Understanding the Chivate Procedure
The Chivate procedure, also known as transanal suture rectopexy or mucopexy, is a surgical method for treating symptomatic hemorrhoids, particularly grades II, III, and IV. It was developed as a less painful alternative to traditional hemorrhoidectomy. Unlike conventional surgery, which involves extensive tissue removal, the Chivate technique focuses on lifting and fixing the hemorrhoidal cushions back into their natural position. This approach not only addresses the prolapse but also helps to ligate the blood vessels that contribute to the engorgement, reducing future recurrence. The procedure is performed by qualified colorectal surgeons and has demonstrated favorable outcomes, including minimal postoperative pain, a shorter hospital stay, and a low recurrence rate in many studies.
The Step-by-Step Process: What are the steps in the chivate procedure?
The procedure is performed in a series of careful and precise steps to ensure optimal outcomes. Here is a detailed breakdown of the surgical process:
- Anesthesia and Positioning: The patient is administered a saddle block or spinal anesthesia to ensure comfort and pain relief during the procedure. They are then placed in a steep Trendelenburg position (head down) while in the lithotomy position. This positioning helps to reduce the prolapsed hemorrhoidal tissue back into the rectum due to gravity.
- Manual Reduction and Lubrication: The anal canal is generously lubricated with jelly, and the engorged hemorrhoidal tissue is manually massaged and compressed to help reduce its size and push it upwards. This step is critical for a clear surgical field.
- Proctoscope Introduction: A specialized self-illuminated slit with a sliding valve proctoscope, often one designed by Dr. Chivate, is gently introduced into the anal canal. This instrument allows the surgeon to visualize the dentate line and the rectal mucosa above it without causing excessive stretching.
- Suturing the Rectal Mucosa: Using an absorbable suture, typically 2-0 polyglycolic acid on a small, half-circle needle, the surgeon begins the suturing process. The sutures are placed through a window in the proctoscope, starting at a specific clock position. The goal is to fix the repositioned rectal mucosa and submucosa to the deeper muscles of the rectal wall.
- Placement of Circumferential Suture Lines: Two circumferential rows of sutures are typically placed at two different levels, commonly 2 cm and 4 cm proximal (above) the dentate line. The first stitch is pulled tight to create a tent of fixed mucosa and muscle. Subsequent stitches are double-locked to prevent a purse-string effect and potential bowel obstruction.
- Inspection and Hemostasis: After the suturing is complete along the entire circumference, the area is inspected for proper fixation and to ensure meticulous hemostasis (control of bleeding). Any oozing from needle pricks can be managed with wet saline-soaked gauze.
Pre-Procedure Preparation and Post-Operative Care
Proper preparation and post-operative care are crucial for a successful outcome and a smooth recovery. The preparation typically involves a bowel prep with oral liquids for 24 hours prior to the procedure, often including laxatives. After the surgery, patients are typically discharged within 24 hours and can expect to return to most normal activities within one to two weeks, with full recovery taking longer. Post-operative care includes:
- Hygiene: Keeping the anal area clean is paramount. Warm sitz baths (15–20 minutes, 3–4 times daily) are highly recommended to soothe the area and promote healing.
- Pain Management: Though less painful than conventional surgery, some discomfort is expected. Mild pain relievers or over-the-counter medication may be used, though narcotic painkillers should be avoided if possible.
- Diet and Bowel Movements: A diet high in fiber and fluids is essential to avoid constipation and straining. Stool softeners may also be recommended.
- Activity: Rest is important, but gentle walking is encouraged. Avoid heavy lifting or strenuous activity for the first couple of weeks.
- Follow-up: A follow-up appointment is necessary to ensure proper healing and check for any complications.
A Comparative Look: Chivate vs. Conventional Haemorrhoidectomy
To better understand the advantages of the Chivate procedure, comparing it to a conventional hemorrhoidectomy is useful. This table highlights some key differences based on clinical studies:
| Outcome | Chivate's Procedure | Conventional Haemorrhoidectomy |
|---|---|---|
| Postoperative Pain | Significantly lower pain, especially in the first few days | Associated with significant pain and prolonged discomfort |
| Hospital Stay | Shorter hospital stay (often 24 hours) | Longer hospital stay often required |
| Complications | Lower complication rates reported in some studies | Higher complication rates for issues like bleeding, infection, and urinary retention |
| Recovery Time | Faster recovery and earlier return to normal activities | Longer recovery period, often 4-8 weeks for full recovery |
| Recurrence Rate | Low recurrence rates reported | Variable recurrence rates, sometimes higher than minimally invasive methods over the long term |
Benefits and Potential Risks
The benefits of the Chivate procedure are significant, especially for patients seeking a less invasive treatment with reduced downtime. These include the preservation of the anal sphincter function, less tissue removal, and generally better patient compliance due to a more comfortable recovery. However, like any surgical procedure, there are potential risks, including:
- Bleeding (intraoperative or postoperative)
- Infection (rare with proper care)
- Urinary retention
- Constipation (often manageable with dietary changes and stool softeners)
- Recurrence (if sutures fail or tissue is inadequately lifted)
The possibility of complications is often mitigated by meticulous surgical technique and attentive post-operative care.
Conclusion
The Chivate procedure is a promising and effective surgical option for treating grades II, III, and IV hemorrhoids, providing a minimally invasive alternative to conventional hemorrhoidectomy. By understanding what are the steps in the Chivate procedure—from patient positioning and tissue reduction to meticulous suturing and careful post-operative care—patients can make an informed decision with their healthcare provider. Its distinct advantages, including reduced pain, a shorter hospital stay, and a lower complication trend, make it an attractive option for many patients suffering from advanced hemorrhoidal disease. For more detailed information on surgical approaches to hemorrhoids, resources like the National Institutes of Health (NIH) provide valuable data.
