Hemorrhoidectomy 

Anal vascular cushions are present in everyone and are believed to contribute, in small part, to overall anal continence. The term hemorrhoids is used to refer to these cushions when they become enlarged and symptomatic.^[1]

These anal cushions are composed of plexuses of vessels within the anal canal that connect arterioles to veins without intervening capillaries. They are also normally supported by smooth muscle fibers (Treitz muscle) and connective tissues in the submucosa that help maintain their position in the upper half of the canal. Repeated stretching of these attachments causes disruption and results in prolapse.^[2] Anatomically, these major vascular cushions are typically located in 3 main positions—left lateral, right anterolateral, and right posterolateral. When hemorrhoids are symptomatic, smaller, secondary cushions may be present between the main cushions. Hemorrhoids present above the dentate line are classified as internal hemorrhoids. Hemorrhoids occurring below the dentate line are classified as external hemorrhoids.

External hemorrhoids are in sensitive anal canal skin and are painful, while internal hemorrhoids are in insensitive anal canal mucosa and are painless (unless complicated).

The anal canal is completely extraperitoneal. The length of the (surgical) anal canal is about 3-5 cm, with two thirds of this being above the dentate line and one third below the dentate line (anatomical anal canal). For more information about the relevant anatomy, see Anal Canal Anatomy.

Development of hemorrhoids

Despite several years of study, the main etiology of hemorrhoidal disease is still largely unknown. Many proposed theories exist, but the most common, and perhaps most accurate, pertains to the abnormal sliding of the vascular cushions that is associated with straining and irregular bowel habits. Hard, bulky stools promote straining, which is more likely to push the cushions out of the anal canal. Furthermore, straining may cause engorgement of the cushions during defecation, making their displacement more likely. Congestion and hypertrophy of the anal cushions ensue, making them more prone to developing edema and bleeding.^[2]

Symptoms

Bleeding

Bleeding is the most common presenting symptom. It usually manifests as bright red blood, recognized first on the toilet paper with defecation and later becoming heavier and noticed in the toilet. With time, bleeding may be unrelated to defecation.^[3]

Prolapse

Prolapse of internal hemorrhoids is highly characteristic of more advanced and chronic hemorrhoidal disease. The prolapsed internal hemorrhoids may reduce spontaneously or may need to be reduced manually. In rare cases, they may prolapse through the anal canal and become incarcerated.

Pain/discomfort

In the absence of thrombosis or incarceration, hemorrhoids are usually painless. Dull pain after defecation is common with prolapsed hemorrhoids and is relieved by reducing the prolapse. If someone is experiencing severe pain, a complication of hemorrhoids or another diagnosis, such as anal fissure, abscess, or rectal ulceration, must be considered.^{[1, 3]}

Discharge/pruritus

Patients may experience mucoid anal discharge or fecal soilage as internal hemorrhoids prolapse through the anal canal. This irritation of the perianal skin can result in significant pruritus.^[1]

Complications

Thrombosis and infection Thrombosis is the most painful complication of internal or external hemorrhoids. The pain is often severe enough to affect routine daily activities. While it can occur in large, prolapsed hemorrhoids, thrombosis is more common in external hemorrhoids. If the epithelium overlying the thrombosed hemorrhoid breaks down and allows invasion of bacteria, it may lead to infection, which is rare.^[3]

Anemia

The incidence of hemorrhoidal bleeding that results in anemia is low.

Classification of hemorrhoids

External hemorrhoids originate below the dentate line and are covered by squamous epithelium.

Internal hemorrhoids are located above the dentate line and are covered by transitional or columnar epithelium.

Internal hemorrhoids can further be divided into 4 categories determined by the extent of prolapse, as follows:

• Grade 1: Hemorrhoids bulge into the lumen of the anal canal but do not descend below the dentate line.
• Grade 2: Hemorrhoids prolapse below the dentate line with straining but reduce spontaneously.Grade 2 hemorrhoids.
• Grade 3: Hemorrhoids prolapse with straining or defecation and have to be reduced manually.Grade 3 hemorrhoids. Grade 3 hemorrhoids.
• Grade 4: Hemorrhoids are permanently prolapsed and irreducible.Grade 4 hemorrhoids.

Although this grading system has limitations, it is beneficial to determine the efficacy of various forms of treatment.^{[3, 2]}

External hemorrhoids

Thrombosed external hemorrhoids diagnosed within 72 hours of symptom onset may undergo excision of thrombus with excellent results. Certain patients with thrombosis longer than 72 hours who still have maximal pain may see some relief, but the clot is usually beginning to resorb and expectant management is appropriate. Overall, base the management on the severity of the patient's symptoms at the time of diagnosis.^[1]

Internal hemorrhoids

For the most part, symptomatic hemorrhoids are a quality of life issue. Start all patients with conservative management as described below. If this fails to improve the patients' symptoms, offer a procedure.

Failed medical management is the primary indication for surgery. The authors usually offer escalating treatments, from least invasive to most invasive. For bleeding hemorrhoids refractory to dietary modification, rubber band ligation is their preferred treatment. Sclerotherapy and infrared coagulation are also options.

With prolapse of tissue, rubber band ligation requires multiple applications, so the authors offer hemorrhoid artery ligation (HAL) or stapled hemorrhoidopexy (procedure for prolapse and hemorrhoids [PPH]). The authors prefer HAL in women, as there is less dilation of the sphincter complex and no cutting of tissue. They believe that this provides a safe and effective treatment without significant risk to the sphincter complex. With large prolapsing hemorrhoids, they offer PPH or excision. In patients with a large external component, excision is the most effective option.

Symptomatic hemorrhoids affecting quality of life is the general indication for intervention. Symptoms include pain, bleeding, and difficulty with hygiene. In some cases of patients on antiplatelet or anticoagulation therapy or patients with hemophilia, surgical intervention is needed to prevent hemorrhage.

Contraindications are dependent on the specific symptoms and therefore the specific therapy being offered. Dietary modification is simple and effective, yet patients with irritable bowel syndrome may not tolerate a high-fiber lifestyle.

Patients with contraindications to anesthesia due to significant medical comorbidities should not be offered surgical therapy for hemorrhoids unless there is sepsis or significant hemorrhage with anemia. Often, these procedures can be performed under local anesthetic.

Relative contraindications include fecal incontinence, rectoceles, bleeding disorders, portal hypertension with rectal varices, and Crohn disease. Hemorrhoids contribute to overall fecal continence, so excision or removal may worsen a patient with borderline sphincter function. Women with rectoceles can develop obstructed defecation syndrome postoperatively if they develop any stenosis, and use of a stapler is discouraged, as there is a risk of incorporating the vaginal mucosa in the staple line and causing a fistula. The authors prefer excision and closure in patients with bleeding disorders because direct suturing of the pedicles may reduce the risk of a postoperative bleed.

In patients with Crohn disease or portal hypertension with rectal varices, surgery should be reserved as a final option because there is a high morbidity rate in these patients.^[1]

Office procedures

The authors use lidocaine 1% with epinephrine for office excision of a clot from a thrombosed hemorrhoid. A standard bilateral pudendal nerve block is used followed by injecting the perianal skin and mucosa. The authors do not use anesthetic for sclerotherapy, rubber band ligation, or infrared coagulation.

Operative procedures

The authors prefer monitored anesthesia care (MAC) with local anesthetic. Most procedures are less than 25 minutes and they can achieve moderate sedation until the block is complete and then lighten the sedation to reduce the risk of apnea. General anesthesia with an endotracheal tube is required in patients at risk for apnea. If the patient is to be in lithotomy position, a laryngeal mask airway (LMA) is preferred.

All patients should receive local anesthesia with lidocaine and bupivacaine with epinephrine before any incision, unless contraindicated.

Bupivacaine liposome

A liposomal form of the local anesthetic bupivacaine (Exparel) was approved by the US Food and Drug Administration (FDA) in October 2011. A single dose infiltrated into the surgical site produces postsurgical analgesia for hemorrhoidectomy. A total dose of 266 mg (20 mL) diluted with 10 mL of saline (for a total of 30 mL) is used once for hemorrhoidectomy. The mixture is divided into 6 aliquots (5 mL each). Perform the anal block by visualizing the anal sphincter as a clock face and slowly infiltrating 1 aliquot into each of the even numbers.

Office equipment

The most common office procedures performed are sclerotherapy and rubber band ligation. In addition to whatever agent is required for sclerotherapy, good lighting and anal retractors are required. The authors use Buie-Hirschmann anoscopes (Hirschmann Rectal Specula) for office procedures. They prefer lighted retractors because they improve visualization. They do not anesthetize for office procedures because they are working above the dentate line.

For rubber band ligation, use a grasping or suction technique. If using the grasping technique, the equipment needed includes a McGivney ligator, grasping forceps, a loading cone, and rubber bands. If using a suction ligator, the equipment needed include a suction apparatus, the suction ligator, and rubber bands.

Operating room equipment

The standard hemorrhoidectomy tray has basic instruments as well as basic retractors and a Bovie cautery. Standard excision with open or closed technique requires no other specialized equipment. Again, the authors prefer lighted retractors because they improve visualization; these are ordered separately.

If using other techniques such as LigaSure, Harmonic, THD, and PPH, these items and the appropriate supplies are purchased separately.

The patient can be treated in several positions. Choose the position in which the patient is the most comfortable.

In the office, the authors use a tilt table and do all office procedures in the prone-jackknife position. In their opinion this affords the best lighting, is tolerated well by most patients, and allows excellent visualization of the anal canal. If a tilt table is unavailable, the left lateral position, with the knee to chest and buttocks over the edge of the table is the most effective.

In the operating room, the authors also prefer the prone jackknife position. The authors routinely use this technique with MAC and sedation. Place the patient in the prone jackknife position and give light sedation. Use a pudendal block and local analgesia and then perform the procedure. In patients who are obese or have airway issues, either general anesthesia or lithotomy position may be used. When the authors use lithotomy, they use Candy Cane stirrups as opposed to yellow fins or Allen stirrups, as they provide better eversion of the perineum.

Medical management

Lifestyle and diet modification are best suited for patients with only minor symptoms and should be attempted before more aggressive treatment is undertaken. In general, topical creams and suppositories are not effective.

Diet modification

Adding bulking agents in the form of fiber is the recommended first-line therapy, and a high-fiber diet should be encouraged. However, compliance is an issue because many people are not motivated to adhere to a long-term, high-fiber diet. In this case, doctors may prescribe psyllium seed extract or methylcellulose to facilitate the consumption of fiber in a more convenient way. Adequate hydration must be encouraged as well. This is generally a good initial approach to reduce hemorrhoidal bleeding and is most ideal for the treatment of grade 1 and some grade 2 hemorrhoids.^{[1, 2]}

Office-based procedures

Sclerotherapy

The goal of sclerotherapy is to produce submucosal fibrosis so that prolapse is less likely to occur. The solutions commonly injected are phenol, quinine urea, and sodium morrhuate. The popularity of sclerotherapy has gradually diminished in favor of the more effective modalities.^{[1, 2]}

Rubber band ligation

Rubber band ligation is a quick and effective office procedure for the treatment of internal hemorrhoids. The principle behind rubber band ligation is similar to that of sclerotherapy, in that it results in fixation of the mucosa. The band leads to ischemic necrosis and finally ulceration of the mucosa. The procedure is performed using an anoscope and a rubber band ligator. The bands should be placed on the rectal mucosa above the hemorrhoidal group. No special bowel prep is required and multiple groups can be banded during one session. The success rate of rubber band ligation is variable in the literature but has been reported to be as high as 75%.^{[1, 3]} More than one banding session may be required.

Infrared coagulation

The infrared coagulator uses heat to induce coagulation of an internal hemorrhoid. Like sclerotherapy and rubber band ligation, the goals are to induce fibrosis and scarring of the hemorrhoids, preventing future bleeding and prolapse.^[1] This procedure is more expensive than rubber band ligation and requires specialized equipment. Like rubber band ligation, repeat procedures are often required.

Operative treatment of hemorrhoidal disease

The classic operative approach, or criterion standard, is excisional hemorrhoidectomy. Excisional hemorrhoidectomy is broadly classified as open or closed. The distinction is made by whether the anorectal mucosa is closed with sutures after the excision. These procedures are indicated for patients who fail to improve after multiple attempts of nonoperative management or office-based procedures and patients who have markedly prolapsed hemorrhoidal disease (grade 3 and 4). Other procedures include stapled hemorrhoidopexy and HAL.

All patients are told to take 2 Fleets enemas 2 hours before the procedure.

Excisional hemorrhoidectomy - closed technique

Position the patient in the prone jackknife position. Apply adhesive tape to the buttocks and to retract it laterally to aid in exposure. Perform a bilateral pudendal nerve block and infiltrate the perianal skin and mucosa with lidocaine 1% or bupivacaine 0.5% with epinephrine. Insert a Hill-Ferguson retractor for inspection of the anal canal and distal rectum. Grasp the prolapsed hemorrhoid in a Kelly clamp and retract toward the center of the anal canal. The authors prefer the Kelly clamp to visualize the internal anal sphincter and ensure they are not too deep. Place a 2-0 chromic suture in a figure eight manner above the pedicle first as this decreases blood loss. Mark an elliptical incision with the knife from the external component of the hemorrhoid group to the proximal end of the clamp. Excise the hemorrhoid with scissors or electrocautery.

This technique allows excision without injury to the underlying internal sphincter muscle. Complete the excision with cautery for hemostasis. Finally, close the wound with a running, absorbable 2-0 suture, beginning at the apex of the wound with a locking stitch. The authors usually use the original stitch from ligating the pedicle. Small bites of internal sphincter muscle are included in the closure to decrease dead space. They often close the incision in an inverted T-shape to ensure no stenosis of the anal canal.

Excisional hemorrhoidectomy - open technique

Place the patient in the lithotomy or prone position and prep and drape the area. Inject local anesthesia as described above. Place a lighted Hill-Ferguson retractor. Grasp the component of hemorrhoidal tissue that is covered by skin with a Kelly clamp. Pull the hemorrhoid downward, prolapsing the hemorrhoid tissue completely out of the anus, making visible the rectal mucosa superior to the hemorrhoid. Use a 2-0 chromic suture to ligate the vascular pedicle as described above.

Excise the hemorrhoid from the underlying sphincter muscle proximally to its apex. Leave the wound open and apply a nonadherent dressing.

The patient is advised to change the outer gauze daily as needed. The packing may be removed in 24 hours. Stool softeners can be used to ensure a more comfortable first bowel movement. Non-narcotic analgesics can be used to alleviate pain. Pain is usually mild during the initial days following the procedure but is exacerbated by bowel movements. Sitting in a warm bath immediately after having a bowel movement may decrease pain.

The patient should be seen for a postoperative visit 4-6 weeks after the procedure; at this point they can tolerate a rectal examination, which is necessary to ensure that there is no stenosis. If stenosis is present, the daily use of an anal dilator is recommended.

Alternative energy devices

Recently, the LigaSure (Coviden), a bipolar cauterizing device, and the Harmonic Scalpel (Ethicon), an ultrasonic energy device, have gained popularity. These techniques use bipolar diathermy and ultrasound energy, respectively, to completely coagulate the vessels while limiting thermal spread and excess tissue injury. The risk of infection and postoperative pain may be reduced when compared with the standard techniques.

Randomized trials have shown that the LigaSure technique is faster and generally produces less blood loss and pain when compared with the conventional hemorrhoidectomy. Information on long-term follow-up is not yet available.^[2]

Stapled hemorrhoidopexy

During stapled hemorrhoidopexy, remove a ring of mucosa and submucosa approximately 4-5 cm from the dentate line using a specific PPH circular stapler. "Pexy" the distal mucosa to the proximal mucosa with the stapling device. The procedure also interrupts the arterial blood supply to the hemorrhoids, allowing involution of the hemorrhoidal plexus. The early experience with this technique found it to be safe and effective. Since all the work is done above the dentate line, there is less pain than with conventional excision. Studies have shown significant reduction in postoperative pain, a quicker recovery and earlier return to work, and few complications. Long-term studies suggest that recurrence may be higher relative to conventional hemorrhoidectomy.^{[1, 3, 2]}

Stapled hemorrhoidopexy - technique

The preparation of the patient is the same as conventional hemorrhoidectomy. Position the patient either in the prone jackknife or lithotomy position. General anesthesia is typically used, although the procedure may also be done with MAC and local anesthesia as described above. Inject local anesthesia as described. Evert the anoderm slightly and insert a circular anal dilator and anoscope, which reduces the prolapse. Remove the dilator and the mucosa that was prolapsed falls into the lumen of the anoscope, which is transparent to facilitate easy visualization of the dentate line.

Place an anal retractor and place a 2-0 Prolene purse string suture in the mucosal layer at least 4-5 cm proximal to the dentate line. Assess the complete purse string via digital examination. Feel the mucosa circumferentially as the string is pulled. No suture should be felt. Open the dedicated 33-mm hemorrhoidal circular stapler fully and introduce it into the anal canal proximal to the purse string, which is then tied. Pull the threads through the holes on the sides of the stapler and knot or hold with forceps. Close the stapler while holding traction on the sutures and gently pull outward.

Once the stapler is completely closed, wait one minute for hemostasis and vessel compression. If this procedure is being performed on a woman, a vaginal examination should be performed before firing the stapler to make sure there is no vaginal entrapment in the device. After firing and removing the stapler, use the retractor to examine the staple line, and if there is any bleeding or gaps, place sutures at this time.^{[3, 2]} Do not pack. Place dry gauze on the anal verge and keep it in place with mesh underwear.

Stapled hemorrhoidopexy - postoperative management

Advise the patient to change the outer gauze daily as needed. Stool softeners can be used to ensure a more comfortable first bowel movement. Pain is usually most severe in the first 72 hours after the procedure and can be alleviated with non-narcotic analgesics. Pain is not exacerbated by bowel movements.

See the patient for a postoperative visit 4-6 weeks after the procedure, as at this point they can tolerate a rectal examination.

Hemorrhoid artery ligation

Excision of anal tissue by any means requires a good deal of prudence. The anal sphincter is at risk for being damaged if the depth of the excision is too great. A technique recently introduced is known as Doppler-guided hemorrhoid artery ligation (HAL). Two platforms are currently available in the United States, transanal hemorrhoidal dearterialization (THD) and one from the Agency for Medical Innovations (AMI). The authors have been using THD for the past 4 years. The procedure involves Doppler-guided ligation of the arteries supplying the hemorrhoidal cushions, thereby decreasing the pressure within the plexus hemorrhoidalis. A hemorrhoidopexy can then be performed if there is redundant mucosa. Since the introduction of endorectal Doppler-guided THD in 1995 by Morinaga, several reviews of this therapy have been completed. This technique has evolved over the past decade, and it is being recognized as both a safe and effective means to treat symptomatic grade 2-4 hemorrhoids.

Hemorrhoid artery ligation - technique

Place patients either in the prone jackknife or lithotomy position. Patient preference and comorbidities dictate the anesthetic plan. Give local anesthetic to all patients. The kit includes a lighted anal retractor with Doppler, needles, and a needle driver. Place the THD device into the anal canal. Use the Doppler probe to identify pulsatile arterial segments. Load the provided absorbable suture to the appropriate marks on the needle driver and then use the suture to ligate the artery with 2 bites until the Doppler signal is obliterated. If there is redundant hemorrhoidal tissue, remove the Doppler slide and perform a hemorrhoidopexy using the same suture running distally. Never come closer than 1 centimeter from the dentate line.^[4]

Duplicate the procedure circumferentially until all signals are obliterated. Six to seven separate bites are commonly required. Do not pack or place gauze. Patients are discharged the same day.

Hemorrhoid artery ligation - postoperative management

Stool softeners can be used to ensure a more comfortable first bowel movement. Pain is usually most severe in the first 72 hours after the procedure and can be alleviated by non-narcotic analgesics. Pain is not exacerbated by bowel movements.

See the patient for a follow-up visit 4-6 weeks after the procedure.

Overview

When dealing with patients with hemorrhoids, isolating the predominant symptom is extremely important. Patients may have external tags and complain of bleeding, so a simple rubber band ligation may suffice. Always tailor the therapy to the specific symptoms, as hemorrhoids are a quality of life issue.

Office procedures

Patient comfort is the key to success. Nothing is worse for a patient than undergoing a procedure of the anorectum. Lidocaine ointment is good to use for a rectal examination and allows some local analgesia. Placing the anoscopes slowly and allowing the anorectal inhibitory reflex to initiate allows for easier placement. Always have all the equipment ready and have back-up materials (second rubber band ligator) ready. After the procedure, allow the patients a few minutes to rest. Beware of a vasovagal response. Patients who get nauseated or have excessive sweating during the procedure are at risk for a syncopal episode.

Operations

Injecting local anesthetic with epinephrine decreases bleeding. Always remember to aspirate first so that epinephrine is not injected into a blood vessel. When injecting the mucosa, elevate it off the internal sphincter with the injection to help ensure the sphincter is not clamped during an excisional hemorrhoidectomy.

During a stapled hemorrhoidopexy, evert the anal canal with 4 silk sutures prior to placing the dilator. It brings the dentate line closer to the anal verge, decreasing the possibility of incorporating anoderm into the staple line. If a large amount of redundant mucosa is present, place a small sponge into the anal canal before inserting the anoscope, as it will allow better visualization of the operative field.

During HAL procedures, make sure the hemorrhoidopexy is not too close to the dentate line; leaving at least a 1-centimeter margin will help decrease postoperative discomfort.

Office-based procedures

Sclerotherapy, rubber band ligation and infrared coagulation have similar morbidities. Potential complications include pain, urinary retention, bleeding, and local sepsis. Complications are generally due to poor placement of injections, rubber bands, and the coagulator.

Bleeding, which is usually limited, may also occur as the mucosa sloughs off and an ulcer forms. This may especially be true in patients continuing antiplatelet medications after treatment. Perianal sepsis after rubber band ligation has been reported. This dreaded complication is exceedingly rare in patients that are not immunocompromised.

Acute postoperative complications

Pain

Pain is an important factor in a patient’s decision whether or not to undergo hemorrhoidectomy. However, postoperative pain is very dependent on the individual patient. Therefore, it is natural for surgeons to want to use a procedure that produces as little pain as possible.^[3] Newer techniques like PPH and HAL have been shown to cause significantly less pain when compared with the conventional techniques.

Urinary retention

Urinary retention can occur in up to 15% of patients posthemorrhoidectomy.^[3] Many factors are thought to contribute to urinary retention following hemorrhoidectomy, with pain being a major contributor. Perioperative restriction of fluid intake has been shown to reduce the need for catheterization. In general, most patients have no further issues after 1 catheterization. Men with enlarged prostates may require an indwelling Foley catheter for up to 72 hours.

Bleeding

Bleeding is often minor and can be stopped with external pressure. If the location of the bleeding is uncertain, or if the patient becomes hemodynamically unstable with undetected bleeding, he or she should be examined in the operating room under general anesthesia. After the rectum is irrigated with sterile saline, the bleeding site should be ligated under direct vision.

Chronic complications

Poor wound healing

An anal fissure or ulceration, although rare, may develop if one of the hemorrhoidectomy sites fails to heal properly. If it develops, supplemental fiber, nitroglycerin ointment, and diltiazem creams may be used to aid healing.^[3] Stools should be kept soft. Healing generally occurs without further intervention.

Abscess or fistula

Anorectal sepsis formation is rarely reported following hemorrhoid procedures. In these cases, the wound should be examined under anesthesia and reopened to promote continued drainage.

Incontinence

Frank incontinence is rare, although some patients experience leakage and soiling from the anus that usually resolves by 6 weeks to 2 months.^[3] There are not enough data to meaningfully comment on the incidence after stapled hemorrhoidopexy or HAL.

Anal stenosis

This complication is uncommon and can be prevented in most cases by leaving significant mucosal bridges between excision sites. Using a closed technique with a retractor in place ensures adequate room in the anal canal.

If any narrowing of the anal canal is observed during the first postoperative visit, encourage the patient to use an anal dilator along with diet modification. Anoplasty may be considered if the anus cannot be easily dilated and medical treatment has failed.^[3]