Hemorrhoidectomy and Hemorrhoidopexy Periprocedural Care

Updated: Apr 11, 2017
  • Author: Sarah E Koller, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Equipment

Office equipment

The office-based procedures most commonly performed for hemorrhoids 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. For the grasping technique, the equipment needed includes a McGivney ligator, grasping forceps, a loading cone, and rubber bands. For the suction technique, the equipment needed includes 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 alternative techniques are to be employed, the relevant items and appropriate supplies are purchased separately.

Next:

Patient Preparation

Anesthesia

The authors use lidocaine 1% with epinephrine for office excision 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.

For operative procedures, the authors prefer monitored anesthesia care (MAC) with a local anesthetic. Most procedures are less than 25 minutes long, 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.

A liposomal form of bupivacaine has been approved by the US Food and Drug Administration (FDA) to produce postoperative analgesia for hemorrhoidectomy. For this operation, a dose of 266 mg (20 mL) diluted with 10 mL of saline (for a total of 30 mL) is infiltrated into the surgical site. The mixture is divided into six aliquots (5 mL each). Perform the anal block by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot into each of the even numbers.

Positioning

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 because they provide better eversion of the perineum.

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