Laser Surgery in Proctology.pptx

PROCTOLOGY AND USE OF LASER SURGERY.
CLINICAL EXAMINATION
RELEVANCE OF PR AND PROCTOSCOPY
HAEMORRHOIDS
FISTULA ANO
PILONIDAL SINUS
FISSURE
ROLE OF LASER SURGERY
PER RECTAL EXAMINATION
PROCTOSCOPY

1. LASER surgery in PROCTOLOGY Dr. NARENDER PAUL MS, FMAS, DipMAS Ex Senior Registrar, DMC Ldh Ex Major, AMC Consultant (General, Laser and Laparoscopic Surgery)

2. ANATOMY

3. HIGHLY VASCULAR AND COMPLEX REGION

4. HAEMORRHOIDS ANAL FISTULA ANAL FISSURE PILONIDAL SINUS PROCTOLOGY AS LESS INVASIVE AS POSSIBLE

5. CLINICAL EXAMINATION IS THE CORNERSTONE

6. PER RECTAL EXAMINATION

7. PR EXAMINATION IS A SKILL, NEEDS EXPERIENCE

8. PROPER BED, PROPER PRIVACY, PROPER POSITION

9. EXPLAIN THE PROCEDURE PROPERLY. ALLAY FEAR AND EMBARRASSMENT

10. INSPECTION Anal fissures. Anal fistula. Genital warts. External hemorrhoids. Pilonidal sinus. Skin disease ( seborrhoeic eczema, skin cancer, natal cleft dermatitis) Skin tags. Skin discoloration with Crohn disease. Rectal prolapse.

11. DIGITAL RECTAL EXAMINATION (DRE) Internal hemorrhoids Rectal carcinoma Rectal polyps Tenderness with prostatitis or acute appendicitis Malignant or inflammatory conditions of the peritoneum with anterior palpation

12. The finger is moved through 180°, feeling the walls of the rectum. With the finger then rotated in the 12 o'clock position, helped usually by the examiner bending knees in a half crouched position and pronating the examining wrist, the anterior wall can be palpated. Rotation facilitates further examination of the opposing walls of the rectum. In men, the prostate will be felt anteriorly. In women, the cervix and a retroverted uterus may be felt with the tip of the finger. It is important to feel the walls of the rectum throughout the 360°. Small rectal wall lesions may be missed if this is not done carefully. DIGITAL RECTAL EXAMINATION (DRE)

13. PROCTOSCOPY

14. HAEMORRHOIDS OR PILES Piles ( Haemorrhoids ) is a bunch of dilated veins in the anus and the lower rectum. Generally classified into two: Internal piles, starts in lower rectum and doesn’t come out of anal opening. External piles, starts in lower rectum and remains outside the anal opening.

15. Painless bleeding while passing stools. Itching. Mucus discharge. Burning on and around the anus. Severe pain, if complication occurs. Sensation of incomplete evacuation. HAEMORRHOIDS - SYMPTOMS

16. CAUSES Chronic constipation. Straining. Standing or sitting for long durations Consuming low fiber diet. Over consumption of junk, spicy and fried food. People who are always in hurry, mostly worry and eat spicy curry. Obesity, Pregnancy, Cirrhosis of liver.

17. GRADING OF HAEMORRHOIDS

18. PROLAPSE ANAL WARTS VARICES

19. HAEMORRHOIDS TREATMENT- FEAR OF PAIN 1200 ACE

20. Change of diet and lifestyle, Lotions, Medicaments, Ointments (Grade I) Rubber Band, Sclerotherapy, Infrared Coagulation (Grade I +II) Open Surgery: Milligan-Morgan, Parks Closed Surgery: Stapler Hemorrhoidopexy (MIPH) Laser Haemorrhoidopexy TREATMENT OPTIONS

21. Laser Hemorrhoidoplasty (LHP) LHP Platform Diode Laser 980/1470nm LHPFiber : Delivery of energy in conical shape LASER HEMORRHOIDOPLASTY

22. Energy of the laser is inserted centrally into the hemorrhoidal node. There is a direct (30%) and successive shrinkage of the piles (6 weeks to final result). The controlled laser energy deposition obliterates the pile mass from the inside and preserves the mucosa and sphincter structure. The homogenous laser emission from the LHP fiber results in: Closure of the arteries entering the haemorrhoidal cushion Tissue reduction in the haemorrhoidal node Maximum preservation of muscle, anal lining and mucosa Restoration of the natural anatomical structure Hemorrhoidal mass shrink. In addition fibrotic reconstruction generates new connective tissue, which ensures that the mucosa adheres to the underlying tissue. This prevents occurrence or reoccurrence of a prolapsed. LASER HEMORRHOIDOPLASTY

23. P ost op period least Painful Daycare procedure Chances of Post-op Bleeding are minimal No need of Post-op dressing No Rectal stenosis No incontinence No significant mucosa damag e Can be done in post C.A.B.G. and postpartum patient’s Several repetitions possible A DVANTAGES

24. ANAL FISTULA

25. ANAL FISTULA

26. Intersphinteric (45%) Trans – Sphincteric (40%) Suprasphincteric (3-4%) Extra sphincteric (1-2%) ANAL FISTULA

27. Discharge of pus or blood on and off from the fistula opening. Pain which is generally consistent, throbbing and more terrible when taking a seat Skin excoriation and itching around the anus. Constipation or torment related with bowel moments Fever in acute cases ANAL FISTULA- SYMPTOMS

28. CAUSES Anal abscess- Crypto glandular Most anal fistulas shape in the back midline. Multiple or found in uncommon location Inflammatory bowel disease Sexually transmitted diseases Injury Tumours including leukaemia Tuberculosis Anorectal growth HIV

29. History & Clinical Examination Fistulogram Transanal Ultrasound M.R.I. Anorectum Colonoscopy Fistula scope ANAL FISTULA- DIAGNOSIS

30. TREATMENTS Open Fistulectomy/ Fistulotomy Seton tie / kshar sutra in Ayurveda.

31. TREATMENTS L.I.F.T (Ligation of Intersphincteric Fistula Tract) V.A.F.T. (Video assisted fistula treatment)

32. Fixcision (Fistula Coring) New innovation: LASER TREATMENT TREATMENTS

33. FiLaC – FISTULA LASER CLOSING

34. First examine the anal canal & search for internal opening Hydrogen peroxide can be pushed through external opening to identify internal opening Widened the external opening Thorough scooping & brushing of tract Irrigation of Tract with saline Pass 8 Fr Feeding Tube into the tract Load Filac Fibre on feeding tube & reach up to internal opening ANAL FISTULA- FiLaC Steps

35. Remove Feeding tube Start Laser Energy on Continuous mode, at 10 watt Withdraw the laser Fibre gradually & deliver energy upto 10 joules for 1 mm of tract, means approx 5 cm tract will require 500 joules,There should not be any skip Area Again scoop the tract & confirm the cleanness Now close the internal opening with P.D.S. Interrupted Suture ( Distal to Proximal) to Achieve Water tight Closer. ( *Parallel to Dentate line) ANAL FISTULA- FiLaC Steps

36. 15 th post-op day

37. FiLaC ADVANTAGES

38. Pilonidal Sinus is a little gap, passage or pit that is created at the highest point of the rear end between the buttocks where they meet at the base of the tailbone causing recurrent episode of pus or blood discharge from it, with or without pain PILONIDAL SINUS

39. It isn’t clear why few people build pilonidal abscess, but certainly irregular hair development is typically at fault. Hair may push into the hair follicles of skin, which might burst in long run. Different components may include: • Being hairier than normal • Curlier hard body hair type • Sitting for long periods • Tight garments • Friction • Personal cleanliness issues PILONIDAL SINUS- CAUSES

40. PILONIDAL SINUS- TREATMENT

41. OPEN SURGERY Takes time to heal Needs dressing for long time Pain

42. LIMBERG FLAP SURGERY

43. PILONIDAL SINUS- LASER SURGERY

44. Immediate post-op 15 th post-op day PILONIDAL SINUS- LASER SURGERY

45. LASER SURGERY BENEFITS

46. Anal fissure is a little tear or split in the coating of the anus. It might happen while passing hard stools. It can bring about sharp pain and bleeding during and after defecation. ANAL FISSURE

47. It can bring about at least one of the accompanying symptoms: A noticeable tear in the skin around the rear-end. A skin tag or a little chunk of skin. Severe pain during defecation. Streaks of blood on stools or on tissue paper subsequent to wiping. Burning or tingling in the butt-centric range. ANAL FISSURE- SYMPTOMS

48. Anal fissure regularly happens while passing hard stools. Chronic constipation or frequent diarrhoea can also be a cause. Other basic causes include: Straining amid delivery Decreased blood stream to the anorectal range Overly tight or spastic butt-centric sphincter muscle In uncommon cases, a butt-centric gap might be created due to: Anal tumor HIV Tuberculosis Herpes After chemotherapy or major surgery. ANAL FISSURE- CAUSES

49.   Sitz bath ???? Ointment (like Nifedipine/Diltiazem) Laxatives (like Isabgol , liquid paraffin, Picosulfate ) Medicines(like oxyrutin ) Surgery- Anal Dilatation Closed lateral internal sphincterotomy Laser sphincterotomy ANAL FISSURE- TREATMENT

50. Day-care procedure . Post-op dressing is not required. Maximum pain relief is obtained in first 24 hours. Can be done in pregnant or lactating patients. Can also be done in CABG (heart surgery) patients. Chances of infections and post-op bleeding are minimal. No risk of incontinence. ANAL FISSURE- LASER TREATMENT ADVANTAGES

51. IS IT ENTIRELY SAFE

52. THANK YOU