Haemorrhoidectomy

Introduction

Haemorrhoidectomy is a surgical procedure involving excision and removal of either internal or external haemorrhoids. The two main approaches to haemorrhoidectomy include either open (more commonly) or closed procedures depending on whether the wounds are closed after surgery. Haemorrhoidectomy is typically performed in advanced cases involving Grade III or IV haemorrhoids which are not responsive to other treatments. Surgery involves excision of the haemorrhoid and the external skin associated with it and is usually conducted as a day-case. 

The surgery is predominantly performed under General Anaesthesia although options exist for Regional Anaesthesia depending on patient and anaesthetist choice. Recovery usually takes up to two weeks and involves dietary control to ensure adequate fibre and fluid intake with the aim of softening stools and preventing straining during defecation. Pain is a common post-operative complaint and can be managed using prescribed pain medication. 

Complications of the procedure range from minor bleeding and urinary tract retention, to more severe yet rare complications such as damage to the sphincter muscles resulting in long-term faecal incontinence. 

What is it?

A haemorrhoidectomy is the surgical removal of large and symptomatic haemorrhoids. These haemorrhoids have typically either prolapsed or thrombosed and hence require more aggressive treatment (1). Haemorrhoids refer to enlarged blood vessels and can either be:   

1) Internal - Where they occur inside the anal canal. These can prolapse and bleed after excessive straining.   

2) External - These occur on the outside of the anal region and are covered by skin, often resulting in irritating skin tags. External Haemorrhoids can become very painful if a blood clot forms inside, resulting in thrombosis (2).   

Haemorrhoidectomy is predominantly conducted on internal haemorrhoids, but also can be done on external haemorrhoids especially if large.   

Why is it done?

Surgical haemorrhoidectomy is usually conducted once conservative, outpatient treatments such as banding, or other types of surgery such as ultrasound guided ligation have failed. This typically occurs in patients with Grade III or IV haemorrhoids, where there is a significant impact to day to day activities and quality of life. These haemorrhoids are typically highly symptomatic and result in an inability to conduct basic activities without persistent discomfort (3).   

Haemorrhoids are typically completely benign and can be safely left alone. Treatment is only indicated if the symptoms are severe enough (4).   

Haemorrhoidectomy may also be conducted to prevent any other problems recurring such as thrombosis (5).   

Will I need any preparation?

Technique

Anaesthesia

There are many different approaches to anaesthesia for haemorrhoidectomy; your surgeon will discuss the various options with you which include: 

 1) General Anaesthesia - You will be unconscious throughout the surgery.

2) Regional Anaesthesia (Spinal/Epidural) - This involves an injection which numbs your waist down.   

3) Local Anaesthesia - This only affects your anus and rectum. This is rarely used as it is not tolerated very well.   

The choice of anaesthesia predominantly depends on surgeon and anaesthetist preference, however your pre-operative assessment is a good time to discuss any of your concerns and preferences (6).   

What does it involve?

You will usually not be aware of your positioning during the surgery as this will be done once after the anaesthetic has started. You will either be placed in the Lithotomy position, or the prone jackknife position depending on surgeon provision. Both of these provide the surgeon with adequate exposure of the perianal region (1).   

The entire surgery usually takes between 15-45 minutes. The two main types of haemorrhoidectomy include:   

1) Open haemorrhoidectomy (Milligan-Morgan) 

2) Closed haemorrhoidectomy (Ferguson) 

There is no clear difference in outcomes for one approach over another, and the choice is predominantly based upon surgeon preference. The Open (Milligan-Morgan) approach involves excising the haemorrhoid without closure of the wound and is most commonly done, whereas a closed approach involves closing the wound.   

You will be given the anaesthetic and positioned in either the lithotomy or jackknife position depending on surgeons choice and individual requirements. The main steps of the procedure include: 

- Preparing and cleaning the overlying skin of the anus using a special iodine solution to reduce infection risk. 

- Incisions are made in the skin around the haemorrhoid using either a scalpel, scissors, or electrocautery pen based on surgeon preference. Care is taken to avoid damaging any of the anal sphincters.  

- The incision is a V-Shaped incision around the base of the haemorrhoid, and scissors are used to dissect into the subcutaneous space surrounding the haemorrhoid. 

- The dissection of the haemorrhoid begins from the pedicle (base), and portion of the haemorrhoid distal to the pedicle is excised and removed. 

- Depending on whether the procedure is either an open or closed procedure, the wound is either left intact or closed using absorbable sutures. 

- If the surgeon feels necessary, a topical antibiotic can be applied to the area to prevent risk of infection (7). 

How long does it take?

The entire surgery usually takes between 15-45 minutes.  

Post procedure course (follow up)

Immediately after the surgery, you will be taken to a recovery room and your vital signs monitored closely. The nurses may apply a dressing to protect the wound, and they will give you advice about caring for any wounds at home including washing the area.   

How long will I stay in hospital?

Most patients either go home the same day or the next day if an overnight stay for recovery is required.   

What care will I need at home?

Rectal and anal pain in the first few days after the operation is very common, and hence your doctor may prescribe you some painkillers to help you with this. In addition to painkillers, the additional steps that you can take to reduce pain and aid recovery include:   

1) Maintaining a high fibre and fluid intake - This helps soften your stool and make it easier to pass. This helps to reduce straining when defecating and hence reduce recurrence of any haemorrhoids (8). 

2) If the above approach does not aid in passing stool, you can also use a stool softener to reduce strain when emptying your bowel. 

3) Having regular warm baths (with sitz salts if you prefer) will also help reduce episodes of pain and feelings of tightness (9). 

Much of the post-operative care is focused on minimizing the pain and ensuring constipation is avoided. This can be prevented by taking the above steps and by only using opiates in accordance with your doctor’s recommendations. The pain is the most severe for the first 4-5 days.   

Will I need someone to stay with me?

No particular need, you should. be fully independent.    

Will I need any special equipment to take home?

Because surgical site infections can result from haemorrhoidectomy, the medical team in charge of your care will give you advice on how to properly care for your wound and minimise chances of infection.    

When can I start normal activities again (e.g. sports, work)

The total time to recover from haemorrhoidectomy is between 10-14 days, and during this time your doctor will ask you to avoid any heavy lifting or strenuous exercise. People are typically able to return to work within 1-2 weeks but some may need longer depending on the pain.