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8/3/2019 Ass Ni Rhogie

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Cesarean section

Definition

A cesarean section (also referred to as c-section) is the birth of a fetus accomplished by

performing a surgical incision through the maternal abdomen and uterus.

Purpose

A c-section allows safe and quick delivery of a baby when a vaginal delivery is not

possible. The surgery is performed in the presence of a variety of maternal and fetal

conditions with the most commonly accepted indications being complete placenta previa,

cephalopelvic disproportion (CPD), placental abruption, active genital herpes, umbilical cord

prolapsed, failure to progress in labor or dystocia, proven no reassuring fetal status, and

benign and malignant tumors that obstruct the birth canal. Indications that are more

controversial include breech presentation, previous c-section, major congenital anomalies,

and cervical cerclage. C-sections have a higher maternal mortality rate than vaginal births

with approximately 5.8 women per 100,000 live births dying, and half of these deaths are

ascribed to the operation and a coexisting medical condition. Perinatal morbidity is associated

with infections, reactions to anesthesia agents, blood clots, and

Precautions

There are some precautions any pregnant woman can follow to enhance her chances of

preventing a c-section. These include the following:

She should check her doctor's c-section rate to see if it is unnecessarily high. Shecan ask what his/her rate is and verify it by checking with the labor and delivery nurses at the

hospital or with a childbirth educator.
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She should not stay on her back during labor. She can walk, rock, or use a hotshower or whirlpool.

From the beginning, she should discuss with her doctor that she wants to avoidhaving a c-section if at all possible and enlist his opinion on how to achieve it.

Studies show that women who go to the hospital early have a higher c-section ratethan those who do not. Therefore, when labor starts, the woman should stay home for as long

as she safely can. She should not go in if contractions are further apart than four to five

minutes.

She should use a midwife since studies show that they have a higher percentage ofnatural childbirths without surgical intervention than obstetricians do.

She should hire a doula to assist during labor birth. Doulas have a lower c-sectionrate and can offer massage, different positions, and support alternatives during the difficult

phases of labor.

She should gather as much information as possible on hospital policies to educateher and then discuss this information with her doctor or midwife. She should keep an open

mind and stay informed.

Preparation

There is no perfect anesthesia for a c-section because every choice has its advantages

and disadvantages. When a c-section becomes necessary and if it is not an emergency, the

mother and her significant other should take part in the choice of anesthetic by being

informed of risks and side effects. The anesthesia is usually a regional anesthetic (epidural or

spinal), which makes her numb from below her breasts to her toes. In some cases, a general

anesthetic will be administered if the regional does not work or if it is an emergency c-

section. Every effort should be made to include the significant other in the preparations and

recovery as well as the surgery if at all possible. An informed consent needs to be signed, and

the physician should explain the surgery at that time. The mother may already have an


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intravenous (IV) line of fluid running into a vein in her arm. A catheter is inserted into her

bladder to keep it drained and out of the way during surgery and the upper pubic area is

usually shaved. Antacids are frequently administered to reduce the likelihood of damage to

the lungs should aspiration of gastric contents occur. The abdominal area is then scrubbed

and painted with betadine or another antiseptic solution. Drapes are placed over the surgical

area to block a direct view of the procedure.

The type of skin incision, transverse or vertical, is determined by time factor, preference

of mother, or physician preference. Two major locations of uterine incisions are the lower

uterine segment and the upper segment of the body of the uterus (classical incision). The

most common lower uterine segment incision is a transverse incision because the lower

segment is the thinnest part of the pregnant uterus and involves less blood loss. It is also

easier to repair, heals well, is less likely to rupture during subsequent pregnancies and makes

it possible for a woman to attempt a vaginal delivery in the future. The classical incision

provides a larger opening than a low transverse incision and is used in emergency situations,

such as placenta previa, preterm and macrosomic fetuses, abnormal presentation, and

multiple births. With the classical incision, there is more bleeding and a greater risk of

abdominal infection. This incision also creates a weaker scar, which places the woman at risk

for uterine rupture in subsequent pregnancies.

Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The

time from the initial incision to birth is typically five to ten minutes. The umbilical cord is

clamped and cut, and the newborn is given to the nursery personnel for evaluation. Cord

blood is normally obtained for analysis of the infant's blood type and pH. The placenta is

removed from the mother and her uterus is closed with suture. The abdominal area may be

closed with suture or surgical staple. The time from birth through suturing may take 30 to 40

minutes. The entire surgical procedure may be performed in less than one hour. Physical

contact or holding of the newborn may take place briefly while the mother is on the operating


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table if the baby is stable. The significant other can go with the baby to the nursery for the

remainder of the operation.

Aftercare

Immediate postpartum care after a c-section is similar to post-operative care with the

exception of palpating the fundus (top of the uterus) for firmness. If an epidural or spinal

were used, Duramorph (a pain medication similar to morphine) is often administered through

these catheters just prior to completion of surgery. It does very well in controlling pain but

may cause itching, which can be managed. During recovery the mother is encouraged to turn,

cough , and deep breathe to keep her lungs clear, and the neonate is usually brought to themother to breastfeed if she so desires. The mother will be encouraged to get out of bed about

eight to 24 hours after surgery. Walking stimulates the circulation to avoid formation of

blood clots and promotes bowel movement. Once discharged home, the mother should limit

stair climbing to once a day, and she should avoid lifting anything heavier than the baby. It is

important to nap as often as the baby does and make arrangements for help with the

housework, meals, and care of other children. Driving may be resumed after two weeks,

although some doctors recommend waiting for six weeks, which is the typical recovery

period from major surgery.

Risks

The maternal death rate for c-section is less than 0.02 percent (5.8 per 100,000 live

births), but that is four times the maternal death rate associated with vaginal delivery. The

mother is at risk for increased bleeding from two incision sites and a c-section usually has

twice as much blood loss as a vaginal delivery during surgery. Complications occur in less

than 10 percent of cases, but these complications can include an infection of the incision,
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urinary tract, or tissue lining the uterus (endometritis). Less commonly, injury can occur to

the surrounding organs, i.e., the bladder and bowel.

Normal results

The after-effects of a c-section vary, depending on the woman's age, physical fitness,

and overall health. Following this procedure, a woman commonly experiences gas pains,

incision pain, and uterine contractions, which are also common with vaginal delivery. The

hospital stay may be three to four days. Breastfeeding the baby is encouraged, taking care

that it is in a position that keeps the baby from resting on the mother's incision. As the woman

heals, she may gradually increase appropriate exercises to regain abdominal tone. Fullrecovery may be seen in four to six weeks.

The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75

percent, especially when the c-section involved a low transverse incision in the uterus, and

there were no complications during or after delivery.

Of the hundreds of thousands of women in the United States who undergo a c-section

each year, about 500 die from serious infections, hemorrhaging, or other complications.

These deaths may be related to the health conditions that made the operation necessary and

not simply to the operation itself.

Parental concerns

Undergoing a c-section may inflict psychological distress on the mother, beyond

hormonal mood swings and postpartum depression. The woman may feel disappointment and

a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father

or birthing coach is not with her in the operating room or if she is treated by an unfamiliar

doctor rather than by her own doctor or midwife. She may feel helpless from a loss of control


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over labor and delivery with no opportunity to actively participate. To overcome these

feelings, the woman needs to understand why the c-section was crucial. It is important that

she be able to verbalize an understanding that she could not control the events that made the

c-section necessary and recognize the importance of preserving the health and safety of both

herself and her child. Women who undergo a c-section should be encouraged to share their

feelings with others. Hospitals can often recommend support groups for such mothers.

Women should also be encouraged to seek professional help if negative emotions persist.


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PROSTATECTOMY

Method of Prostatectomy

- TURP

- Open prostatectomy- Laparoscopic

INDICATIONS

- enlarged lateral lobes of prostate

- enlarged median lobe

TRANSURETHRAL RESECTION

- Removal of prostatic tissue perurethrally

- No incision

- Less operative time

- Early mobilization

- Less post . op. complications

- Early recovery

INSTRUMENTS & MATERIALS

- Cystoscope

- Resectoscope

- Cautery ( diathermy )

- Irrigating fluid

ANAESTHESIA

- Spinal anaesthesia

- Epidural anaesthesia

- General anaesthesia

POSITION OF THE PATIENT

- Lithotomy position

COMPLICATIONS

- Haemorrhage

- Stricture

- rupture urethra

- Incontinence


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Bilateral Tubal Ligation

The bilateral tubal ligation procedure in women is a form of sterilization which involves

severing or sealing the fallopian tubes. It can be performed under local or general

anesthesia depending on the surgeons instructions. Tubal ligation can be done onwomen who have just had a normal vaginal birth or to women who are not pregnant but

want to become sterilized. Many women consider having this procedure done because it

gives them sexual freedom, and married women prefer to undergo a bilateral tubal

ligation procedure as a permanent means of family planning.

However, before a woman decides to undergo this kind of operation, she should consider

several factors, some of which are the potential risks of a bilateral tubal ligation

procedure. Like all operations, tubal ligation can be risky for the patient as several

problems might occur such as infection, blood clots, bleeding, allergic skin reactions,

blood vessel injury or adverse reactions to anesthesia or medication. These are just

minor complications though, and they are not likely to happen if the patient coordinates

well with her surgeon before the bilateral tubal ligation procedure. The patient should

inform her doctor of any medical conditions she might have, especially allergies to

drugs.

Bilateral tubal ligation is a procedure done to prevent any more pregnancies in women; it

is basically vasectomys counterpart in terms of sterilization. Its said to have an

effectiveness rate of around 99 percent, so this type of procedure fails in only about 10

out of a thousand women.

The bilateral tubal ligation procedure basically eliminates the middle man in

fertilization, the fallopian tubes. During fertilization, the sperm cells travel up the

fallopian tubes to fertilize the ovum, so obstructing or severing the tubes will prevent

them from meeting. The procedure involves cauterizing (burning), clipping, cutting, or

tying the fallopian tubes.

There are some advantages and disadvantages to undergoing bilateral tubal ligation, and

couples are normally advised to think it over before undergoing the procedure. It is

considered a permanent sterilization, though reversal is possible. Tubal reversal is

usually done by a specialist microsurgeon for higher chances of success since most

ligation methods dont leave enough of the fallopian tubes to reconnect together again.


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METHODS

Partial salpingectomy is a bilateral tubal ligation method where the tubes are cut and

then sutured to obstruct them. The Pomeroy technique, a popular version of this ligation

method, entails tying a small loop of the tube together and then cutting off a segment of

the loop.

Another method used in performing bilateral tubal ligation is electrocoagulation or

cauterization. This method involves the use of electric current coagulates that burn a

small part of the fallopian tubes. Electric current enters and leaves through a forcepsends when using bipolar coagulation, while the current leaves through an electrode in the

patients thigh if unipolar coagulation is used.

Silicone rings can also be used in bilateral tubal ligation procedures. With this method,

the fallopian tubes are blocked by tubal rings that are similar to clips. When a smallsilicone ring encircles the fallopian tube, the blood supply to that small loop will be

blocked, resulting in the scarring of that loop.

Another common method used in performing bilateral tubal ligation employs the use of

clips. These clips inhibit the flow of blood to a portion of the fallopian tube by clamping

a part of the tube. When blood flow is blocked, scarring or fibrosis will take place which

prevents the fertilization of egg. The Filshie clip which is made from titanium and the

Wolf clip which is made from plastic are the two most commonly used clips.

PROCEDURE

After your anesthesia takes effect, to help reduce the chance of infection, the surgical

area will be washed with a special disinfectant solution, and you will be covered with

sterile sheets.

Your doctor will begin the tubal ligation surgery by making a small incision, or cut, in or

below your navel. Your doctor will then place a finger into your abdomen and locate the

first fallopian tube. The tube will then be gently pulled out through the incision.

Absorbable threadlike material will be tied around the tube, creating a small loop. A part

of the loop will then be removed. The tube is then returned to the abdomen. The process

is repeated on your other fallopian tube. This threadlike tie will dissolve on its own, and

the two ends of the cut tube will separate and remain closed.


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After both tubes have been tied off and cut, your doctor will then stitch the incision in

your navel closed and a sterile bandage will be applied. Over time, these stitches will be

dissolved by your body. Tubal ligation surgery itself lasts between 15 and 45 minutes.

Tubal ligation or tubectomy (informally known as getting one's "tubes tied") is a form of

female sterilization, in which the fallopian tubes are severed and sealed or "pinched

shut", in order to prevent fertilization.

Procedure

There are mainly four occlusion methods for tubal ligation, typically carried out on the

isthmic portion of the fallopian tube, that is, the thin portion of the tube closest to theuterus.

Partial salpingectomy, being the most common occlusion method. The fallopiantubes are cut and realigned by suture in a way not allowing free passage. The

Pomeroy technique, is a widely used version of partial salpingectomy, involving

tying a small loop of the tube by suture and cutting off the top segment of the

loop. It can easily be applied via laparoscopy. Partial salpingectomy is considered

safe, effective and easy to learn. It does not require any special equipment to

perform; it can be done with only scissors and suture. Partial salpingectomy is not

generally used with laparoscopy.

Clips: Clips clamp the tubes and inhibits blood flow to the portion, causing asmall amount of scarring or fibrosis, in turn, preventing fertilization. The most

commonly used clips are the Filshie clip, made of titanium, and the Wolf clip (or

"Hulka clip"), and made of plastic. Clips are simple to insert, but require a specialtool to put in place.

Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically. Itencircles a small loop of the fallopian tube, blocking blood supply to that small

loop, resulting in scarring that blocks passage of the sperm or egg. A commonlyused type of ring is the Yoon Ring, made of silicone.

Electrocoagulation or cauterization: Electric current coagulates or burns a smallportion of each fallopian tube. It mostly uses bipolar coagulation, where electric

current enters and leaves through two ends of a forceps applied to the tubes.

Bipolar coagulation is safer, but slightly less effective than unipolar coagulation,
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which involves the current leaving through an electrode placed under the thigh. Itis usually done via laparoscopy.

Interval tubal ligation is not done after a recent delivery., in contrast to postpartum tubal

ligation.

In addition, a bilateral salpingectomy is effective as a tubal ligation procedure. A tubal

ligation can be performed as a secondary procedure when a laparotomy is done; i.e. a

cesarean section. Any of these procedures may be referred to as having one's "tubestied."

Tubal ligation can be performed under either general anesthesia or local anesthesia

(spinal or epidural, often supplemented with a tranquilizer to calm the patient during the

procedure). The default in tubal ligations following on from cesarean birth is usually

spinal/epidural, while the default in non-childbirth related situations may be generalanesthesia as a matter of doctor preference. However, tubal ligations under local

anesthesia, either inpatient or outpatient, may be performed under patient request.

Entry to the site of tubal ligation can be done in many forms; through a vaginal

approach, through laparoscopy, a minilaparotomy ("minilap"), or through regular

laparotomy.

Effectiveness

A tubal ligation is approximately 99% effective in the first year following the procedure.In the following years the effectiveness may be reduced slightly since the fallopian tubes

can, in some cases, reform or reconnect which can cause unwanted pregnancy. Method

failure is difficult to detect, except by subsequent pregnancy, unlike with vasectomy or

IUD. If pregnancy does occur it carries a 33% chance of being an ectopic pregnancy.

Two economic studies suggest that laparoscopic bilateral tubal ligation could be less

cost-effective than the Essure procedure, which uses a special type of fiber to induce a

benign fibrotic reaction.

Reversal

Generally tubal ligation procedures are done with the intention to be permanent. Tubalreversal is microsurgery to repair the fallopian tube after a tubal ligation procedure.

Usually there are two remaining fallopian tube segmentsthe proximal tubal segment

that emerges from the uterus and the distal tubal segment that ends with the fimbria next
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to the ovary. The procedure that connects these separateds of the fallopian tube is calledtubal reversal or microsurgical tubotubal anastomosis.

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of

the fallopian tube and no proximal tubal opening into the uterus. This may occur when

monopolar tubal coagulation has been applied to the isthmic segment of the fallopian

tube as it emerges from the uterus. In this situation, a new opening can be created

through the uterine muscle and the remaining tubal segment inserted into the uterine

cavity. This microsurgical procedure is called tubal implantation, tubouterineimplantation, or uterotubal implantation.

Tubal reversal, if done by a specialist microsurgeon, has a high success rate and few

complications. Successful repair of the fallopian tubes is now possible in 98% of womenwho have had a tubal ligation, regardless of the type of sterilization procedure.

In vitro fertilization may overcome fertility problems in patients not suited to a tubal

reversal.

Prevalence

Worldwide, female sterilization is used by 33% of married women using contraception,

making it the most common contraceptive method. As of June 2010, there is a recent

decline of tubal ligation procedures in the United States after two decades of stable rates,

possibly explained by an improved access to a wide range of highly effective reversible

contraceptives.

Advantages and disadvantages

Tubal ligation is a more major surgery than vasectomy. One study found that

postoperative complications from tubal ligation are more likely than with vasectomy and

more costly. However, this study did not consider post-vasectomy pain syndrome. In

industrialized nations, mortality is 4 per 100,000 tubal ligations, versus 0.1 per 100,000

vasectomies.

Tubal ligation has a larger initial cost than other contraceptive methods. Typicallyvasectomies are more cost-effective than tubal ligation because they are less expensive.

It may take more than a decade of use for tubal ligation to become as cost-effective as

other highly effective, long term methods like IUD or implant. Continued method costs

or costs from unintended pregnancies make many other methods as or more costly than

tubal ligation if used for several years. The cost of tubal ligation is reduced if it is
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performed during a cesarean section since the tubes are already exposed during thelaparotomy.

Tubal ligation may reduce the risk ofovarian cancer, with some studies estimating the

relative riskat 0.66 for epithelial types, 0.40 for endometrioid types and 0.73 for seroustypes.
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Phacoemulsification

form of cataract removal is a cataract surgery in which an

ultrasonic device is used to break up

and then remove a cloudy lens, or

cataract, from the eye to improve

vision.

Involves removing the eye's naturallens while leaving in place the back

of the capsule, which holds the lens in place.

When the natural lens becomes cloudy,

usually because of the aging process, it

keeps light rays from passing through ordiffuses the light in such a way that vision

becomes fuzzy or hazy.

Cataracts also can occur anytime because of

injury, exposure to toxins, or diseases such as

diabetes. Congenital cataracts are caused by

genetic defects or developmental problems, or

exposure to some contagious diseases during

pregnancy.

Purpose

Phacoemulsification, or phaco, as

surgeons refer to it, is used to restore

vision in patients whose vision has

become cloudy from cataracts. In the first

stages of a cataract, people may notice

only a slight cloudiness as it affects only a

small part of the lens, the part of the eye

that focuses light on the retina. As thecataract grows, it blocks more light and

vision becomes cloudier. As vision

worsens, the surgeon will recommend

cataract surgery, usually phaco, to restore

clear vision. With advancements in

cataract surgery such as the IOL


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through the same incision that was used to remove the cataract.

The folded lens is pushed out of the tube by a tiny plunger and, as

it unfolds, is positioned by the surgeon in the center of the lens capsule.

Risks

Complications are unlikely, but can occur. Patients may

experience spontaneous bleeding from the wound and recurrent

inflammation after surgery. Flashing, floaters, and double vision

may also occur a few weeks after surgery. The surgeon should be

notified immediately of these symptoms. Some can easily be

treated, while others such as floaters may be a sign of a retinal

detachment.

Retinal detachment is one possible serious complication. The

retina can become detached by the surgery if there is anyweakness in the retina at the time of surgery. This complication

may not occur for weeks or months.

Infections are another potential complication, the most serious

being endophthalmitis, which is an infection in the eyeball. This

complication, once widely reported, is much more uncommon

today because of newer surgery techniques and antibiotics.

Patients may also be concerned that their IOL might become

displaced, but newer designs of IOLs also have limited reports of intraocular lens

dislocation.

After Care / Management

Immediately following surgery, the patient is monitored in an

outpatient recovery area. The patient is advised to rest for at

least 24 hours, until he or she returns to the surgeon's office

for follow-up. Only light meals are recommended on the day of

surgery. The patient may still feel drowsy and may experience

some eye pain or discomfort. Usually, over-the-counter

medications are advised for pain relief, but patients shouldcheck with their doctors to see what is recommended. Other

side effects such as severe pain, nausea, or vomiting should be

reported to the surgeon immediately.

There will be some changes in the eye during recovery.

Patients may see dark spots, which should disappear a few

weeks after surgery. There also might be some discharge and


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itching of the eye. Patients may use a warm, moist cloth for 15

minutes at a time for relief and to loosen the matter. All matter

should be gently cleared away with a tissue, not a fingertip.

Pain and sensitivity to light are also experienced after surgery.

Some patients may also have slight drooping or bruising of the eye which will improve

as the eye heals.

Patients have their first postoperative visit the day after

surgery. The surgeon will remove the eye shield and prescribe

eye drops to prevent infections and control intraocular

pressure. These eye drops are used for about a month after

surgery.

Patients are advised to wear an eye shield while sleeping, andrefrain from rubbing the eye for at least two weeks. During that

time, the doctor will give the patient special tinted sunglassesor request that he or she wear current prescription eyeglasses

to prevent possible eye trauma from accidental rubbing or

bumping. Unlike other types of cataract extraction, patients

can resume normal activity almost immediately after phaco.

Subsequent exams are usually at one week, three weeks, and

six to eight weeks following surgery. This can change, however,

depending on any complications or any unusual postoperative

symptoms.

After the healing process, the patient will probably need new

corrective lenses, at least for close vision. While IOLs can

remove the need for myopic correction, patients will probably need new lenses for close

work.


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HEMORRHOIDECTOMY

REASON FOR VISIT

Internal hemorrhoidsInternal hemorrhoids that still cause symptoms after nonsurgical treatment.Large external hemorrhoids that cause significant discomfort and make it difficult tokeep the anal area clean.

Both internal and external hemorrhoids.Had other treatments for hemorrhoids (such as rubber band ligation) that have failed.Persistent itchingAnal bleedingPainBlood clots (thrombosis of the hemorrhoids)Infection

RISK ASSESSMENT

Bleeding disorderAdvanced agePrior anal surgery History of fecal incontinence (involuntary leaking of stool)History of allergies to medicationHistory of allergies to anesthesia.

PREPARATION OF THE PATIENT

Blood tests Urine tests Chest x-ray Digital examination Anoscope Sigmoidoscopy and colonoscopy
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EKG/ECG Enema was given Aspirin and other blood thinning medications were stopped before procedure Patient was on fasting for _____hrs before the procedure

ANESTHESIA:

General anesthesia Spinal anesthesia Local anesthesia

POSITION OF THE PATIENT

Lithotomy position

Prone position

THE PROCEDURE:

Types:

Stapled Hemorrhoidectomy

Open Hemorrhoidectomy Closed Hemorrhoidectomy

STAPLED HEMORRHOIDECTOMY:

A circular, hollow tube was inserted into the anal canal.Through this tube, a suture (a long thread) was placed, actually woven,circumferentially within the anal canal above the internal hemorrhoids.

The ends of the suture were brought out of the anus through the hollow tube.The stapler was placed through the first hollow tube and the ends of the suture werepulled.

Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jawsof the stapler.
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The hemorrhoidal cushions were pulled back up into their normal position withinthe anal canal.

The stapler was then fired. When it fires, the stapler cuts off the circumferentialring of expanded hemorrhoidal tissue trapped within the stapler and at the same time

staples together the upper and lower edges of the cut tissue.

OPEN HEMORRHOIDECTOMY (MILLIGANMORGAN TECHNIQUE)

The anal canal and lower rectum were manually cleaned by using soft moist tissues,and antiseptic solution was applied to the buttocks and anus.

Adrenaline in bupivacaine or lignocaine injection was given at three or four sitesaround the anus to constrict the blood vessels and reduce bleeding.

The hemorrhoids were teased out gently with the finger.Small forceps were clipped on the base of each hemorrhoid and the pile was pulledout gently to expose the apex, onto which a second forceps were clipped on.

This produces a triangular shape, called triangle of exposure which marks out theshape of the tissue to be cut.

Starting at the wide base, then dissects the hemorrhoidal tissue slowly from theunderlying sphincter muscle. The wound was then dried, by using diathermy

/cauterization by electricity /ligature/ suturing.

At the end of the dissection, three triangular-shaped wounds were created with awide base of approximately ___cm.

At this time, the hemorrhoidal mass was still attached at the apex, just above thedentate line. The excision of the hemorrhoid mass was completed by first ligating the

pedicle/ stalk with a fine surgical suture.

At the end of this step, three dry and clean triangular wounds are left, separated bythree skin bridges of 2.0 cm width or more.

At the end of the operation, a single layer of non-adhesive gauze was used to dressthe wounds.

CLOSED HEMORRHOIDECTOMY

Hill-Ferguson retractor was inserted into the anal canal. A plan for removing the affected hemorrhoid was then established.
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A knife was used to make a circular incision starting at the dentate line andextending well past the anal verge around the hemorrhoid.

Scissors were then used to lift the skin from the external sphincter. The mucosa was freed from the internal sphincter cephalad The incisions will reveal the muscle of the Treitz anchoring the internal sphincter

to the mucosa.

The mucosa suspensory ligament was divided using the scissors. The proximal part of the internal sphincter was cut free and the hemorrhoid

complex was removed.

A partial and superficial internal sphincterotomy was performed at the base of thewound.

The wound was closed with sutures.

AFTER PROCEDURE

Patient was shifted to intensive care unit

DURATION

________hrs

POSTOPERATIVE CARE

Take pain medication as prescribedTake antibiotics as prescribedSoaking in a sitz bath (a shallow bath of warm water) several times a day helps easethe discomfort.

Use a donut ring (cushion with a hole in the middle) can make sitting upright morecomfortable.

Avoid constipationEat a high-fiber diet and drink plenty of liquids.Avoid heavy lifting for 2 to 3 weeks.

COMPLICATIONS
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Constipation Excessive bleeding Excessive discharge of fluid from the rectum Inability to urinate or have a bowel movement Severe pain, especially when having a bowel movement Hematoma formation Infection of the surgical area fecal Impaction Stenosis of the anal canal Recurrence of hemorrhoids Fistula formation Rectal prolapse
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