Stapled haemorrhoidopexy

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding from the staple line, early or delayed
• retention of urine
• persistent pain or urgency after surgery
• recurrence of prolapse or bleeding (higher than with excision)
• anal or rectal narrowing
• rectal perforation or pelvic sepsis (rare, serious)
• recto-vaginal fistula in women (rare)
• residual skin tags that may need excision

Pre-operative details for this operation

1. Grade and extent of haemorrhoidsGrade IIGrade IIICircumferential prolapse
2. Associated anal disease excludedfissure, fistula, abscess, anal stenosis, full-thickness rectal prolapse
3. Colon evaluationcolonoscopy / sigmoidoscopy findings as per age and risk
4. Bowel preparationenema(s), time
5. Stapler kit availablecircular haemorrhoidal stapler with anal dilator and purse-string anoscope
6. Anticoagulants / antiplateletsstopped when

Anaesthesia and position

1. AnaesthesiaSpinalGeneral
2. PositionLithotomyProne jack-knife
3. Local anaesthetic blockGivenNot given

Operative findings

1. DRE and anoscopy under anaesthesiatone, mass, fissure
2. Haemorrhoidspositions, circumferential or not, external component, reducible fully
3. Mucosal prolapsePresentAbsent
4. DoughnutComplete ringIncomplete (site)width; muscle seen or not
5. Staple lineheight above dentate line in cm; bleeding points

Procedure (steps)

1. Anal canal gently dilated with obturatorno manual stretch
2. Circular anal dilator inserted and fixed to perianal skinprolapse reduced; dentate line covered by dilator; fixing suture
3. Purse-string suturematerial and size; height above dentate line (cm); mucosa and submucosa only; complete circle checked with finger
4. Vaginal examination (women)Done, posterior wall freeNot applicable
5. Stapler passed fully open beyond purse string; purse string tied on the shaft
6. Suture ends brought out through side ports; traction applied
7. Stapler closed in line with anal canalclosure indicator in range; vaginal wall rechecked; time held closed before firing
8. Stapler firedtime held closed after firing; opened how many turns; removed
9. Doughnut checkedcomplete / incomplete
10. Staple line inspectedposition above dentate line; bleeding points secured with figure-of-eight absorbable sutures (material, size, number)
11. Additional proceduresNoneSkin tag excisionLateral internal sphincterotomy

Closure, drains and dressing

1. Anal wick / gauze ribbonNoneGauze ribbon placed (removal time)
2. Haemostatic sponge in anal canalYesNo
3. Dressingpad and T-bandage

Specimens and implants

1. Doughnut sent for HPEYesrequest comment on muscle in the doughnut
2. Staplermake, model, size, lot no.; sticker pasted in file

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Pulse and BPfrequent checks for staple-line bleeding
2. Wick / ribbon removaltime; before sensation returns if placed
3. Urinefirst void time; watch for retention
4. Diet and laxativesliquids then soft high-fibre diet; laxative drug and duration
5. Analgesiadrug, dose, frequency
6. Warning signsincreasing pain, fever, retention of urine, bleeding, inability to pass stool: report at once
7. Discharge and follow-upsame evening or next day after normal voiding; review date with HPE

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery