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. She

can 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.

She should not stay on her back during labor. She can walk, rock, or use a hot

shower or whirlpool.

From the beginning, she should discuss with her doctor that she wants to avoid

having 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 rate

than 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 of

natural childbirths without surgical intervention than obstetricians do.

She should hire a doula to assist during labor birth. Doulas have a lower c-section

rate 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 educate

her 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 csection. 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

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

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 the mother 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,

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. Full recovery 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

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.

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

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 on women 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.

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 forceps ends 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 small silicone 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.

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 the uterus.

Partial salpingectomy, being the most common occlusion method. The fallopian tubes 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 a small 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 special tool to put in place. Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically. It encircles 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 commonly used type of ring is the Yoon Ring, made of silicone. Electrocoagulation or cauterization: Electric current coagulates or burns a small portion 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,

which involves the current leaving through an electrode placed under the thigh. It is 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 "tubes tied." 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 general anesthesia 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. Tubal reversal 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

to the ovary. The procedure that connects these separateds of the fallopian tube is called tubal 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, tubouterine implantation, 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 women who 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. Typically vasectomies 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

performed during a cesarean section since the tubes are already exposed during the laparotomy. Tubal ligation may reduce the risk of ovarian cancer, with some studies estimating the relative risk at 0.66 for epithelial types, 0.40 for endometrioid types and 0.73 for serous types.

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 natural lens 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 or diffuses 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 the cataract 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

(intraocular lens) patients can sometimes experience dramatic vision improvement. The technique of phacoemulsification utilizes a small incision. The tip of the instrument is introduced into the eye through this small incision. Localized high frequency waves are generated through this tip to break the cataract into very minute fragments and pieces, which are then sucked out through the same tip in a controlled manner. A thin 'capsule' or shell is left behind after cleaning up of the entire opaque cataract. The incision size for phacoemulsification is approximately 3.0 millimeters in width. If a lens implant that can be folded is used following removal of the cataract, this incision may not have to be enlarged.

What happens during Phacoemulsification Procedure? In phacoemulsification cataract surgery, the surgeon makes a very small incision -- about 1/8th of an inch -- in the white of the eye near the outer edge of the cornea. A small ultrasonic probe is inserted through this opening and, oscillating at 40,000 cycles per minute, is used to break up (emulsify) the cataract into tiny pieces. The emulsified material is simultaneously suctioned from the eye by the open tip of the same instrument. The hard central core of the cataract (the nucleus) is removed first, followed by extraction of the softer, peripheral cortical fibers that make up the remainder of the lens. The front (anterior) section of the lens capsule is removed along with the fragments of the natural lens. The back (posterior) portion of the capsule is left in place to hold and maintain the correct position for the implanted intraocular lenses. After removal of the cataract, a prescription intraocular lens, or IOL, is permanently implanted in the lens capsule to replace the natural crystalline lens of the eye that was removed during the surgery. This lens is rolled inside a tiny hollow tube and inserted

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 any weakness 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 should check 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

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, and refrain from rubbing the eye for at least two weeks. During that time, the doctor will give the patient special tinted sunglasses or 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.

HEMORRHOIDECTOMY

REASON FOR VISIT Internal hemorrhoids Internal hemorrhoids that still cause symptoms after nonsurgical treatment. Large external hemorrhoids that cause significant discomfort and make it difficult to keep the anal area clean. Both internal and external hemorrhoids. Had other treatments for hemorrhoids (such as rubber band ligation) that have failed. Persistent itching Anal bleeding Pain Blood clots (thrombosis of the hemorrhoids) Infection RISK ASSESSMENT Bleeding disorder Advanced age Prior anal surgery History of fecal incontinence (involuntary leaking of stool) History of allergies to medication History of allergies to anesthesia.

PREPARATION OF THE PATIENT Blood tests Urine tests Chest x-ray Digital examination Anoscope Sigmoidoscopy and colonoscopy

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 were pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler.

 The hemorrhoidal cushions were pulled back up into their normal position within the anal canal. The stapler was then fired. When it fires, the stapler cuts off the circumferential ring 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 sites around 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 pulled out 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 the shape of the tissue to be cut. Starting at the wide base, then dissects the hemorrhoidal tissue slowly from the underlying 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 a wide base of approximately ___cm. At this time, the hemorrhoidal mass was still attached at the apex, just above the dentate 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 by three 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 dress the wounds. CLOSED HEMORRHOIDECTOMY Hill-Ferguson retractor was inserted into the anal canal. A plan for removing the affected hemorrhoid was then established.

 A knife was used to make a circular incision starting at the dentate line and extending 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 the wound. The wound was closed with sutures. AFTER PROCEDURE Patient was shifted to intensive care unit DURATION ________hrs POSTOPERATIVE CARE Take pain medication as prescribed Take antibiotics as prescribed Soaking in a sitz bath (a shallow bath of warm water) several times a day helps ease the discomfort. Use a donut ring (cushion with a hole in the middle) can make sitting upright more comfortable. Avoid constipation Eat a high-fiber diet and drink plenty of liquids. Avoid heavy lifting for 2 to 3 weeks. COMPLICATIONS

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