International Journal of Science and Research (IJSR) ISSN (Online): 2319-7064 Index Copernicus Value (2013): 6.14 | Impact Factor (2015): 6.391 Volume 5 Issue 7, July 2016 www.ijsr.net Licensed Under Creative Commons Attribution CC BY The Surgical Treatment of the Anal Stricture Post Hemorrhoidectomy Milligan-Morgan. A Comparison of Two Operatory Techniques Enton Bollano PhD 1 , Krenar Lilaj PhD 2 , Dariel Thereska PhD 3 , Arben Gjata 4 1, 3 QSUT, Surgeon 2 QSUT, Anesthesiologist 4 Professor, QSUT, Surgeon Abstract: Surgical treatment of anal stricture in open posthemorrhoidectomy brings various complications to the open hemorrhoidectomy in 5%-10% of the cases. In books it is widely known as “the fibrotic benign stricture” or as “iatrogenic stricture”. Clinically, it is manifested with pain during defecation, minimal rectoragy and abdominal discomfort accompanied with a feeling of not having adequately emptied the bowels. Locally, it is manifested in the form of a rigid ring where even the small finger can hardly be penetrated. These symptoms can severely affect the quality of life in patients. Depending on the grade of the anal canal stricture, we can say that the anal stricture is found on three grades: light anal stricture, moderated anal stricture and expressed anal stricture. All our patients resulted in expressed anal stricture. In our research we have compared two operative techniques which were applied for the surgical treatment of the pathology. Partial posterior internal sphincterotomy technique with anoplastic in the open wound (SIPA) and the plastic with skin flap and closed internal lateral sphincterotomy, V-Y advancement flap (PLSL). Each technique aims at relaxing the anal canal with as less continence damage as possible and faster rehabilitation of the patient. The patients were divided into two groups: Group A of 15 patients treated with the SIPA technique and Group B of 14 patients treated with the PLSL technique. The study was conducted during February 2006 – March 2014. The results favored the PLSL technique. Keywords: surgical treatment anal stricture post hemorrhoidectomy Milligan-Morgan 1. Patients and Method This research summarizes the results of the surgical treatment in 29 patients diagnosed in open posthemorrhoidectomy anal stricture. The study was conducted during February 2006 – March 2014. Average age resulted: 47.21 year old (36-64 years old). The patients were called in for a visit after approximately 64.6 days (45- 78 days) after the first intervention. The second intervention was conducted within ten days from submission. It was performed with spinal anesthesia, by injecting 2 ml lidocain solution, 2 % in the intervertebral area L3-L4. Before surgery all patients had the routine tests done, were evaluated about the accompanying pathologies and were performed an anoscopy with pediatric anoscope (Hill- Ferguson) (1.5). Preoperative preparation consisted in light hydric diet for two days before surgery and four microclismas four and two hours before surgery. The A Technique consists in posterior excision of mucotaneous area approximately 0.5 cm along the circumference of the stricture ring. The intraanal excision extends to the Morgan crypt level, whereas the perianal excision approximately 0.5 cm from the anal margo. The excised material has the form of a trapezium. Later, a partial internal posterior sphincterotomy at the crypt level is performed. The last phase consists in fixing the anal mucous above the internal anal muscle with special vicruly sutures 3-0. Not more than four sutures. The wound below the suture’s line is left open. The B Technique consists in deep posterior intraanal linear incision at six o’clock, up to the level of Morgan crypts. The wound comes in the form of “V”. Then the incision extends in the perianal area, thus forming a “leather triangle” (a skin flap in the form of a triangle). The triangle legs must have almost the same length of the intraanal incision (3, 5, 9, 10). Then, the triangular skin flap moves along with the subcutaneous fat tissue (to maintain regular blood supply in the skin flap) and is fixed at the intraanal incision spot. For fixing the skin flap in the intraanal area we use special 3-0 vicryl sutures (2, 7, 9). In the end, a left lateral intern sphincterotomy with a round edge lancet (no. 15) is performed. The last stage of the surgery is the suturation of the perianal wound. Two are the key moments in this technique: 1) avoid tension during skin flap fixing and: 2) optimal blood supply in the skin flap. We have chosen the posterior part for performing this technique due to the fact that there were no manipulations in this area in the previous intervention. In both techniques we put perianal swab gauze, because intraanaly we have applied 5 ml of lidocaine gel, 2 %. Accompanying diseases resulted in: three patients suffered of HTA, stabilized under therapy; one patient was diagnosed with acalculous cholecystitis and; one patient was operated long ago of dexter inguinal hernia. None of the patients suffered of inflamatory pathologies of the colon or any kind of malign pathology. Most of the patients (25 in all) had undergone colonoscopy before the first intervention (hemorrhoidectomy). 2. Post Operative Follow Up Pain relief after surgery consisted in the application of a hydrochloride morphine ampoule of 10 mg / ml Paper ID: ART2016697 DOI: 10.21275/v5i7.ART2016697 2037