Anal sac excision

RE: Anal sac excision

Will McMullan — Wed, 01 Mar 2017 13:20:26 GMT

Use a 6 or 8 Fr usually, pass it down the duct, fill with air or saline, the gently tug on it to make sure it's snug in place. Then dissect out the gland around the bulb. Quite simple really. Useful too if the sac has ruptured, I'm sure the gel would get everywhere in that situation.

RE: Anal sac excision

Beats — Tue, 28 Feb 2017 19:31:54 GMT

I do this rarely (and use the gel if I can - hate doing it when the duct is not patent and don't enjoy it at best of times).

Does anyone have a detailed descirption of the foley technique to share, I can't quite imagine what's being described to date? oh, and what size foley and do you fill with saline and how much on average?

RE: Anal sac excision

Will McMullan — Mon, 27 Feb 2017 09:25:35 GMT

I use the foley catheter method (although rarely remove anal sacs) and find it works very well. The sac is easy to identify and manipulate and the catheter bulb gives you something to work against when dissecting surrounding tissues.

RE: Anal sac excision

Anthony Todd — Sun, 26 Feb 2017 22:01:15 GMT

[quote user="Phil R."]Criteria for anal sac excision could be adapted from those used for tonsillectomy in the NHS :-[/quote]

Not so stupid so why the anonymous one star?

I'll bet you don't vote for RCVS councillors either, and just moan [anonymously, of course]

RE: Anal sac excision

easy307 — Sun, 26 Feb 2017 21:40:49 GMT

Criteria for anal sac excision could be adapted from those used for tonsillectomy in the NHS :-

"A tonsillectomy will only be considered for a recurrent sore throat in both children and adults if certain criteria are met. You must have:

a sore throat caused by tonsillitis
episodes of sore throat that are disabling and stop you functioning normally
seven or more well documented, clinically significant, adequately treated sore throats in the preceding year or
five or more such episodes in each of the preceding two years or
three or more such episodes in each of the preceding three years"

NHS Choices Information (2014) Tonsillitis - treatment. [Online] Available from http://www.nhs.uk/Conditions/Tonsillitis/Pages/Treatment.aspx

RE: Anal sac excision

Anthony Todd — Sat, 25 Feb 2017 23:47:30 GMT

What was the criterion/criteria for excision?

How many, and how often, were they packed with AB/steroid or whatever before removal?

How many were just expressed a few times then removed?

Were any sucessfully sclerosed?

RE: Anal sac excision

Lindsey Edwards — Sat, 25 Feb 2017 20:36:24 GMT

Previous boss of mine used to 'marspialise' ducts - place grooved introducer into duct and incise to neck of gland, suture open to surrounding skin. Never saw a repeat impaction in any of the cases on follow up. Haven't seen the need personally as I find correcting diet/fibre levels results in very few cases

RE: Anal sac excision

grumpyoldman — Thu, 23 Feb 2017 18:17:08 GMT

[quote user="robloxley"]Tim Charlesworth published a recentish paper for closed technique which had a higher complication rate (albeit minor complications) where the gel was used.[/quote]

I have to say i did not agree with those findings , I thought the gel was a lot easier to use than fiddling about with a cat spay hook and the only ones that gave you problems were those that had recently ruptured/fistulated. The minor initial complication rates relating to a bit of a sore ass were <10% and longer term problems probably 0. That is 1-2 a month for 20 years.

The most important thing is a good light, small sharp dissection kit and a 3.5 x operating loupe.

RE: Anal sac excision

Anthony Dennison — Thu, 23 Feb 2017 14:54:39 GMT

[quote user="Clare Tapsfield-Wright"]yes it's all fine unless it's overpacked and explodes into the surrounding tissue or if previous abscess result in diverticulae and fragments of sac lining being left behind with or without gel.[/quote]

This is what happened when I did my first anal sacculectomy. I put a whole syringe/tube in to each gland. Looking back that's why they ruptured; they were so full there was no give.

I'll remember that for next time!

RE: Anal sac excision

Clare Tapsfield-Wright — Thu, 23 Feb 2017 13:42:44 GMT

[quote user="robloxley"]

There was a study some years ago that reported a much higher complication for 'open' compared to 'closed' anal sacculectomy; not sure if there's more recent comparing the two?

Tim Charlesworth published a recentish paper for closed technique which had a higher complication rate (albeit minor complications) where the gel was used.

[/quote]yes it's all fine unless it's overpacked and explodes into the surrounding tissue or if previous abscess result in diverticulae and fragments of sac lining being left behind with or without gel. I used to enjoy the challenge but might be looking at them with rose tinted specs

RE: Anal sac excision

Rob Loxley — Thu, 23 Feb 2017 13:07:32 GMT

There was a study some years ago that reported a much higher complication for 'open' compared to 'closed' anal sacculectomy; not sure if there's more recent comparing the two?

Tim Charlesworth published a recentish paper for closed technique which had a higher complication rate (albeit minor complications) where the gel was used.

RE: Anal sac excision

gdbvet — Thu, 23 Feb 2017 05:26:06 GMT

by far the easiest approach.hold both sides of excised glnd with fine hemostats to dissect accurately.

RE: Anal sac excision

Laurence Webb — Thu, 23 Feb 2017 00:05:16 GMT

As I said, I've not done an anal sac excision using a foley, but the time that I used it to remove an adjacent tumour I could see how it would avoid muscles etc. Under tension the anal sac was just under the mucosa and could be readily identified by its grey/silvery sheen. Muscles were deep to the area, but mainly because the sac was lifted up

In the op that I referred to I dissected around the lateral side but can't imagine it being any more difficult medially.

RE: Anal sac excision

Martin Atkinson — Wed, 22 Feb 2017 16:29:23 GMT

I haven't felt the necessity to excise an anal gland in many a year. I found the Vettec Gel method best but it didn't always go in completely. However the problem I see with dissecting down the duct is the risk of damaging the anal sphincter muscle or innervation so would prefer to steer clear of that and dissect it out through a vertical skin incision lateral to the anus, sans or avec gel.

RE: Anal sac excision

Rob Davis — Wed, 22 Feb 2017 15:50:23 GMT

[quote user="Clive Ansell"]I never could get along with the gel, or stuffing them full with cotton wool, so now use the open dissection technique described by Braden - tissue forceps into the gland, and an incision from the duct opening to ventral gland, then open dissection[/quote]

Ditto - much prefer this technique, though the foley catheter idea sounds interesting.

RE: Anal sac excision

Laurence Webb — Tue, 21 Feb 2017 22:40:18 GMT

The op I referred to was a 64kg Newfoundland (though not overweight). Take what you want from benefits of size/obesity! I suspect a 50% overweight animal is always going to be a struggle.

RE: Anal sac excision

Joyce Whitehead — Tue, 21 Feb 2017 21:57:37 GMT

Sounds like a brilliant but fairly simple suggestion! Having said I like this op, today's was a bit of a nightmare, partly due to it being in a very overweight 50kg lab, so the glands were very deep, so quite a bit of bleeding around. It took me much longer than usual.

RE: Anal sac excision

Laurence Webb — Tue, 21 Feb 2017 20:40:55 GMT

At a CPD lecture I heard of a technique that involved putting a small foley catheter into the sac, inflating the bulb then using gentle traction to lift the sac superficially to dissect around.

I haven't used it to remove a sac but last month used it to identify the sac whilst I excised an adenocarcinoma lateral to the sac.

Identifying the sac was a doddle and having a catheter to get hold of and manipulate the sac was a great improvement with previous experience with gels, artery forceps etc. My excision was within 1mm of the sac but that was enough to preserve the sac and get clear margins. I can imagine that it would make removing a sac just as straight forward

RE: Anal sac excision

Clive Ansell — Tue, 21 Feb 2017 16:36:45 GMT

[quote user="Robin Grimmer"]Hi Clive, I used to do a lot of these, but haven't done one for a while. What technique do you use? I used that stuff that sets, Vettec I think it was called? It came in a vial that you put in boiling water, then you'd squirt it up the ducts in to the anal sacs and it would set. Made it a doddle to dissect the anal sacs out. Plus the heat would help cauterise blood vessels. Is it still available?[/quote]

Hi Robin,

I never could get along with the gel, or stuffing them full with cotton wool, so now use the open dissection technique described by Braden - tissue forceps into the gland, and an incision from the duct opening to ventral gland, then open dissection. If possibly neoplastic will dissect without opening the gland if possible. Close in 2 layers and prefer Monocryl or Vicryl Rapide.

Fairly quick and easy to do as long as careful, and satisfying op. Not aware of one going wrong.

If a history of recurrent infections, prefer a swab for C&S and on antibiotics 2 -3 days prior to surgery.

RE: Anal sac excision

Anthony Todd — Mon, 20 Feb 2017 23:18:40 GMT

[quote user="Evelyn Barbour-Hill"] not to mention the phenol irrigation method[/quote]

You've forgotten "sclerosing solution"...... but then forget it..... [phenol, formalin and something I've forgotten, and so should it.] Dangerous stuff if the syringe was pressurised.....

RE: Anal sac excision

Evelyn Barbour-Hill — Mon, 20 Feb 2017 22:59:37 GMT

[quote user="Anthony Todd"]Ever since I started to express, then pack them with dear old Panolog I don't think we ever had to remove any.[/quote]

I assure you that in my earlier years I was so scared of the surgery that I have tried "packing" with just about everything including Panolog (which was indeed a great product), not to mention the phenol irrigation method (instructions on request to anyone who wants to try it) but I am now firmly in favour of excision for the repeatedly troublesome cases.

I admit that you may draw at least three different conclusions from this expression.

RE: Anal sac excision

Anthony Todd — Mon, 20 Feb 2017 22:44:03 GMT

Ever since I started to express, then pack them with dear old Panolog I don't think we ever had to remove any.

Mind you these were chronic "infected" glands with grossly abnormal content.

Worth a thought if the client is averse to removal.

PS Worked in cats too.

Easy to pack with one of those lovely 20 or 22G Venocaths, not those old angled metal catheter thingys with the knob on the end.

RE: Anal sac excision

Evelyn Barbour-Hill — Mon, 20 Feb 2017 22:43:01 GMT

[quote user="Clare Tapsfield-Wright"]I packed them with gel then made an incision ventrolateral to the palpable sac and dissected them out till just attached by the duct to the anal ring. Then you could clamp and legate the duct keeping the anal ring discrete and I think it helped prevent post op infection and minimised inflammation and excessive licking.[/quote]

I'd second that. (Not saying any other method is inferior though).

[quote user="Clare Tapsfield-Wright"] i weirdly enjoyed doing them. One client said " I understand you are the bum expert" . Nice ! [/quote]

Not so weird...... It's the satisfaction of expertly doing what one is good at. It's not so far removed from oral, or indeed aural, surgery: an exercise in precision, blunt dissection on a small scale, fine (in both senses) suturing; and confidence in how to salvage the situation if something goes wrong.

(Was that narcissssistisssistic?)

Whatever the institution, I've noticed that the regular soft tissue surgeons often dislike anal surgery, and it generally gets done by whoever is interested: at Langford, it was Jerry Lucke, and he was supposed to be the anaesthetist!

RE: Anal sac excision

Clare Tapsfield-Wright — Mon, 20 Feb 2017 22:22:42 GMT

I packed them with gel then made an incision ventrolateral to the palpable sac and dissected them out till just attached by the duct to the anal ring. Then you could clamp and legate the duct keeping the anal ring discrete and I think it helped prevent post op infection and minimised inflammation and excessive licking. i weirdly enjoyed doing them. One client said " I understand you are the bum expert" . Nice !

RE: Anal sac excision

Stephanie Wellings — Mon, 20 Feb 2017 22:17:48 GMT

I use a gel but it goes in cold - it comes in little cartridges and is put in via a scary looking gun like implement, and it sets after a couple of minutes.

The way I was taught to do it was to dissect around the opening, grab the opening with artery forceps and continue to dissect from there til the whole gland is out. Do other people make the incision in the skin over the main 'sac' bit? (i'm thinking that would be a better place for the wound to be!)