Surgical Proctologic Emergency in Isolated Sea-Based Environment: How It Is Performed in the French Navy

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1 MILITARY MEDICINE, 178, 4:e498, 2013 Surgical Proctologic Emergency in Isolated Sea-Based Environment: How It Is Performed in the French Navy MAJ (OF 3) Emmanuel Hornez*; MAJ (OF 3) Julien Pontis ; MAJ (OF 3) Faye Rozwadowski ; COL (OF 5) Patrice Ramiara ; LT (OF 1) Stephane Bourgouin ; MG (OF 7) Bruno Palmier ; MG (OF 7) Herve Thouard ABSTRACT Proctologic emergency are very common and are a true challenge for a general practitioner (GP) in a sea-based environment. Performing simple surgical procedures could be essential for the management of these patients. Thrombosed external hemorrhoids are very painful and necessitate the extraction of the blood clot under local anesthesia. The perianal abscess and the pilonidal abscess are also painful entities and represent a significant septic risk. The surgical management of the latter two is simple but requires general anesthesia. Using ketamine and midazolam with these procedures offers a very high level of anesthetic safety. This short article describes the mentioned procedures that are richly illustrated. INTRODUCTION Proctologic emergencies are frequently encountered, yet their management is commonly challenging in an isolated environment. Aboard French warships, many GPs prefer to medically evacuate these patients to a surgical team rather than manage the problem alone. Two issues arise with these types of evacuations. First, delaying the time to surgical treatment increases the pain, the risk of septic complication, and the related morbidity. Secondly, the medical evacuation could be very difficult because of the operational setting and the geographical isolation of the warship, which leads to an even longer delay. In these situations, the GP must be able to practice basic proctologic surgery onboard. This short article is structured as a guideline for Navy practitioners. The pathologies are clearly depicted with illustrations. The goal is to permit the GP to manage the proctologic emergencies following the current recommendations without requiring a MEDEVAC. Thrombosed external hemorrhoids, perianal abscess, and pilonidal abscess are surgical problems that are discussed in this article. PROBLEMS WITH PROCTOLOGIC PATHOLOGY IN AN ISOLATED SEA-BASED ENVIRONMENT Limitations Associated With Pathology Proctologic emergencies are common and largely dominated by hemorrhoidal pathology, second by anal fissures, and last by infectious diseases. The great majority of these emergencies can be conservatively treated, which will not be discussed here. However, three situations require a rapid and simple surgical treatment: Thrombosed external hemorrhoids are the most frequent complication of hemorrhoidal disease and the only case in which an emergency surgical procedure is needed. A manual expulsion of the blood clot is recommended and usually permits an immediate remission of the pain. 1 5 The perianal abscess is secondary to a fistula that develops between an anal crypt and the skin. The path of the fistula can sometimes be complex and can travel through the anal sphincter. The major associated risk is the extension of the infection deep to the pararectal spaces. The worst complication is Fournier s gangrene. Antibiotics are not effective with these abscesses and surgical treatment is mandatory. 6 8 The pilonidal sinus abscess is commonly incorrectly classified as a proctologic emergency. The etiology of the pilonidal abscess is the incarceration of a hair under the skin, usually at the upper part of the sacrum. It is a chronic condition with occasional acute exacerbations. The sinus is sometimes extended under the skin, close to the anal margin, mimicking a perianal abscess. It is commonly painful and predisposes the patient to infectious complications. An emergent surgical debridement is needed *Department of Digestive Surgery, Military Teaching Hospital Percy, Clamart, France. Medical Service, Missile-Launching Nuclear Submarines Squadron, Brest, France. Earle Branch Health Clinic, Colts Neck, NJ. Intensive Care Unit, Military Teaching Hospital, Sainte Anne, Toulon, France. kdepartment of Digestive Surgery, Military Teaching Hospital, Sainte Anne, Toulon, France. doi: /MILMED-D Limitations Because of the Sea-Based Environment In France, the management of these pathologies is done in the emergency department or the operative room. In the French Navy, because of the isolation, the delay before medical evacuation is sometimes more than 48 hours long, necessitating surgical treatment to occur onboard. The French warships are usually staffed with a GP and a nurse who have completed specialized training for maritime medicine at the French military naval institute. e498

2 The ships are equipped with a medical center with advanced materials: ultrasound, monitoring devices, emergency and resuscitative medications, ventilator, X-ray, dental kit, etc. This basic equipment is usually sufficient to provide acute surgical care under secure conditions while ensuring an unaffected naval mission. PROCTOLOGIC EMERGENCY REQUIRING A SURGERY UNDER LOCAL ANESTHESIA: THE THROMBOSED EXTERNAL HEMORRHOIDS Clinical The patient presents for sudden and acute anal pain. There is no spontaneous remission. The clinical assessment of the anal margin shows a dark clot in an external hemorrhoid. It is tender to palpation (Fig. 1). A prolapsing internal hemorrhoid is the most common differential diagnosis. The management involves extraction of the clot under local anesthesia. For a patient who has a thrombosed external hemorrhoid over 2 to 3 days old, it often is better to treat it conservatively and not excise it. The equipment required for the surgery is very simple and detailed in Table I. TABLE I. Kit for Emergency Proctologic Surgery Quantity No. 10 Blade 1 Forceps 1 Hemostats 2 Mayo Scissors 1 Curette 1 Irrigation Syringe 60 ml 1 Normal Saline 500 ml Wick Alginate 1 Patient s Placement The patient is ideally placed in the genupectoral position; however, this can be disconcerting for the patients. An alternative way to do the surgery is to place him in lateral decubitus position, with flexion of the hips and knees. The nurse exposes the buttocks and stretches the anal margin. Analgesia Protocol Lidocaine 1% is commonly used with epinephrine, i.e., 5 to 10 ml are injected proximal to the thrombosed external hemorrhoids and into the blood clot (Fig. 2). It is very important to avoid direct intravascular injection. Surgical Procedure A 1-cm incision is performed directly on the blood clot with a no. 10 blade (Fig. 3). The blood clot is then expelled between the thumb and the index finger (Fig. 4). This procedure commonly provides immediate alleviation of the pain. To avoid an immediate reaccumulation of the blood clot, it is necessary to remove part of the mucosa around the initial incision. It can be done with scissors. The goal is to leave wound open. FIGURE 1. Thrombosed external hemorrhoids: the clinical assessment of the anal margin shows a dark clot in external hemorrhoids. The palpation is painful. FIGURE 2. Lidocaine 1% (5 10 ml) is injected proximal to the thrombosed external hemorrhoids and in the blood clot. e499

3 FIGURE 3. no. 10 blade. FIGURE 4. index finger. A 1-cm incision is performed directly on the blood clot with a The blood clot is then expelled between the thumb and the Postoperative Follow-up The postoperative cares are performed by the patient himself: basic cleaning with a soft soap is mandatory after every bowel movement. PROCTOLOGIC EMERGENCY REQUIRING A SURGERY UNDER GENERAL ANESTHESIA: THE PERIANAL ABSCESS AND PILONIDAL ABSCESS Clinical A perianal abscess begins with anal pain that is rapidly progressive within a few days. It becomes unbearable and affects sleep. Sometimes a fever develops. The clinical assessment will reveal a mass close to the anal margin. This mass is warm, inflamed, and painful. Sometimes it extends into the anal canal when the digital rectal examination is done. At this step, looking for an anal fistula with anoscopy is not necessary. Frequently, a spontaneous fistula tract to the skin with associated discharge and can temporarily alleviate the patient s pain. Finally, the clinical assessment must differentiate this from perineal cellulitis and a Fournier s gangrene. Concerning the pilonidal abscess, the pain characteristics are the same, but the location is different. It is commonly at the upper part of the gluteal groove, paramedian, and centered on a cutaneous opening. A detailed clinical examination usually reveals some secondary opening, with a spontaneous or expressed purulent discharge. In both, the clinical examination is very painful and a surgical treatment under local anesthesia is not recommended. The surgery is done under general anesthesia and lasts 10 minutes. The equipment required for the surgery is very simple and detailed in the Table I. The equipment required for general anesthesia is detailed in the Table II. Patient s Placement To surgically treat the anal abscess, the patient is best placed in the lithotomy position, the buttocks placed at the edge of the table. Onboard the warship, the gynecological brackets are usually not available. They can be easily substituted by two assistants only dedicated to this task. Alternatively, it is possible to place the patient in lateral decubitus position with flexion of the hips and knees (Fig. 5). An assistant separates the buttocks and exposes the perianal area. For the pilonidal abscess, the patient is simply placed in the lateral decubitus position. Anesthesia Protocol A 6-hour fast is always necessary before procedures. The patient is prepared with a peripheral venous access, as well as blood pressure, heart rate, and oxygen saturation monitoring. TABLE II. Kit for Sedation/Analgesia Protocol Dilution (mg/ml) Syringe Size (ml) Tray 1: Sedation/Analgesia Kit Ketamin Midazolam 1 5 Tray 2: Emergency Kit Atropine 20 5 Epinephrine Ephedrine 3 10 Quantity Peripheral Venous Catheter 18G 1 Intravenous Tube With Voluven 500 ml 1 Ventilation Device (Ambu bag)/filter/ 1 Ballon/Oxygen Suction Device 1 e500

4 FIGURE 5. Simple positional placement of the patient in lateral decubitus with a flexion of hips and knees. An assistant separates the buttocks and exposes the perianal area. Once the patient is prepared with an oxygen mask, the sedation may be initiated if 3 conditions are met: The patient is prepared in position, surgically prepped, and draped. The operative table is ready. The GP is prepared with sterile dress. The procedure used onboard is a sedation/analgesia protocol maintaining the spontaneous ventilation of the patient. It offers a very high level of anesthetic safety and an excellent surgical comfort. It is divided in two stages: Stage 1: Injection of 1 or 2 mg of midazolam (according to the weight of the patient). Then wait for 5 to 10 minutes. Stage 2: Injection of 1 mg/kg of ketamine. Preparing a resuscitation kit is necessary, including the suction, air-bag valve mask, and an orotracheal intubation kit. Surgical Procedure First, a surgical cleansing of the perineum is done. A sterile draping with exposure of the anus is applied. Perianal Abscess The borders of the abscess are defined on palpation (Fig. 6). The physician performs a distal rectum examination to assess the position of the abscess in relation to the anal sphincter. The incision is made with a no. 10 blade. It is performed tangentially and not radially to the anal margin to preserve the sphincters (Fig. 7). The incision must be done as close as possible to the anal verge which shortens, if necessary in the future, the length of a fistulotomy incision. The incision extends 1- to 2-cm long and 1.5-cm deep but can be extended if necessary. It usually results an immediate FIGURE 6. The borders of the abscess are defined on palpation. FIGURE 7. The incision is made with a no. 10 blade. It is performed tangentially to the anal margin. purulent discharge (Fig. 8). The physician then breaks up the loculations of the abscess cavity with his finger and macerates with a compress. The cavity is washed with normal saline and iodized solution. An alginate wick (Algosteril) is placed inside the cavity and the dressing completed. e501

5 medications. The dressing is changed daily until wound healing is complete. FIGURE 8. The incision usually results in purulent discharge. Pilonidal Abscess The operative procedure is exactly the same as the perianal abscess, although the digital rectal examination is not needed. Postoperative Follow-up At the end of the surgery, the patient is placed in a semisitting position until the anesthetic sedation wears off. Monitoring is performed for 1 hour and the patient hospitalized in the infirmary. The pain is controlled by intravenous or oral CONCLUSION When the operational setting of a warship delays a possible medical evacuation, it is possible for the Navy practitioner to perform surgery for the treatment of proctologic emergency. A sedation/analgesia protocol based on the association ketamine/ midazolam allows for effective anesthesia with high level of safety. The surgery is essentially performed to save the patient from excessive pain and the risk of infection and sepsis. Finally, this surgery capability decreases the need for medical evacuations at sea. REFERENCES 1. Kondylis PD, Lieberth MT: Office-based management of haemorroids. Semin Colon Rectal Surg 2007; 18(3): Cataldo P, Ellis CN, Gregorcyk S, et al: Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum 2005; 48(2): Sneider EB, Maykel JA: Diagnosis and management of symptomatic hemorrhoids. Surg Clin North Am 2010; 90(1): Hall NR: Medical vs. surgical management of thrombosed external hemorrhoids. Dis Colon Rectum 2005; 48(11): Madoff RD, Fleshman JW, Clinical Practice Committee, American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126(5): Malik AI, Nelson RL, Tou S: Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev 2010; (7): CD Rizzo JA, Naig AL, Johnson EK: Anorectal abscess and fistula-in-ano: evidence-based management. Surg Clin North Am 2010; 90(1): Malik AI, Nelson RL: Surgical management of anal fistulae: a systematic review. Colorectal Dis 2008; 10(5): Hussain ZI, Aghahoseini A, Alexander D: Converting emergency pilonidal abscess into an elective procedure. Dis Colon Rectum 2012; 55(6): Horwood J, Hanratty D, Chandran P, Billings P: Primary closure or rhomboid excision and Limberg flap for the management of primary sacrococcygeal pilonidal disease? A meta-analysis of randomized controlled trials. Colorectal Dis 2012; 14(2): Al-Khamis A, McCallum I, King PM, Bruce J: Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2010; (1): CD McCallum IJ, King PM, Bruce J: Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ 2008; 336(7649): e502