In obese cases there difficulties are even move and so the responsibility of the surgeon and his team becomes many folds because these patients may have associated problems i.e. diabetes, hypertension, dyspnoea arthritis especially knee point. Female patients are more difficult to handles as compare to male patients. Over the period a obese patients were treated and the difficulties encountered are being presented.
Examination at first visit
- 1. All the patients needed help to stop on the examination table and holding of the patients by the assistant was necessary.
- 2. Positioning the patients in lithotomic was also difficult because of the thick thigh s pressing against the fat on the belly.
- 3. Hip joints could be flexed up to certain extent only .
- 4. At this juncture, the patients complain of dyspnoea and to relieve. If the table had to be tilted so that the head end was raised and the pressure of the belly fat on the diaphragm was relieved.
- 5. Because of fat in the gluteal folds the perianal region was seen th be covered by it and in order to expose it to find out the fistulous opening the help of two assistants, one on each side to retract the folds laterally was required.
- 6. To introduce the finger in the anal canal was also quite difficult and so had to be pushed to reach to point where the internal opening of the tract through which the blunt end of the probe could be felt.
Fistulography
To assess the exact tract was advised in all the patients and the radiologist also experienced the same difficulties. In such obese patients the radiologist always wanted the surgeon to be present to introduce the dye in the tract so that the radiologist may concentrate on the exposure. In normal built patients the radiologist alone could perform the fistulography with the help of his assistant.
Because of excessive fat the x- ray pictures were not very sharp.
Investigations
Before application of ksharsutra following investigations wre done in all cases:
- Hematological : TC, DC ,Hb%, ESR, BT, CT ,Blood sugar( fasting, random, post prandial)
- ECG
Application of Ksharasutra
Ksharasutra was applied in all cases.
Changes of ksharasutra
The change of ksharasutra was though not difficult but certain associated problems were observed i.e.
- The skin on the opposite side of threading showed signs of rubbing with ksharasutra knot such as redness and erosion. The patient's were advised to apply jatyadi taila.
- Thick discharge was also seen sticking on the opposite skin fold and patients were advised o wash the part with water and after drying the skin with cotton a pad of cotton between the gluteus folds and change his pad whenever necessary.
Last change of ksharasutra
As the fistula cut through the loop of thread becomes small and is found to be buried in between the folds. This poses a real difficulty for the surgeon .The two assistants have to retract the skin folds apart, which in turn cause tension on the thread, while the surgeon has to hold the two ends of the knot to pull. It and tie a new ksharasutra through the loop. Thus the surgeon has to use all his ability while being delicate to the tissues and the patient as well.
Lengths of Initial thread
The initial length of thread was measured at the time of first change and was found to be between thighs.
Cutting and healing
It was more in obese than in normal built patients. Unit cutting was 9 days/cm. while in normal built patients it was 7 days/cm.
Associated diseases
All the essential medical care was done for the associated disease so that no complain comes up.
Conclusion
From this study it can be concluded that the obese patients present various difficulties which can be carefully taken care of by an observant and skilled surgeon. The essential knowledge of wound healing is the key to success.