Suture (The Bleeding Worlds Book 2)

The mainstay of treatment therefore is surgical. But unfortunately, operative hemorrhoidectomy is usually associated with significant postoperative complications, including pain, bleeding and anal stricture, which can result in protracted period of convalescence. Recent advances in instrumental technology have led to the development of the bipolar electro-thermal devices — ultrasonic scalpel, circular stapler and the ligasure vessel-sealing systems. Some of the surgical options for treating hemorrhoids include the following:.

Rubber band ligation, sclerotherapy, infrared photocoagulation, cryotherapy, manual anal dilatation, LASER hemorrhoidectomy, the harmonic ultrasonic scalpel hemorrhoidectomy, Doppler-guided hemorrhoidal artery ligation, and the new atomizing technique that uses the atomizer wand to excise and vaporize hemorrhoids. Most nonoperative procedures are reserved for first- and second-degree hemorrhoids and are usually carried out on outpatient basis. Operative hemorrhoidectomies are reserved mainly for third- and fourth-degree hemorrhoids.

Bleeding from first-, second- and some selected third-degree hemorrhoids can be treated by rubber band ligation. By this method, mucosa cm above the dentate line is grasped and pulled into a rubber band applier the Barron gun.

After firing the gun, the rubber strangulates the underlying tissue causing scarring and preventing further bleeding and prolapse. Generally, only one or two quadrants are banded per visit. No anesthesia is required. Results are superior to those of injection sclerotherapy. A recent meta-analysis of hemorrhoidal treatment concluded that rubber band ligation was the initial mode of therapy for first- to third-degree hemorrhoids.

Mitchell of Illinois, USA first used carbolic acid for injecting hemorrhoids in The objective is to cause thrombosis of the vessels and promote fibrosis, which retracts the prolapse. Where possible, the Gabriel's syringe should be used.

It is specially adapted to pass through the proctoscope. Disposable syringes have however now replaced the Gabriel's syringe. Not more than 3 injections at 6-week intervals should be given in one phase of treatment. Complications are few, though infection and fibrosis have been reported. Infrared photocoagulation is an effective outpatient treatment for first- and second-degree hemorrhoids.

Exposure is for 1 second at each site. Results are similar to those of banding and sclerotherapy, but the procedure is less painful. This procedure is indicated for first-, second- and some selected third-degree hemorrhoids.

• Navigation menu?
• CUTTIN UP;
• TITIAN ; a collection of fifteen pictures and a portrait of the painter.

The cryoprobe of liquid nitrogen is applied to the hemorrhoid for about 3 minutes to produce liquefaction of frozen tissue, over the ensuing weeks. This procedure indicated mostly for second- and third-degree hemorrhoids was advocated by Lord in It aims to dilate the anal sphincter to accept 4 fingers of each hand and to maintain sphincter laxity by regular use of a dilator.

It is now largely abandoned due to the frequently occurring complication of incontinence, especially when combined with open hemorrhoidectomy. LASER therapy may be used alone or in combination with other modalities. The harmonic scalpel uses ultrasonic energy, which allows for both cutting and coagulation of hemorrhoidal tissue at precise points of application, resulting in minimal lateral thermal damage.

The vibrating blade at 55, Hz couples with protein and denatures it to form a coagulum that seals bleeding vessels. It is an outpatient procedure reserved for first- and second-degree hemorrhoids.

chapter and author info

It however has longer operating time and more pain when compared to the ligasure hemorrhoidectomy. The atomizer wand is an innovative wave form of electrical current wherein a specialized electrical probe excises or vaporizes one or more cell layers at a time, reducing the hemorrhoids to minute particles of fine mist or spray, which are immediately vacuumed away.

Results are similar to those of LASER hemorrhoidectomy except that there is less bleeding using the atomizer and that the atomizer costs less. Patient does not require hospital stay. Presently, atomizing hemorrhoids is offered exclusively in Arizona, USA.

This is also a new technique first described by the Japanese surgeon Kazumasa Morinaga in , who identified the hemorrhoidal arteries by means of a Doppler ultrasound technique. It is a day care procedure suitable for first-, second- and some selected third-degree hemorrhoids, and the patient goes home after sedation wears off. There is little or no bleeding postoperatively. Bowel preparation before operation minimizes fecal contamination and keeps the colon quiet for the first few days of the operative period.

This method is now obsolete but has the advantage in not having any form of dissection of tissue planes. The hemorrhoid is grasped in-between the insulated blades of Smith's pile clamp. The greater part of the hemorrhoid mass is then cut away with scissors, leaving only a stump, which is burned with heated copper cautery to arrest bleeding. The electric cautery or diathermy knives are unsatisfactory substitutes because they are ineffective in arresting hemorrhage and because the coagulating current may penetrate tissues too deeply.

The operation is reserved for second- to fourth-degree hemorrhoids and it is done under general anesthesia. This is the most commonly used technique and is widely considered to be the most effective surgical technique for treating hemorrhoids. Adotey and Jebbin in PortHarcourt, Nigeria, showed that open hemorrhoidectomy was the predominant surgical method for treating hemorrhoids. It is the procedure of choice for third- and fourth-degree hemorrhoids [ Figure 3 ]. This method was developed in the United Kingdom by Drs.

The dissection is carried cranially to the pedicle, which is ligated with strong catgut and the distal part excised [ Figure 4 ]. Other hemorrhoids are similarly treated, leaving a skin bridge in-between to avoid stenosis. The wound is left open and a hemostatic gauze pad left in the anal canal [ Figure 5 ]. The procedure is done under general or epidural anesthesia.

Postoperative pain and acute urine retention are common complications. Developed in the United States by Drs. Ferguson and Heaton in , this is a modification of Milligan-Morgan method described above. Here the incisions are totally or partially closed with absorbable running suture, following surgical excision of the hemorrhoids [ Figure 6 ].

The Ferguson method has no advantage in terms of wound healing because of the high rate of suture breakage at bowel movement. This procedure was developed in the s by Parks, who published results and details of the technique in It is indicated for second- to fourth-degree hemorrhoids. A Parks retractor is inserted. A point just below the dentate line at the hemorrhoid is grasped with a hemostat. A —mL saline containing 1: Scissors are used to excise a small diamond of anal epithelium around the hemostat. The incision is continued cranially for 2. This dissection is continued into the rectum, where the resulting broad base of tissue is suture-ligated and divided.

The mucosal flaps are then allowed to flop back into position. No suture or any intra-anal dressing is used. The same procedure is carried out on the other hemorrhoids. Parks hemorrhoidectomy is done under general or epidural anesthesia. It is safe and associated with low rates of complications and recurrence. A recent study by Yang et al. This procedure, also known as total or circumferential hemorrhoidectomy, was first described by Dr. Walter Whitehead in The procedure entails circumferential removal of the hemorrhoid, hemorrhoid-bearing.

Incisions are made by curved double-operating scissors just proximal to the dentate line and continued along this path around the anal canal in stages. Clamps are used to lift the cut edge of the hemorrhoid rectal -bearing mucosa and mucosal prolapse. The hemorrhoidal masses are then suture-ligated and excised, followed by closure of the incisions by suture. Here, a retractor is used to stretch the internal sphincter, so that the suture goes through the endoderm to the neo-dentate line. A hemostatic sponge is left in the anal canal.

The procedure is reserved only for circumferential hemorrhoids, and it is done under general or epidural anesthesia.

Recent works by Maria et al. It was first described in by Longo for prolapsing second- to fourth-degree hemorrhoids. A circular anal dilator is introduced into the anal canal. The prolapsed mucous membrane falls into the lumen after removing the dilator. A purse-string suture anoscope is then introduced through the dilator, to make a submucosal purse-string suture around the entire anal canal circumference [ Figure 7 ]. The circular stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string suture, which is then tied with a closing knot [ Figure 8 ].

The entire casing of the stapler is then pushed into the anal canal, tightened and fired to staple the prolapse. Firing the stapler releases a double-staggered row of titanium staples through the tissue [ Figure 9 ]. A circular knife excises the redundant tissue, thereby removing a circumferential column of mucosa from the upper anal canal. The staple line is then examined with the anoscope for bleeding, which if present may be controlled by placement of absorbable sutures.

The staple line should be maintained at a distance of Patients experience less pain and achieve a quicker return to work compared to conventional procedures; and bleeding is less. Radiofrequency waves ablate tissue by converting radio waves into heat.

The alternating current generates changes in the direction of ions within the tissue fluid. This creates ionic agitation and frictional heating, leading to coagulative necrosis of tissue. Thereafter, the hemorrhoids are plicated using strong absorbable sutures. The plication begins from the most distal end of the hemorrhoid at the anal verge and is carried towards the pedicle in a continuous locking manner and knotted at the pedicle, thereby fixing the hemorrhoidal mass.

The method entails use of three interrupted sutures to secure the hemorrhoids in place without excision. This operation is indicated mostly for second- to fourth-degree hemorrhoids. With the aid of a bipolar diathermy set on cutting and coagulation, dissection is carried from a V-shaped incision in the skin around the base of the hemorrhoid unto the pedicle, which is dissected and divided [ Figure 10 ].

The diathermy is set on coagulation only during dissection and division of the pedicle. No ligature is used. A randomized trial study by Andrews et al. The ligasure vessel-sealing generator is an isolated-output electrosurgical generator that provides power for vessel sealing and bipolar surgery. The Starion thermal welding system is similar to the ligasure generator but uses the tissue-welding technology to simultaneously fuse vessels and tissue structures closed. The operation is done under general or epidural anesthesia.

A V-shaped incision at the junction of the hemorrhoid and the peri-anal skin is made by a scalpel, followed by dissection of the hemorrhoidal bundles off the underlying sphincter. The ligasure or Starion handset is applied to the dissected hemorrhoids and activated to seal mucosal edges and divide the pedicle. A hemostatic sponge is inserted into the anal canal.

Early — severe postoperative pain lasting weeks; wound infection; bleeding; edema of the skin bridges; major short-term incontinence; difficult urination or urinary retention; delayed hemorrhage, usually days postoperatively,[ 40 ] which is probably due to sloughing of vascular pedicles or infection. Late — anal stenosis, formation of skin tags, recurrence. The surgical options for the treatment of hemorrhoids are many; and even though the majority of surgical techniques are based on the ligation and excision principles, newer techniques are designed to minimize tissue dissection with the aim of reducing postoperative pain and bleeding.

National Center for Biotechnology Information , U. J Surg Tech Case Rep. Author information Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Arax the Soul Stealer. Silver the Wild Terror. Rokk The Walking Mountain. Murk the Swamp Man. Jack and the Beanstalk.

Old England Fairy Tales. Krestor the Crushing Terror. Emman Hunt for a Monster. Ravira Ruler of the Underworld. The Friendly Creeper Diaries: The Moon City, Book 4: Snowball The Oddball Kobold. Knowledge of Good and Evil. Codes of Shovelry Handbook. The Girl from the Rune Yard. Inock Tehan and the Phantom of the Ruins. The King of the Creepers, Book 1: Dylan and the Captain. The Mountains of Kohqaf. How to write a great review.

The review must be at least 50 characters long. The title should be at least 4 characters long. Your display name should be at least 2 characters long. At Kobo, we try to ensure that published reviews do not contain rude or profane language, spoilers, or any of our reviewer's personal information.

• Join Kobo & start eReading today.
• Suture – The Bleeding Worlds Book 2.
• Lei che nelle foto non sorrideva (Italian Edition).
• Connect.
• The Count of Lopinot?

You submitted the following rating and review. We'll publish them on our site once we've reviewed them. Item s unavailable for purchase. Please review your cart.