pass to lessen the irritation of existing hemorrhoids or to achieve the daily limit of well under 1 minute (ideally 10 seconds) straining at stool.
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The Doctors Lounge does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.
Gangrene
Gangrene is the death and subsequent decay of body tissues caused by infection, also known as tissue necrosis. It is most commonly the result of critically insufficient blood supply sometimes caused by an injury and subsequent contamination of the wound with bacteria. This condition is most common in the extremities.
One specific example of gangrene is so called diabetic foot that can be seen in long-standing complicated diabetes. It is caused by a combination of arterial ischemia, injury and poor healing that is rather common in diabetics.
The most common medical treatment for irreversible gangrene is amputation.
Anal fissure
Anal fissure is an unnatural crack or tear in the anus, usually extending from the anal opening and the midline of the anus. Anal fissure is usually shallow (less than a quarter of inch or 0.64 cm deep).
Causes
Most anal fissures are caused by stretching of the anal sphincter muscle beyond its capability. Various causes of this fissure include:
- straining to defecate, especially if the stool is hard and dry
- severe and chronic constipation
- severe and chronic diarrhea
- Crohn's Disease
- rough anal sex
- insertion of foreign objects into the anus
- spastic tight sphincter muscles
- Anal fissure is common in women after childbirth and in infants.
Symptoms
The symptoms of anal fissure include:
- Pain during, and even hours after, defecation
- Visible tear in the anus
- Blood in stool or on toilet paper
- Constipation
Treatment
A large majority of fissure are shallow or superficial fissure. These fissures self-heal within a couple of weeks. While waiting for the fissure to heal, topical or suppository containing anti-inflammatory agents and local anesthetic can be used. Furthermore, treatment used for hemorrhoid such as eating a high-fiber diet, using stool softener, taking pain killer and sitz bath can help.
Anal fissure in infant usually self-heal without anything more than frequently changing diapers.
Deep fissures, on the other hand, may require surgery. These painful fissures cut through the sphincter muscle thus making it prone to spasm, which exacerbates the fissure and aborting the healing process. Surgical procedures for deep anal fissure are:
- Anal dilation or stretching of the anal canal.
- internal lateral sphincterotomy or excising a portion of the sphincter.
- Despite the high success rate of these surgical procedures (~95%), there are potential side effects, which include: risks from local anesthesia, infection, anal leakage or fecal incontinence.
- Medications can also be prescribed. Nitroglycerine and nifedipine ointments can relax the sphincter muscle, thus allowing the healing to proceed. Botulinum toxin injection can also be used to relax the sphincter muscle.
Prevention
In infants under one year old, frequent diaper change can prevent anal fissure. For adults, the following can help prevent fissure:
- Treating constipation by eating food rich in fiber, drinking a lot of water, and taking stool softener
Treating diarrhea promptly - Lubricating the anal canal with petroleum jelly
- Avoiding straining or prolonged sitting on the toilet
- Using a moist wipe instead of perfumed and harsh toilet paper.
- Keeping the anus dry and hygienic.
Abscess
An abscess is a collection of pus collected in a cavity formed by the tissue on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g. bullet wounds). It is a defensive reaction of the tissue to prevent the spread of infectious materials to the other parts of the body.
Causes
The organisms or foreign materials that gain access to a part of tissue kill the local cells, release toxins and trigger an inflammatory response by drawing huge amounts of white blood cells to the area and increasing the regional blood flow. So, pus is a collection of local dead tissue cells, white blood cells, infecting organisms or foreign material and toxins released by both organisms and blood cells. The final structure of the abscess is an abscess wall that is formed by the adjacent healthy cells in an attempt to build a barrier around the pus that limits the infected material from neighboring structures.
Symptoms
The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling and pain. Abscesses may occur in any kind of solid tissue but most frequently on skin surface (where they may be superficial pustules or deep skin abscesses), in the lungs, brain, kidneys and tonsils. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death (gangrene). Abscesses in most parts of the body rarely heal themselves, so prompt medical attention is indicated at the first suspicion of an abscess.
Treatment
The treatment of first choice is the surgical drainage of the abscess. It is important to note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective. However, in critical areas where surgery presents a high risk (such as the brain), surgery may be delayed or used as a last resort. The drainage of the lung abscess may be performed by giving the patient a certain position that enables the contents to be discharged via the respiratory tract. After surgical drainage, antibiotics are usually used to control the infection. Warm compresses and elevation of the limb may be beneficial for skin abscess.
Perianal abscesses are seen in patients with inflammatory bowel disease, Crohn's disease, or diabetes. Often the abscess will start as an internal wound caused by ulceration or hard stool. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the anus which grows larger and more painful with the passage of time.
A sterile abscess is a medical condition caused by injecting large amounts of material. It is most often relatively minor.
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