HAEMORRHOIDAL ARTERIAL LIGATION

Haemorrhoidal disease is a common problem, with a clear impact in patients´s quality of life. Usually associated with pain, pruritus (meaning perianal itching) and haemorrhoidal prolapse, which can alter normal day activities.

Different tratments have been described, from conservative treatments in order to change alimentary and hygienic habits, up to more radical surgical techniques to try to ease this problem.

Arterial dearterialization was first described by Morinaga in 1995. Surgical technique implies localization of the haemorrhoidal plexus (meaning blood vessels feeding the haemorrhoid) by a doppler probe and then suturing it with a Stich. This procedure is repeated in all the haemorrhoids revelaed ( usually up to 6).

By this procedure, we can treat the haemorrhoid without excising it, thus allowing for a better postoperative recovery, associating less pain than coventional haemorrhoidal excision.

 

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RUBBER BAND LIGATION

By this procedure, a plastic band is placed around the haemorrhoid pedicle, thus causing ischemia of the tissue (by stopping blood supply) until the haemorrhoid and the band fall after 3 to 7 days.

This ambulatory, almost painless, procedure may be  recommended in the treatment of some cases of haemorrhoidal disease.

 

TAMIS (Transanal Minimally Invasive Surgery).

Surgical approach to rectal lesions may be difficult, due to the location of the disease. Abdominal surgical approach is related to an important rate of morbidity.

The implementation of Minimally Invasive Surgery to the transanal approach led to the appraisal of TAMIS.

By this technique, a Single Port surgical device is introduced transanally, thus allowing us to insert different instruments in order to complete the resection.

Different rectal lesion can be treated by this technique, like benign tumors non resectable by endoscopy, and even malignant lesion in early stage.

Correct preoperative staging of the lesion is mandatory in order to evaluate the indication for TAMIS.

RECTOCELE

A rectocele is defined as the protusion (hernia) of the rectum to teh posterior vaginal wall, (It can arouse uncommonly in males to the prostatic región)rectocele

It is indeed a common disease, frequently understimated, being tolerated by the patients for long periods of time, even when it can induce symptoms such as vaginal bulging (tipically when defecating), pain related to sexual intercourse (dyspareunia) and even prolapse of the rectocele trough the introitus.

It can often be associated to the Obstructive Defecation Syndrome(ODS), when a failure to relax the anal sphincter or pelvic floor muscles occurs while trying to defecate, therefore causing pain, constipation and tenesmus.

A rectocele can be treated by conservative measures such as bulky laxatives, high fiber diet, and adecuate water intake, but when this measures are not enough, a surgical repair may be needed.

This surgical intervention muy be done trough the vagina, rectum, perineum, or trough the abdomen (laparoscopic rectopexy), and sometimes by a combination of them.

Before a surgical approach to treat a pelvic floor disorder is chosen, including a rectocele, it is mandatory to perform a good medial examination, stablishing the severity and type of symptoms, on order to determine the best surgical treatment. Endorectal Ultrasound (ERUS) as well as ecodefecography are of great use in the diagnose of this pathology.

LAPAROSCOPIC RECTOPEXY

Pelvic floor disorders develop after a direct damage or by a weakness at the level of the pelvic floor muscles.

Frequently (but not only) affecting women after pregnancy and child delivery, and afterwards, when muscular weakness appears with aging.

This situation may lead to Pelvic Organ Prolapse (POP), as rectal, uterus and vagina (colpocele/uterine prolapse), urinary bladder ( cystocele) as well as rectocele (protusion of the rectum to the posterior vaginal wall).

By Laparoscopic rectopexy and/or sacrocolpopexy and rectopexy we can perform a global repair of the pelvic floor. By placing a mesh at this level we can, therefore, obtain proper correction of rectal prolapse, rectovaginal wall, as well as uterus, vaginal and bladder if needed.

Minimally invasive laparoscopic surgical approach diminishes agression, allowing for a quicker recovery and less postoperative pain.

SPHINCTEROPLASTY

Iatrogenic sphincteric lessions after surgery, specially obstetrics (after clild delivery) when instrumentation manouvers with forceps or an episiotomy were needed, are the main causes related to Fecal Incontinence associated to sphincter damage.

Surgical sphincter repair (Sphincteroplasty) consists on anal sphincter suturing or plication, allowing for an anatomical reconstruction of the anal canal. By this, we can achieve improvement or correction of fecal incontinence.

However, proper physical examination as well as Endorectal Ultrasound (ERUS) is mandatory, in order to locate the damage as well as the extension, so that we can perform a correct surgical reconstruction.

 

BULKING. Bulky agents injection for the treatment of fecal incontinence

The origin of Fecal Incontinence is multifactorial.

When a surgical repair is not possible, or when optimal results are not gained after applying other techniques is when this bulking procedure may be useful.

We can augmentate the sphincter by injecting a Bulky Agent, thus allowing for a better function and therefore, improving continence.

Different agents may be used, and lenght and periodicity of treatments may vary.

This minimally invasive therapy may be done as an ambulatory procedure, sometimes requiring mild sedation.

POSTERIOR TIBIAL NERVE STIMULATION (PTNS)

Many different alternatives may be used for the treatment of Fecal Incontinence, depending on the cause and severity of symptoms.

By stimulating the posterior tibial nerve (PTNS) we activate a retrogradous mechanism trough the cortex to the sacral nerve roots.

A needle electrode is inserted close to the medial malleolus (ankle) posterior to the tibia, stimulating the nerve at this level.

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The treatment is achieved by 30 min aprox. sessions weekly or twice a month, and this can be done ambulatory in the office.

By this almost painless therapy we can treat fecal as well as urinary incontinence, specially in cases when surgical approach is not recommended, as well as idiophatic cases.