**3. Anaesthesia**

Ambulatory anaesthesia has to provide a rapid onset analgesic effect, ensuring pain control and allowing an early discharge after the treatment is performed. The choice of the intra-operative anaesthetic management should consider patient's related factors, such as age, clinical condition and preference, surgeons' preference and procedural related factors, such as the kind of treatment and its length [5]. Anaesthesia for ambulatory procedures ranges from local to loco-regional anaesthesia, including pudendal nerve block and posterior perineal block; however, the easiest and shortest therapeutic sessions could even be performed without any anaesthesia, paying attention to the post-operative management, especially in terms of post-operative pain control.

Local anaesthesia is obtained through subcutaneous, intradermal or submucosal 1% lidocaine injections. Complications rate following local anaesthesia are extremely low, thus allowing to safely perform it in an outpatient setting. They include pain, which is usually due to the injected anaesthetic volume causing tissue distension, allergic reactions, and infections. Cardiovascular collapse is a rare but potentially life-threatening complication, requiring promptly intubation and vosoactive substances, steroids and myorelaxant drugs administration. Local anaesthesia is a quick and easy to perform anaesthesia, that allows performing minor ambulatory procedures, keeping pain under control.

Loco-regional anaesthesia includes pudendal nerve block and posterior perineal block. Pudendal nerve block, firstly described by Mueller in 1908, is performed with the patient in gynaecological position and is usually preceded by local anaesthesia administration if carried out in an ambulatory setting to an awake patient. After identifying the ischial spine, the needle punctures the skin transperineally, medial to the ischial tuberosity, 2–3 centimetres away from the anal margin. The needle is advanced in the posterolateral direction until the ischial spine and then rotated in the medial inferior direction to the ischial spine, passing through the sacrospinous ligament. After negative aspiration, the local anaesthetic, usually ropivacaina, is injected. Posterior perineal block, also known as Marti's technique, is performed with the patient in gynaecological or lithotomic position and preceded –in case of outpatient setting, by local anaesthesia administration, just as for pudendal nerve block. It involves infiltration of the inferior hemorrhoidal nerves, the posterior branch of the internal pudendal nerves, and the anococcygeal nerves and block of the inferior gluteal nerves and of perineal branches of minor nerves from the sacral plexus. It is achieved injecting ropivacaina or lidocaine 2 cm from the anal verge in the posterior commissure, 8 to 10 centimetres deeply into each ischiorectal fossa and superficially in the anterior commissure to achieve a complete infiltration of the perineal skin. Loco-regional anaesthesia is usually suitable to perform exploration under anaesthesia (EUA) of the anal canal in operative theatre and is associated to general anaesthesia to reach a complete multimodal pain control. In the ambulatory setting loco-regional techniques are unfrequently used, but

sometimes may be required to perform more invasive treatments. Complications are the same as for local anaesthesia, thus even if more invasive than local anaesthesia, these techniques may be safely performed for outpatient treatment.

#### **4. Postoperative management**

Postoperative management after proctologic office-based procedures mostly focuses on post-procedural pain control. It starts with anaesthesia performed during the procedure, so that the dose of analgesic drugs thereafter required is reduced and recovery time and return to daily living activities are shortened. After officebased procedures the pain can be controlled with oral pain killers administration. While the use of non-steroidal anti-inflammatory drugs (NSAIDs) alone is poorly effective to control severe pain and the use of narcotics alone may cause various side effects such as nausea, vomiting, dizziness and constipation (thus ultimately exacerbating pain symptoms), multimodal or balanced analgesia is the most effective treatment. It consists of administering in addition to narcotics, drugs with different mechanisms of actions and target pathways, including NSAIDs, acetaminophen, gabapentinoids, dexamethasone, alpha 2 agonists, NMDA receptor antagonists, and duloxetine. Acetaminophen and NSAIDs such as ketorolac and ibunoprofen successfully manage pain, resulting in an effective narcotic-sparing approach. The administration of pain killers drugs belonging to different classes results in increased analgesic effect and reduced drugs-induced side effects [5–7].

Analgesia may be provided by lidocaine and prilocaine ointment, too, ensuring supplemental pain relief and furtherly sparing narcotics.

Besides oral pain killers administration and local analgesic ointments application, anal burning and patient satisfaction may be improved by warn sitz baths. They are considered a worthwhile potential adjunct with little associated risk even if do not significantly reduce actual pain. Sitz baths or showers starting within 24 hours of the operation should be performed three times per day and after bowel movements for comfort and cleanliness [8].

Finally, to ensure pain control, it is fundamental to avoid constipation. Usually increased dietary fibre and fluid intake is sufficient to reduce postoperative constipation and pain upon defecation. However, even if dietary modification could guarantee stool softening, some physicians feel more comfortable recommending stimulant laxatives and stool softeners [5].

Postoperative management includes also follow-up instructions and written discharge instructions, improving patient satisfaction and decreasing the need for patients to seek additional medical attention, thus even reducing costs.

### **5. Haemorrhoids**

Haemorrhoids are arteriovenous sinusoids, located in the sub-epithelial space, embedded in connective tissue and smooth muscle fibres, participating to 15–20% of the anal continence [9–12]. Haemorrhoidal disease (HD) is characterised by abnormally congested and downward displaced haemorrhoids [11–13].

HD is one of the most frequent medical and surgical diseases and the commonest proctologic disease, experienced by more than 50% of the population over 50 years old in various degree. Reports on HD prevalence rate widely varies (4,4– 39%) [9, 14–16] because clinical manifestations may overlap with those of others anorectal diseases and may be wrongly attributed to other proctologic conditions; moreover many patients are asymptomatic, not requiring any treatment, while others self-diagnose and self-manage without referring to a specialist.

#### *Ambulatory Surgery for Perianal Disease DOI: http://dx.doi.org/10.5772/intechopen.97119*

Increased intraabdominal pressure due to constipation and prolonged straining are the commonest conditions leading to haemorrhoidal disease because of obstruction of venous return, resulting in engorgement of the haemorrhoidal plexus [17]. Moreover, defecation of hard faecal material increases shearing force on the anal cushions.

Painless rectal bleeding is the commonest onset of haemorrhoidal disease, which may present as minimal bright red bleeding per rectum or hematochezia after bowel movements [18–20], or even severe acute lower gastrointestinal bleeding requiring hospitalisation and blood transfusion in the most severe cases [17, 19]. Although rectal bleeding is the commonest sign of HD, less frequent presentations may be prolapse (even determining difficult defecation), mucous discharge, swelling, soiling, perianal skin irritation, itching, feeling of a lump, and discomfort. Acute anal pain is rarely a presentation symptoms, appearing only in case of thrombosed external haemorrhoids.

Despite such a variable clinical onset, HD diagnosis is easily achieved collecting the medical history and performing a physical examination including abdominal examination, and a local examination with the patient on a left lateral position, including inspection of the perianal tissues, anorectal digital examination, and anoscopy. However, even if haemorrhoids are easily recognised, it is necessary to perform an endoscopic examination to exclude more severe colorectal conditions [17].

Once HD has been diagnosed, the chosen treatment depends on haemorrhoids location, on the severity of the disease and on an eventual previously administered treatment. Haemorrhoids location refers to the dentate line, allowing a distinction between internal (above the dentate line and covered with mucosa) and external haemorrhoids (below the dentate line and coated with squamous epithelium), which differ not only for their position, but also blood supply, drainage, epithelization and innervations [20]. In particular, internal haemorrhoids receive visceral innervations and are less sensitive to pain, thus amenable to office-based treatment performed without or with minimal anaesthesia. On the contrary, external haemorrhoids are more sensitive to pain receiving somatic innervations and, therefore, require surgical treatment performed under anaesthesia, thrombosed external haemorrhoids being the only exception.

Regarding to haemorrhoids severity, while no widely accepted classification exists for external haemorrhoids, the extent of internal haemorrhoids is usually assessed with the Goligher classification [10, 17, 21], depending on the degree to which they prolapse from the anal canal, so that bleeding without prolapse stands for grade I, haemorrhoidal piles prolapsing during straining correspond to grade II and III if they respectively reduce spontaneously or manually, and non reducible haemorrhoids are classified as grade IV. As the grade becomes worse, office-based procedures or surgery are required. In particular grade I treatment is usually conservative, grade II and III are amenable of office-based procedures, and grade IV haemorrhoids require surgery.

However, even if the chosen treatment depends on both haemorrhoids location and severity degree, usually the first therapeutic step is conservative and consists on dietary and lifestyle modifications, if necessary associated to topical or oral medication. Conservative treatment is successful for the majority of patients and could be periodically administered for as long as the patient wishes. If conservative treatment fails or the patient chooses a more invasive approach, office-based procedures or surgery are indicated [12, 14, 22].

#### **5.1 Outpatient treatment**

Outpatient treatment is recommended for symptomatic patients affected by grade I, II or III haemorrhoidal disease refractory to conservative treatment [12, 14, 22]. It encompasses rubber band ligation, sclerotherapy, infrared coagulation, excision of

thrombosed external haemorrhoids and few other techniques, not frequently used, such as electrotherapy, HET bipolar system, YAG or carbon dioxide laser and cryosurgery [23]. Their common aim is to slough haemorrhoidal tissue and generate a scar so that residual tissue is fixated to the underlying sub-mucosal tissue and anorectal muscular ring. Each procedure is adopted in specific circumstances, being rubber band ligation the most frequently performed with a wider therapeutic range. Even if they differ for technical features and indications, all the office-based procedures are characterised by faster recovery and less pain than surgical treatment [24]. Moreover, complication rate following outpatient treatment is extremely low, varying between post-procedural pain –usually easy-controlled by oral painkillers, to perineal sepsis –the most severe and life threatening condition, which is extremely rare.

Ambulatory procedures may require more than one treatment session and can be repeated until a complete response, if the patient agrees. In fact, since haemorrhoidal disease is not a severe clinical condition, it is up to the patient whether to manage them with a conservative approach or surgery. Choice of the outpatient treatment should take into consideration patient preferences, availability of procedures and fitness for further procedures. Only in case of coexisting internal haemorrhoids and additional anorectal pathologies surgery should be suggested as first line treatment [12, 14, 22].
