(Reference to the original article published in Chinese Journal of General Surgery, Vol. 10, 2011; Luo Yong One-time radical treatment of perianal abscess by open-window drainage with hanging wire: with 214 case reports)
Perianal abscess is a purulent infection of the perianal rectal space tissue, and is a common clinical disease in anorectal surgery. Mixed infections with Gram-negative bacilli and anaerobic bacteria predominate. Patients often do not pay enough attention at the initial onset, and most of them have abscess formation by the time they come to the clinic. The main manifestations are pain and masses around the anus. The diagnosis is confirmed by perianal finger diagnosis and ultrasound of the perianal and rectal cavity. Further development of the disease mostly breaks down on its own, but it can also develop to high interstitial space to complicate the disease. Incision and drainage alone cannot shorten the course of the disease, and the disease may develop elsewhere over time or form complex intractable anal fistulas, which increases the pain of patients. Therefore, for all types of perianal abscesses, one-time radical surgery is the best method of choice, and the sooner the surgery is performed, the better. The authors insisted on the treatment principle of performing radical surgery as soon as the diagnosis was confirmed, and adopted open-tube drainage with hanging wire for 214 cases of abscesses in the sciorectal space and pelvic rectal space, with a one-time cure rate of 96.7% in the postoperative follow-up period of 9 months to 3 years. Luo Yong, Department of General Surgery, Affiliated Hospital of Inner Mongolia Medical University
In terms of specific surgical methods, the authors’ experience is that in the acute stage of perianal abscess, the anatomical relationship around the anal canal is not very clear at this time due to inflammation and edema. It is not necessary to force a one-time incision for scirorectal interstitial abscess, but to find the internal opening and selectively open a window for drainage plus hanging thread according to the height of the position, so that there is no need to worry about damaging the anorectal ring and causing damage to the anal contractile function. It has been reported that the total incision or excision of the fistula through the superficial part of the external sphincter can cause damage to the function of the anal sphincter to some extent, and the role of the subcutaneous and superficial part of the anal sphincter cannot be ignored. At the same time, after hanging the wire, due to chronic cutting, the trauma to the anal canal is smaller, which also facilitates postoperative management. The hanging wire was loosened and tightened appropriately, and postoperative injection of long-acting analgesic into the sphincter area and trauma at both ends of the hanging wire could effectively reduce the spastic pain of the internal sphincter. Most of the cases in the whole group were dislodged after 7-10 days and discharged from the hospital after 14-20 days.
It is very important to accurately find the internal orifice during surgery to ensure the success of the operation. During the operation, the hard nodes or depressions near the tooth line can be touched with the index finger, which is the location of the internal orifice. For patients with inconspicuous internal orifices, especially those with a long duration of disease of more than 10 d, this is mostly seen in high abscesses in the pelvic-rectal space, or after the application of a large number of antibiotics, when the internal orifices have mostly formed fibrinous healing and are difficult to find. However, the real foci of abscess endografts that need to be searched for and treated are usually in the rectal sinus near the dentate line. The author experienced that the action of finding the internal mouth should be “light” and “smart”, and the deepest and highest part of the abscess cavity is not necessarily where the internal mouth is located. reliable. High abscesses are usually formed when the abscess passes above the deep part of the sphincter, but the internal opening is always in the anal sinus. When the internal opening cannot be found, the hanging of the wire from the highest part of the abscess cavity is performed, which has more postoperative complications and is prone to recurrence or formation of different degrees of air and fecal leakage or even anal incontinence. It is better to give up the hanging thread than to force it.
During surgery, the window incision should be correctly designed according to the scope of the abscess cavity and the location of the internal port. We should master the principles of vertical hanging, unobstructed drainage and no dead cavity. First of all, according to the position of the internal orifice, the window should be chosen to be perpendicular to the internal orifice and 2 cm away from the anal edge. The posterior rectal hiatus is then connected to the contralateral side. According to the rule that the internal opening of high abscess is mostly located at the posterior median anal sinus, a window can be opened at 11 or 1 point of the thoracic knee position, and the internal opening can be found and then hung vertically. For horseshoe type multiple interstitial abscess, multiple windows need to be opened to place multiple drainage tubes. When the window is opened, the abscess cavity should be formed as small as possible to facilitate drainage. For pelvic-rectal interstitial abscess, because the abscess cavity is deep, simply opening a window still cannot achieve the purpose of adequate drainage, so the reasonable placement of drainage tubes becomes very important. Silicone drainage tubes of 18#-20# are used and placed in the deepest part of the abscess cavity after completion of hanging, and 2-3 of them can be placed in different directions as needed. The authors experience that the drainage tube can be placed anywhere in the abscess cavity, especially for high pelvic-rectal space abscesses, which ensures unobstructed drainage. It can also flush the abscess cavity after surgery, which is important for reducing pain during dressing changes, inhibiting anaerobic bacterial infection, and promoting healing of the abscess cavity.