1- local Anesthesia with sedation is best for all but an extremely small and rare portion of proctology patients, it is safe, effective, convenient, cost effective, very well liked by patients , it allows for early discharge and return to home, and best of all, I ‘ve had no complications with it over the last 5000 cases I’ve done.

Local anesthesia solution mix that I use is very diluted, I learned it from the Elves procedure I do for legs varicose veins (that is the Endolaser varicose veins saphenous treatment) and before that from what plastic surgeons used on their liposuction patients.

When applied as described in this course, via a drug dispenser, and by the method explained, it allows for a very good anal / rectal block that make the patient comfortable during and after the procedure.

Sedation is mainly needed during the actual application of local anesthesia which takes only less than 30 seconds with the use of drug dispenser, so a small and safe amount of IV (or IM) sedation is needed, we use mainly four drugs for sedation, all proven to be very safe and effective, all doses and monitoring are described in the course, they are short acting and can be reversed at any point.

2- The need for an Assistant, although not exactly a must in the beginning, it becomes soon necessary for a busy practice. It allows the Surgeon to concentrate on his/her work and gives the patient a comfortable, reassuring face to interact with during the case, and provides a better monitoring of the patient’s vital signs , pain , need for Oxygen supplement ... etc.

We regularly monitor O2 Saturation, BP and EKG. Our pre-op instructions are simple and straightforward and so are our post-op instructions, all described in details during this course.

3- The Left Lateral Decubitus position is excellent for all proctology cases; it is comfortable for both the patient and Physician, less embarrassing for the patient, provides for ?better breathing especially in obese patients and it is preferred by most Assistants.

It is going to be the rule in all the videos of this course that the patient is in LLD position with the head being on the left of the screen and the feet on the right, the right side of hips is up and the left is down.

The only exception is Pilonidal Cyst patient where we actually administer local anesthesia with sedation while the patient is in LLD position but we then turn the patient to prone and tape the buttocks and continue the case under pure local anesthesia.

4- Time of surgery matters, the shorter the procedure the better, from all points of view, but this should not be on the account of good surgical work. On the contrary, it forces you to prepare your equipments and instruments well and it explains the need for the equipments described in this course because they make your life so much easier and they provide for a fast, bloodless, atraumatic procedure.

5- Minimal dissection is a good rule in proctology, the lesser the amount of retraction and pulling and cutting and suturing and grabbing, the better. The patient’s pain is less, the infection rate is lower, the healing is faster and the post surgical edema or ecchymosis becomes minimal.

The Surgitron and Ligasure and infrared Coagulator have afforded us this luxury as you’re going to see for your self in this course.

6-The No tension principle is important in a successful proctology practice, since this is one of the few areas in the body that stretches and expands on a regular basis, and worst of all, we sit on it, and so any tension will cause pain and will lead eventually to the breakdown of the sutures line.

I learned from the open fistula cases that these patients do not complaint of pain postoperatively in spite of the open large incisions they are left with, whereas, a small excised hemorrhoid with an incision closed with a couple of sutures will hurt for a couple of weeks at least...so slowly, I started to leave - those incisions that I felt that I don’t have enough skin to close them without tension – open. And I was encouraged by the results. Some times, I closed one side and left the other side open , then compared during follow up the pain between the two sides, it was clear that the open side was less painful while the healing time is almost the same!...so, it was only natural to understand the no tension principle and apply it to all proctology cases.

7- Good, clear, typed post-op instructions and medications are a necessary for smooth post op course, I concentrate on three points during the first 15 days postoperatively:

- No Constipation.

- Good local hygiene.

- Good analgesics.