Lasers in Proctology

Description

​This multidisciplinary book introduces all the known and unknown facts, tips, and tricks of laser procedures in various anorectal disorders including haemorrhoids, fistula in ano, anal fissure, pilonidal sinus, etc. It describes minimally invasive procedures, provides authoritative, in-depth presentations of all perspectives of this latest technique. Each chapter includes surgical anatomy, clinical evaluation, and the principle behind hybrid procedures, complications, and solutions that may arise while using Lasers. The book also discusses case presentations in various scenarios and a brief comparison of laser techniques with conventional procedures. It includes an up-to-date scientific and clinical data for quick reference. It emphasizes on “What to do, How to do and What not to do.” This is a must-read book for all trainees and surgeons practicing anorectal disorders, providing an overview of the latest treatment options. This book empowers surgeons with in-depth knowledge and enhance their skills to manage common anorectal diseases. It will serve as a valuable guide for residents, clinicians, surgeons, researchers, and proctologists keen to use lasers as a futuristic approach to deal with anorectal disorders Foreword Foreword Foreword Foreword Foreword Preface Acknowledgments Contents About the Author 1: Lasers in Surgery: From Past to Present 1.1 Introduction 1.2 History of Lasers 1.3 Classification 1.4 Laser Light Characteristics 1.5 Thermal Relaxation Time 1.6 Delivery Systems 1.7 Laser and Tissue Interaction 1.7.1 Photothermal Interactions 1.7.2 Photochemical Interactions 1.7.3 Photodisruption (Photoacoustic) Interactions 1.7.4 Photoablation Interactions 1.7.5 Plasma-Induced Ablation 1.8 Interaction Parameters 1.9 The Optical Fibers: Size, Structure, and Power Density 1.10 Types of Fibers to Be Used in Proctology 1.11 A Comparative Study of the Various Wavelengths of Diode Laser 1.12 Tips Before Use of Lasers 1.13 Laser Safety 1.13.1 Safety Measures While Using Laser Fibers 1.13.2 Precautions 1.14 Laser Versus Cautery 1.15 Your Queries! My Answers! 1.16 Discussion 1.17 Terminology References 2: Surgical Anatomy of Anal Canal 2.1 Introduction 2.2 Anatomical Relations of Anal Canal 2.3 Urogenital Triangle 2.4 Interior of Anal Canal 2.5 Upper Columnar Zone: Contents 2.5.1 Morgagni Columns 2.5.2 Anal Valves 2.5.3 Anal Crypts and Anal Glands 2.5.4 Dentate Line 2.5.5 Anal Papillae 2.5.6 Anal Cushions 2.5.7 Anal Transitional Zone (ATZ) 2.6 Intermediate Zone 2.7 Lower Cutaneous Zone 2.8 Internal Anal Sphincter (IAS) 2.8.1 Origin and Insertion 2.8.2 Thickness 2.8.3 Importance 2.8.4 Innervation 2.8.5 Blood Supply 2.8.6 Functions 2.8.7 Features 2.9 Conjoined Longitudinal Muscle (CLM) 2.9.1 Thickness 2.9.2 Functions 2.10 EAS (External Anal Sphincter) 2.10.1 Origin and Insertion 2.10.1.1 Subcutaneous Part 2.10.1.2 Superficial Part 2.10.1.3 Deep Part 2.10.2 Thickness 2.10.3 Relations of External Anal Sphincter with Muscles of Perineum 2.10.4 Innervation 2.10.5 Blood Supply 2.10.6 Functions 2.10.7 Features 2.11 Blood Supply to Anal Canal 2.11.1 Arterial Supply 2.11.2 Venous Supply 2.12 Escape Valve Mechanism: A Significant Finding 2.13 Anal Canal Lymphatic Drainage 2.14 Anal Canal Innervation 2.14.1 Above Dentate Line 2.14.2 Below Dentate Line 2.15 Anal Canal Histology 2.16 Pelvic Floor Muscles 2.16.1 Levator Ani 2.16.2 Blood Supply 2.16.3 Innervation 2.16.4 Functions 2.16.5 Features 2.17 Anorectal Ring 2.18 Anorectal Triangle 2.19 Anorectal Angle 2.20 Physiology of Anal Canal and Defecation References 3: Anal Cushions and Pathophysiology of Hemorrhoids 3.1 Introduction 3.2 Anatomy of Anal Cushions and Hemorrhoids 3.2.1 Nonvascular Component of Anal Cushions 3.2.2 Vascular Component of Hemorrhoids 3.3 Functions of Anal Cushions 3.4 Superior Hemorrhoidal Artery (SHA) and Formation of Corpus Cavernosum Recti (CCR) 3.5 Physiological Significance of Anal Cushions and Their Relation to Defecation 3.6 Pathophysiology of Hemorrhoids 3.6.1 Sliding Anal Cushion Theory 3.6.2 Hypervascularization Theory 3.6.3 Theory of Straining and Constipation 3.7 Correlation Between Anal Tone and Formation of Hemorrhoids 3.8 The Fate of Anal Cushions 3.9 Classification of Hemorrhoids 3.9.1 Internal Hemorrhoids 3.9.2 External Hemorrhoids 3.9.3 Mixed Hemorrhoids 3.10 Rectal Varices and Hemorrhoids References 4: Clinical Evaluation of Hemorrhoids 4.1 Introduction 4.2 Clinical Features 4.2.1 Bleeding 4.2.2 Prolapse 4.2.3 Thrombosis 4.2.4 Mucus Discharge 4.2.5 Pain 4.2.6 Pruritus Ani 4.2.7 Feeling of Lump 4.3 History for Evaluation of Hemorrhoids 4.4 Physical Examination 4.4.1 Inspection 4.4.2 Palpation 4.4.3 Digital Rectal Examination (DRE) 4.4.4 Proctoscopy 4.4.5 Symptoms, Signs, Examination Findings and Differential Diagnosis at a Glance 4.5 Evaluation and Clinical Correlation of Anorectal Symptoms 4.5.1 Rectal Bleeding 4.5.2 Pain 4.5.3 Perianal/Rectal Mass 4.5.4 Mucus Discharge 4.6 Diagnostic Evaluations 4.6.1 Sigmoidoscopy 4.6.2 Colonoscopy 4.7 Indications and Contraindications of Colonoscopy and Sigmoidoscopy (Tables 4.9 and 4.10) References 5: Nonsurgical Management of Hemorrhoids 5.1 Introduction 5.2 History 5.3 Nonsurgical Management of Hemorrhoids 5.3.1 Lifestyle and Dietary Modification 5.3.2 Medical Management 5.3.2.1 Role of Flavonoids 5.3.2.2 Topical Treatment of Hemorrhoids 5.3.2.3 Sitz Bath 5.3.3 Ambulatory Treatment (Office Procedures) 5.3.3.1 Infra-Red Coagulation 5.3.3.2 Sclerotherapy 5.3.3.3 Rubber Band Ligation 5.4 A Word About Cryotherapy 5.5 Discussion 5.6 Which Is the Best Office Procedure Out of Sclerotherapy, Infrared Coagulation, and Rubber Band Ligation? References 6: Hemorrhoidectomy: The Gold Standard 6.1 Introduction 6.2 Historical Background 6.3 Indications of Hemorrhoidectomy 6.4 Principle of Hemorrhoidectomy 6.5 Modifications in Hemorrhoidectomy Over the Years 6.6 Evolution of Hemorrhoidectomy 6.6.1 Excision and High Ligation 6.6.1.1 Technique 6.6.1.2 Pitfalls of Salmon’s Technique 6.6.2 Miles’ Hemorrhoidectomy (Excision with Low Ligation) 6.6.2.1 Pitfalls of the Miles’ Technique 6.6.3 Milligan-Morgan’s Hemorrhoidectomy 6.6.3.1 Technique 6.6.3.2 Pitfalls of Milligan-Morgan Hemorrhoidectomy 6.6.4 Ferguson’s Closed Hemorrhoidectomy 6.6.4.1 Advantages of Ferguson’s Over Milligan Morgan 6.6.5 Whitehead Hemorrhoidectomy 6.6.5.1 Pitfalls of Whitehead Hemorrhoidectomy 6.6.6 Submucosal Hemorrhoidectomy (Park’s Procedure) 6.6.7 Rise and Fall of Lord’s Procedure 6.6.7.1 Principle 6.6.7.2 Indications 6.6.7.3 Technique 6.7 Thermal Devices in Hemorrhoidectomy 6.7.1 Bipolar Diathermy in Hemorrhoidectomy 6.7.1.1 Indication 6.7.1.2 Technique 6.7.1.3 Results 6.7.2 Ligasure in Hemorrhoidectomy 6.7.2.1 Indications 6.7.2.2 Technique 6.7.2.3 Results 6.7.3 Harmonic Scalpel in Hemorrhoidectomy 6.8 Carbon Dioxide Laser Hemorrhoidectomy 6.8.1 Principle 6.8.2 Technique 6.8.3 Advantages 6.9 Radiofrequency Ablation 6.9.1 Principle 6.9.2 Technique 6.9.3 Advantages of Radiofrequency Ablation 6.10 Complications of Excisional Hemorrhoidectomy 6.11 Management of Commonest Complications After Hemorrhoidectomy 6.11.1 Bleeding 6.11.2 Postoperative Pain 6.11.3 Urinary Retention 6.11.4 Local Infection and Sepsis 6.11.5 Anal Tags 6.11.6 Anal Stenosis 6.12 Comparative Study of Hemorrhoidectomy with Minimally Invasive Techniques 6.13 Discussion References 7: Minimal Invasive Procedures for Hemorrhoids 7.1 Introduction 7.2 Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL) 7.2.1 Principle 7.2.2 Indication 7.2.3 Contraindication 7.2.4 Instrumentation 7.2.5 Technique 7.2.6 Advantages 7.2.7 Results 7.3 Stapled Hemorrhoidopexy (Procedure for Prolapsed Hemorrhoids: PPH) 7.3.1 Principle 7.3.2 Indication 7.3.3 Contraindication 7.3.4 Instrumentation 7.3.5 Technique 7.3.6 Results 7.3.7 Complications 7.4 Comparison of Excisional Hemorrhoidectomy with DGHAL and PPH 7.5 Transanal Suture Rectopexy 7.5.1 Principle 7.5.2 Indications 7.5.3 Technique 7.5.4 Results 7.6 Superior Hemorrhoidal Artery Embolization 7.6.1 Principle 7.6.2 Indications 7.6.3 Technique 7.6.4 Results 7.7 Discussion References 8: Laser Hemorrhoidoplasty 8.1 Introduction 8.2 Principle of Laser Energy 8.3 Laser Hemorrhoidoplasty 8.3.1 Indications 8.3.2 Contraindications 8.4 Hybrid Procedure: A Combination of Finger-Guided Hemorrhoidal Artery Ligation and Laser Hemorrhoidoplasty (FGHAL with LHP) 8.4.1 Procedure for FGHAL and LHP 8.4.2 Instrument Required (Figs. 8.1 and 8.2) Steps 8.4.3 Finger-Guided Hemorrhoidal Artery Ligation - An Introduction 8.4.3.1 Technique 8.4.4 Laser Hemorrhoidoplasty 8.4.4.1 Energy! Dosage! Fiber! Mode 8.4.4.2 Point of Entry of Fiber 8.4.4.3 The Technique of Laser Hemorrhoidoplasty 8.4.4.4 Postoperative Care 8.5 Hemorrhoids in Patients with Anticoagulants 8.6 Why Recurrence After Surgical Procedures for Hemorrhoids? 8.6.1 Diversion of Blood Flow and Formation of Collaterals 8.6.2 Persistence of the Greater Caliber of the Superior Hemorrhoidal Artery in Hemorrhoidal Disease 8.6.3 Inability to Ligate Posterolateral Branches of SHA 8.7 Recurrence After Laser Hemorrhoidoplasty 8.8 Complications Following FGHAL and LHP: Why and How to Manage? 8.8.1 Hematoma Formation at the Site of HAL 8.8.2 Bleeding at the Point of Entry of Laser Fiber 8.8.3 Pain: VAS Score of 4–5 Within 24 h 8.8.4 Postoperative Edema: (2.34%) 8.8.5 Thrombosis: (0.89%) 8.8.6 Burning and Itching: (10.1%) 8.8.7 Hemorrhage and Abscess: (0.58%) 8.8.8 Skin Tags: (0.2%) 8.9 Your Queries, My Answers! 8.10 Discussion 8.11 Case Presentations 8.12 Bottom Line References 9: Lasers in External and Complicated Internal Hemorrhoids 9.1 Introduction 9.2 External Hemorrhoids 9.2.1 Thrombosed External Hemorrhoids 9.2.1.1 Pathophysiology of Thrombosed External Hemorrhoids 9.2.1.2 The Pathophysiology of Pain 9.2.1.3 Clinical Evaluation 9.2.1.4 Management of Thrombosed External Hemorrhoids 9.2.1.5 Role of Lasers in Thrombosed External Hemorrhoids 9.2.1.6 Postoperative Care 9.3 Thrombosed Internal Hemorrhoids 9.3.1 Pathophysiology of Thrombosed Internal Hemorrhoids 9.3.2 Management of Thrombosed Internal Hemorrhoids 9.4 Strangulated Internal Hemorrhoids 9.4.1 Pathophysiology of Strangulated Hemorrhoids 9.4.2 Management of Strangulated Hemorrhoids 9.5 Discussion References 10: Anatomy of Para-Anal and Pararectal Spaces 10.1 Introduction 10.2 Anatomy of Para-Anal and Pararectal Spaces 10.2.1 Ischioanal/Ischiorectal Space 10.2.1.1 Boundaries 10.2.1.2 Contents 10.2.2 Perianal Space 10.2.2.1 Boundaries 10.2.2.2 Contents 10.2.3 Intersphincteric Space 10.2.3.1 Boundaries 10.2.3.2 Contents 10.2.4 Submucosal Space 10.2.4.1 Boundaries 10.2.4.2 Contents 10.2.5 Superficial Postanal Space 10.2.6 Deep Postanal Space 10.2.6.1 Boundaries 10.2.7 Supralevator Space 10.2.7.1 Boundaries 10.2.8 Retrorectal Space 10.2.8.1 Boundaries 10.3 Anal Glands 10.3.1 Location of Anal Glands 10.3.2 The Fate of Anal Glands 10.3.3 Surgical Importance of Anal Glands 10.4 The Relation of Anal Glands with Crohn’s Disease, Ulcerative Colitis, and Carcinoma Rectum 10.5 Importance of Anatomical Landmarks Related to the Conjoined Longitudinal Muscle 10.6 A Word About Milligan’s Septum 10.7 Anococcygeal Ligament and Anococcygeal Raphe 10.8 A Word About Deep Intersphincteric Space 10.8.1 Boundaries 10.8.2 Surgical Relevance of Deep Intersphincteric Space 10.9 A Word About Deep Anterior Anal Space 10.9.1 Surgical Relevance 10.10 A Word About Infralevator Space 10.10.1 Surgical Importance 10.11 Discussion References 11: Evaluation and Management of Anorectal Abscess 11.1 Introduction 11.2 Epidemiology 11.3 Etiology of Anorectal Abscess 11.4 Pathogenesis of Abscess 11.5 Organisms Responsible for Abscess 11.6 Relation Between Fistulas and Abscess 11.7 Fate of Abscess 11.8 Types of Abscesses 11.9 Pathway of the Spread of an Abscess 11.9.1 Formation of a Horseshoe Abscess and Fistula 11.10 Clinical Evaluation 11.11 Imaging in Anorectal Abscesses 11.12 Perianal Abscess 11.12.1 Differential Diagnosis 11.12.1.1 Diagnosis 11.12.1.2 Managing Perianal Abscess 11.13 Ischiorectal Abscess 11.13.1 Managing Ischiorectal Abscess 11.13.2 How to Identify Communicating Fistula Tract? 11.14 Intersphincteric Abscess 11.14.1 Differential Diagnosis 11.14.2 Managing Intersphincteric Abscess 11.15 Supralevator Abscess 11.15.1 Managing Supralevator Abscess 11.15.2 Principle of Drainage of Supralevator Abscess: A Paradigm Shift 11.16 Deep Postanal Abscess 11.16.1 Managing Deep Postanal Abscess (Hanley’s Technique) 11.16.1.1 Disadvantages of Hanley’s Technique 11.16.2 Modified Hanley’s Technique 11.16.3 Core Tip 11.17 Deep Anterior Anal Space Abscess 11.17.1 Management of Deep Anterior Abscess 11.18 Superficial Postanal Space Abscess 11.19 Horseshoe Abscess 11.19.1 Managing Horseshoe Abscess 11.20 A Word About Retrorectal Abscess 11.20.1 Management 11.21 Whether to Perform Primary Fistulotomy in Patients with Anorectal Abscess! 11.21.1 Absolute Contraindications for Primary Fistulotomy 11.21.2 Tips and Tricks of Doing Primary Fistulotomy 11.22 Complications of Anorectal Abscess 11.23 Postoperative Care 11.24 Case Studies 11.25 Discussion References 12: Clinical Evaluation and Classification of Anal Fistula 12.1 Introduction 12.2 Symptoms 12.3 History 12.4 Clinical Examination 12.4.1 Inspection 12.4.2 Palpation 12.4.3 Digital Rectal Examination (DRE) 12.4.3.1 The Internal Opening 12.4.3.2 The External Opening 12.4.4 Proctoscopy 12.4.5 Sigmoidoscopy 12.4.6 Fistula Tract Identification 12.5 Goodsall’s Rule and Its Clinical Significance 12.5.1 Exceptions to the Rule 12.6 Classification of Fistula! Why Do We Classify Them? 12.7 Park’s Classification 12.7.1 Intersphincteric Fistula 12.7.1.1 A1: Intersphincteric Fistula with Low Tract 12.7.1.2 A2: Intersphincteric Fistula Having a High Blind Tract 12.7.1.3 A3: Intersphincteric Fistula with a Rectal Opening 12.7.1.4 A4: Intersphincteric Fistula with No Perineal Opening 12.7.1.5 A5: Intersphincteric Fistula with Pelvic Extension 12.7.1.6 A6: Intersphincteric Fistula Secondary to Pelvic Infection 12.7.2 Trans-Sphincteric Fistula 12.7.2.1 B1: Uncomplicated 12.7.2.2 B2: Trans-Sphincteric Fistula Associated with the High Blind Tract 12.7.3 Suprasphincteric Fistula 12.7.4 Extrasphincteric Fistula 12.7.4.1 Extrasphincteric Fistula Resulting from Trans-Sphincteric Fistula 12.7.4.2 Extrasphincteric Fistula Resulting from Trauma 12.7.4.3 Extrasphincteric Fistula Due to Specific Anorectal Diseases 12.7.4.4 Extrasphincteric Fistula as a Consequence of Pelvic Inflammation 12.8 Simple and Complex Fistula 12.8.1 Simple Fistula 12.8.2 Complex Fistula 12.9 Preoperative Evaluation and Imaging in Anal Fistula 12.9.1 Anal Endosonography 12.9.2 Magnetic Resonance Imaging (Fig. 12.14a–c) 12.9.2.1 Indications 12.9.2.2 Advantages 12.9.2.3 Classification of St James’s University Hospital 12.9.2.4 Efficacy Results 12.9.2.5 Can MRI Be Deceptive? 12.10 Differential Diagnosis 12.11 Evaluating Incontinence 12.11.1 Wexner’s Score References 13: Fistulotomy: Still a Gold Standard! 13.1 Introduction 13.2 Fistulotomy 13.2.1 Principle 13.2.2 Indications 13.2.3 Contraindications 13.3 Management of Intersphincteric Fistula 13.3.1 Simple Intersphincteric Fistula (A1) 13.3.2 Intersphincteric Fistula with High Blind Tract (A2) 13.3.3 Intersphincteric Fistula with an Opening in the Lower Rectum (A3) 13.3.4 High Intersphincteric Fistula Without an External Opening (A4) 13.3.5 High Intersphincteric Fistula with Pelvic Extension (A5) 13.3.6 Intersphincteric Fistula Extending from Pelvic Disease (A6) 13.4 Management of Trans-sphincteric Fistula 13.4.1 B1 Uncomplicated 13.4.2 B2 Complicated 13.5 Management of Suprasphincteric Fistula 13.6 Management of Extrasphincteric Fistula 13.7 Simple Fistulotomy Technique 13.7.1 Advantages of Marsupialization 13.7.2 Results 13.8 Discussion 13.8.1 Intersphincteric Fistula 13.8.2 Trans-sphincteric Fistulas 13.8.3 Suprasphincteric Fistula 13.8.4 Extrasphincteric Fistula 13.9 Points to Ponder 13.10 Core Tips 13.11 Fistulectomy 13.11.1 Indications 13.11.2 Technique 13.11.3 Advantages 13.11.4 Disadvantages 13.12 Fistulotomy Versus Fistulectomy: A Surgeon’s Dilemma! 13.13 Primary Sphincter Repair 13.13.1 Indications 13.13.2 Advantages 13.13.3 Technique 13.13.4 Postoperative Care 13.13.5 Core Tips 13.13.6 Discussion 13.13.7 Core Tips 13.14 Case Studies References 14: Sphincter-Saving Techniques 14.1 Introduction 14.2 Principle 14.3 Endorectal Advancement Flap 14.3.1 Principle 14.3.2 Indications 14.3.3 Contraindication 14.3.4 Some Aspects of the Surgical Technique 14.3.4.1 Type of Flap 14.3.4.2 Shape of Flap 14.3.4.3 Flap Thickness 14.3.5 Technique 14.3.6 Core Tip 14.3.7 Advantage 14.3.8 Results 14.4 Fibrin Glue 14.4.1 Principle 14.4.2 Mechanism of Action 14.4.3 Indications 14.4.4 Technique 14.4.5 Results 14.4.6 Advantages 14.4.7 Complications with Fibrin Glue 14.5 Fistula Plugs 14.5.1 Principle 14.5.2 Indications 14.5.3 Contraindications 14.5.4 Technique 14.5.5 Core Tips for Fistula Plug Usage 14.5.6 Complications 14.5.7 Results 14.6 Seton 14.6.1 Principle 14.6.2 What All to Include While Placing Seton? 14.6.3 Types of Seton 14.6.4 Loose Setons 14.6.5 Tight Setons 14.6.6 Materials Used for Setons 14.6.7 Indications 14.6.8 Complications 14.6.9 Technique 14.6.10 Seton and Staged Fistulotomy 14.6.11 Snug Seton Technique 14.6.12 Double Seton Technique 14.6.13 Kshar Sutra 14.6.14 Results 14.6.15 Core Tips 14.7 Ligation of Intersphincteric Fistula Tract (LIFT) 14.7.1 Principle 14.7.2 Indication 14.7.3 Technique 14.7.4 Results 14.7.5 Advantages of LIFT 14.7.6 Pitfalls of LIFT 14.7.7 Complications After LIFT 14.8 Video-Assisted Anal Fistula Treatment (VAAFT) 14.8.1 Principle 14.8.2 Indications 14.8.3 Contraindications 14.8.4 Equipment 14.8.5 Technique 14.8.5.1 Operative Phase 14.8.6 Advantages 14.8.7 Results 14.8.8 Pitfalls of VAAFT 14.9 Stem Cells 14.9.1 Principle 14.9.2 Indications 14.9.3 Technique 14.9.4 Results 14.9.5 Core Tip 14.9.5.1 Choosing Stem Cells 14.10 Submucosal Ligation of Fistula Tract (SLOFT) 14.10.1 Principle 14.10.2 Indications 14.10.3 Contraindications 14.10.4 Technique 14.10.5 Results 14.10.6 Comparison with LIFT 14.11 Discussion References 15: Role of Lasers in Fistula: Fistula Laser Closure (FiLaC) 15.1 Introduction 15.2 Principle 15.3 Indications 15.4 Contraindications 15.5 Technique 15.6 Pitfalls 15.7 Results 15.8 Discussion 15.9 Core Tips 15.10 Your Queries! My Answers! References 16: Hybrid Procedures-Future of Fistula Surgery! 16.1 Introduction 16.2 Why Hybrid Procedures! Aims and Objectives! 16.3 Indications 16.4 Contraindications 16.5 Hybrid Procedures 16.6 Distal Laser Proximal SLOFT (DLPS) 16.6.1 Principle 16.6.2 Indications 16.6.3 Advantages 16.6.4 Technique 16.6.5 Results 16.6.6 Discussion 16.7 Distal Coring Using FiXcision with Proximal SLOFT (DCPS) 16.7.1 Principle 16.7.2 Indications 16.7.3 Contraindications 16.7.4 FiXcision Instrument 16.7.5 Technique 16.7.6 Pitfalls 16.7.7 Discussion 16.8 Distal Laser with Proximal LIFT (DLPL) 16.8.1 Principle 16.8.2 Technique 16.8.3 Results 16.8.4 Discussion 16.9 VAAFT with LIFT with Laser Ablation of the Distal Tract (VA-LIFT) 16.9.1 Principle 16.9.2 Indications 16.9.3 Technique 16.9.4 Results 16.9.5 Discussion 16.10 Distal Coring with Proximal Fistulotomy and Laser Ablation (DCPF) 16.10.1 Principle 16.10.2 Indications 16.10.3 Technique 16.10.4 Discussion 16.10.4.1 The Difference Between Park’s Procedure and Our Approach 16.10.4.2 Why Do I Prefer Coring of the Distal Fistula Tract? 16.10.5 Results of Histopathology Examination of Fistula Tracts 16.11 Anal Glands: Pathological Insight! 16.11.1 Does Epithelialization of the Tract or Anal Glands Have Any Role in Persistent Fistula! 16.12 How to Select a Hybrid Procedure 16.12.1 What to Do and When to Do It? 16.12.1.1 Intersphincteric Tract 16.12.1.2 Trans-sphincteric Tract 16.12.1.3 Suprasphincteric Fistulas 16.12.1.4 Extrasphincteric Fistula 16.12.1.5 Horseshoe Fistula 16.13 Core Tips While Performing Fistula Surgery 16.14 Your Queries! My Answers! 16.15 Case Presentations 16.16 Conclusion References 17: Role of Lasers in Pilonidal Sinus 17.1 Introduction 17.2 Epidemiology 17.3 Location 17.4 Risk Factors of Pilonidal Sinus 17.5 Etiology 17.5.1 Bascom Theory 17.5.2 Karydakis Theory 17.5.3 Stelzner Theory 17.6 Pathophysiology 17.7 Histopathology 17.8 The Direction of the Sinus Tract 17.9 Clinical Presentation of the Disease 17.9.1 History 17.9.2 Physical Examination 17.10 Navicular Area 17.11 Classification of Pilonidal Sinus 17.12 Imaging 17.13 Differential Diagnosis 17.14 Management of Pilonidal Sinus Disease 17.14.1 Minimally Invasive Techniques for Pilonidal Sinus: Newer Surgical Modalities 17.15 Video-Assisted Laser Ablation of the Pilonidal Sinus (VALAPS) 17.15.1 Principle 17.15.2 Device for Video-Assisted Endoscopy 17.15.3 Device for Pit Excision 17.15.4 Energy! Dosage! Fiber! 17.15.5 Technique 17.15.6 Postoperative Care 17.15.7 Results of VALAPS 17.15.8 Results of Minimally Invasive Procedures 17.16 Discussion 17.17 Case Presentation 17.17.1 Opinion 17.18 Your Queries, My Answers References 18: Role of Lasers in Anal Fissures 18.1 Introduction 18.2 Historical Aspect 18.3 Epidemiology 18.4 Etiology of Anal Fissure 18.5 Risk Factors 18.6 Pathophysiology of Anal Fissure 18.7 Types of Anal Fissures 18.8 Classification of Anal Fissures Based on Morphology 18.8.1 Characteristics of Superficial Anal Fissure 18.8.2 Characteristics of Deep Anal Fissure 18.9 Grading of Anal Fissures 18.10 Location of Anal Fissure 18.11 Anatomical Considerations: Why Anal Fissures Are Painful? 18.12 Why Does a Sentinel Pile Form in an Anal Fissure? 18.13 Clinical Evaluation of Anal Fissure 18.13.1 History 18.13.2 Physical Examination 18.13.3 Inspection 18.13.4 Palpation 18.13.5 Digital Rectal Examination (DRE) 18.13.6 Proctoscopy 18.14 Role of Anal Manometry in the Diagnosis of Anal Fissure 18.15 Differential Diagnosis of Anal Fissure 18.16 Complications of Anal Fissure 18.17 Why Is an Anal Fissure Described as an Ischemic Ulcer? 18.18 Management of Anal Fissures 18.18.1 Dietary Modification 18.18.2 Sitz Bath 18.18.3 Medical Management 18.18.3.1 Laxatives Mechanism of Action of Laxatives 18.18.3.2 Topical Agents and Their Mechanism of Action 18.18.3.3 Botulinum Toxin (Botox) 18.18.4 Surgical Management 18.18.4.1 Anal Dilatation 18.18.4.2 Fissurectomy 18.18.4.3 Lateral Internal Sphincterotomy Open Lateral Internal Sphincterotomy Closed Lateral Internal Sphincterotomy (CLIS) 18.18.4.4 Advancement Flap (Anoplasty) 18.19 Laser Lateral Internal Sphincterotomy 18.20 How Much Sphincter Should Be Divided? 18.21 Why Should Posterior Sphincterotomy Not Be Done? 18.22 Results of Closed Versus Open Lateral Internal Sphincterotomy 18.23 Anal Fissure in Crohn’s Disease 18.23.1 Management 18.24 Management of Anal Fissure in HIV 18.25 A Word About Relapsing and Refractory Fissures 18.26 Discussion 18.27 Case Presentation 18.27.1 Opinion 18.28 Your Query, My Answer References 19: Postoperative Management of Anorectal Wounds 19.1 Introduction 19.2 Aims and Objectives 19.3 Why Is Wound Care Necessary After Anorectal Surgeries? 19.4 Healing Phases of Wound 19.5 Postoperative Wound Care After Anorectal Surgery 19.5.1 Ice Packs 19.5.1.1 The Principle Behind Using Ice Finger 19.5.2 Sitz Bath 19.5.3 Topical Ointments After Surgery 19.5.3.1 A Combination of Metronidazole, Sucralfate, and Lidocaine Mechanism of Action Metronidazole Mechanism of Action Sucralfate Mechanism of Action Lidocaine Mechanism of Action Commonest Uses 19.5.3.2 Calcium Dobesilate for Local Application in Hemorrhoids Mechanism of Action 19.5.3.3 A Combination of Lidocaine and Nifedipine and Diltiazem Mechanism of Action Commonest Uses 19.5.4 Use of Laxatives 19.5.4.1 Mechanism of Action of Bulk-Forming Laxatives 19.5.4.2 Mechanism of Action of Osmotic Agents 19.6 Wound Cleaning 19.6.1 The Best Cleansing Agent: Povidone-Iodine or Water! 19.6.2 Cleaning of the Wound After Fistula and Fissure Surgery 19.6.3 Cleaning of Wounds After Pilonidal Sinus 19.7 Special Dressings for Anal Fistula and Pilonidal Sinus Wounds 19.7.1 Hemoglobin Spray 19.7.1.1 Mechanism of Action 19.7.2 Dried Amnion Chorion Granules with PHMB 19.7.2.1 Mechanism of Action 19.7.3 Use of Silver Dressings for Pilonidal Sinus 19.7.3.1 Mechanism of Action 19.8 Discussion References Hemorrhoids Fistula in Ano Pilonidal Sinus Fissure in Ano