Lord's Procedure (Manual Anal Dilatation / Lord's Operation)

Background & Rationale

Indications

• 1st and 2nd degree internal haemorrhoids (best results)
• Anal fissure (acute or chronic)
• 3rd degree haemorrhoids (less satisfactory results - about half become symptom-free)
• Patients with a tight, high-pressure anal sphincter respond better

Pre-operative Assessment

1. Digital Rectal Examination (DRE) - performed before the procedure to:
   • Feel for the constricting band of muscle (usually at the level of the anorectal line)
   • Assess anal tone - a tight anus predicts better outcome
2. Proctoscopy and sigmoidoscopy/colonoscopy as indicated
3. Informed consent

Anaesthesia

• General anaesthesia (preferred) or intravenous sedation
• Care is taken to avoid laryngeal spasm

Step-by-Step Technique

1. Positioning: Patient placed in lithotomy position (standard for anorectal procedures)
2. Lubrication: Lubricate the index and middle fingers of both hands with 2% xylocaine (lignocaine) jelly
3. Initial digital examination: Confirm findings under anaesthesia
4. Finger insertion - gradual and sequential:
   • Insert index finger of one hand gently
   • Then insert index finger of the other hand
   • Then middle finger of one hand
   • Finally, middle finger of the other hand (crossing hands)
   • End point: four fingers total (two from each hand) inserted into the anal canal
   • Dilation target: up to 40 mm
5. Technique of stretching:
   • All fingers must be kept straight - bending fingers like a claw is avoided
   • Pressure is applied only from the distal and intermediate phalanges; proximal digits remain outside the anus
   • Fingers are pronated and distracted in opposite directions
   • Strain is applied at the 3 o'clock and 9 o'clock positions
   • 6 o'clock and 12 o'clock positions are avoided because the sphincter is weaker there (higher risk of tear)
   • Sphincters are gradually allowed to relax, then fingers are advanced further
   • Positions are then changed to 12 and 6 o'clock as well once relaxation is achieved
6. Duration: Stretching is maintained for exactly 4 minutes by clock
7. End of procedure:
   • A gauze soaked in povidone-iodine and anaesthetic jelly is placed in the anal canal
   • Antiseptic dressing is applied
   • A small sponge/gauze pack may be inserted to reduce haematoma/blood clot formation

Post-operative Care

• Patients are instructed to intermittently self-insert an anal dilator at home for 6 months - this prevents re-stenosis and maintains the effect of the stretch
• Follow-up is arranged

Results

• 1st and 2nd degree haemorrhoids: Excellent long-term results
• 3rd degree haemorrhoids: Only ~50% become symptom-free
• Anal pressure is significantly reduced by the dilation and remains reduced over 5 years
• Patients with the most active internal sphincter (highest resting pressures) tend to have the best clinical results

Complications & Downfall

Summary

Lord's Procedure (Plication) for Hydrocele

What is a Hydrocele?

Surgical Options for Hydrocele - Overview

Lord's Plication - Indication

• Thin-walled tunica vaginalis sac
• Smaller volume hydrocele (not massive)
• Teenage boys with non-communicating hydrocele
• Preferred when minimal dissection is desired (e.g., to reduce haematoma risk)

If the sac is chronic and thick-walled, Lord's is not suitable - prefer Jaboulay's or excision.

Lord's Plication - Step-by-Step Technique

• General or spinal/regional anaesthesia
• Patient in supine position
• Scrotal approach

• A transverse or vertical scrotal incision is made through skin and dartos muscle
• The hydrocele sac is delivered into the wound by gentle dissection through fascial layers (dartos, cremaster, tunica vaginalis)

• Unlike other techniques, there is minimal dissection of the sac from surrounding tissues
• The sac is NOT fully mobilized - it remains largely attached to surrounding scrotal structures
• This is the key advantage - it greatly reduces the risk of haematoma

• The hydrocele sac (parietal tunica vaginalis) is opened along its anterior surface
• Hydrocele fluid is drained

• The testis is delivered (extruded) through the aperture in the opened sac
• The testis now sits outside the sac

• Multiple interrupted absorbable sutures (e.g., chromic catgut or Vicryl) are placed in the redundant tunica vaginalis
• Sutures are placed radially (like spokes of a wheel) in a circumferential fashion around the sac
• When these sutures are tied, the tunica bunches/gathers at its attachment to the testis
• The redundant sac is thus pleated/gathered up rather than excised

• The testis is replaced back into the scrotum
• The bunched-up, plicated tunica sits around the testis

• Because no excision is performed and dissection is minimal, no drain is needed
• This contrasts with excisional techniques, which often need a drain due to higher haematoma risk

• Dartos and skin are closed in layers
• Dissolvable sutures are typically used

Why Lord's Works

Advantages of Lord's Plication

• Minimal dissection - the sac is not fully mobilized
• Lowest risk of haematoma among all hydrocele operations - because scrotal wall vessels are not disturbed
• No drain needed
• Quick and technically straightforward
• Low recurrence rate (comparable to excisional techniques in appropriate cases)

Disadvantages / Limitations

• Not suitable for thick-walled sacs - the thick wall cannot be neatly plicated; it remains bulky and may cause discomfort or recurrence
• Not ideal for very large hydroceles - excessive redundant tissue makes plication unwieldy
• Higher complication rate compared to Jaboulay's in some studies (particularly for large hydroceles where it is used inappropriately)

Comparison: Lord's vs Jaboulay's

Key Takeaway

• Bailey and Love's Short Practice of Surgery, 28th Ed., p. 1587
• Campbell-Walsh-Wein Urology, p. 83.5