Hemorrhoids, Inguinal Hernia, and Anal Fistula: Overview and Treatment

Hemorrhoids, Inguinal Hernia, and Anal Fistula: Overview and Treatment

Hemorrhoids

• Classification & Treatment of Internal Hemorrhoids:

• Grade I: Cryotherapy, sclerotherapy

• Grade II: Cryotherapy, hemorrhoid ligation

• Grade III: Hemorrhoid ligation, surgery

• Grade IV: Surgery

• Treatment Trends for Hemorrhoids:

• Preserve anal cushions

• Reduce hemorrhoid size

• Minimize pain

• Masuda Classification (2005):

• Internal Hemorrhoids:

• P0: no prolapse

• P1: internal hemorrhoids prolapse but retract spontaneously

• P2: internal hemorrhoids prolapse but do not retract spontaneously

• External Hemorrhoids:

• E0: no external hemorrhoids

• E1: involve less than half the circumference of the anus

• E2: involve more than half the circumference of the anus

• Classification by Degree of Circumferential Involvement:

• C0: individual hemorrhoid piles, not connected

• C1: individual hemorrhoid piles partially connected

• C2: individual hemorrhoid piles connected to form a ring

Inguinal Hernia

• Triangle of Death:

• Inner boundary is the vas deferens, outer boundary is the testicular vessels, and lower boundary is the peritoneal fold.

• The iliac artery and vein pass through this triangle.

• The genital branch of the genitofemoral nerve lies over the external iliac artery before entering the deep inguinal ring

• Triangle of Pain:

• Lower inner boundary is the genital vessels and upper outer boundary is the iliopubic tract.

• Sutures or a stapler placed in this triangle can damage the femoral branch of the genitofemoral nerve, the lateral femoral cutaneous nerve, and the femoral nerve.

Differential Diagnosis of Inguinal Hernia:

• Irreducible:

• Adherent to skin: hematoma, abscess

• Not adherent to skin: lymph node, lipoma, spermatocele

Differential Diagnosis of Femoral Hernia:

• Irreducible:

• Adherent to skin: hematoma, abscess

• Not adherent to skin: lymph node, lipoma, FEMORAL HERNIA

Surgical Treatment of Inguinal and Femoral Hernia:

• Femoral Hernia:

• Male: Mesh repair

• Female: Laparoscopic surgery

• Inguinal Hernia:

• Male: Mesh repair

• Female: Laparoscopic surgery

• Strangulated Hernia:

• No bowel necrosis: Mesh repair

• Bowel necrosis: Abdominal wall reconstruction using autograft tissue

Anal Fistula

• Cases where an anal fistula should not be excised:

• High transsphincteric anal fistula: >50% of the external sphincter in the posterior half or >30% of the external sphincter in the anterior half

• Fistula with anal abscess

• High transsphincteric anal fistula in the anterior half in females

• Anal fistula in patients with HIV/AIDS

• High transsphincteric anal fistula in patients with Crohn’s disease

• Anal Fistula Imaging:

• Endorectal ultrasound: inexpensive, gold standard in assessing the internal and external sphincter, and detecting fistula tracts

• Magnetic Resonance Imaging (MRI): when patients have multiple external openings, the internal opening is not identified, or the fistula has recurred –> accurate assessment of anal fistula tracts and complications

• Fistula Tract Laying Open:

• Inter-sphincteric or low transsphincteric anal fistula

• Loose Rubber Band Ligation:

• Anal abscess + Crohn’s disease