Hemorrhoidectomy

Description

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

The surgery is predominantly performed under General Anesthesia although options exist for Regional Anesthesia depending on patient and anesthetist choice. Recovery usually takes up to two weeks and involves dietary control to ensure adequate fiber 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 fecal incontinence.

What is it?

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

Internal - Where they occur inside the anal canal. These can prolapse and bleed after excessive straining.
External - These occur on the outside of the anal region and are covered by skin, often resulting in irritating skin tags. External Hemorrhoids can become very painful if a blood clot forms inside, resulting in thrombosis (2).

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

Why is it done?

Surgical hemorrhoidectomy 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 hemorrhoids, where there is a significant impact to day to day activities and quality of life. These hemorrhoids are typically highly symptomatic and result in an inability to conduct basic activities without persistent discomfort (3).

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

Anesthesia

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

General Anaesthesia - You will be unconscious throughout the surgery
Regional Anesthesia (Spinal/Epidural) - This involves an injection which numbs your waist down
Local Anesthesia - This only affects your anus and rectum. This is rarely used as it is not tolerated very well.

The choice of anesthesia 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).

Will I need to do any preparation?

Before undergoing the surgery, you will need to undergo a comprehensive preoperative assessment in the clinic. This involves:

Inspection of the anus and a digital rectal examination
Anoscopy - This procedure involves evaluating the hemorrhoids and their position.

If you are taking NSAIDs or other medication like warfarin, aspirin, and clopidogrel, your doctor may recommend you to temporarily stop taking them prior to the operation to reduce chances of bleeding.

Before the procedure, you will be required to stop eating for at least 6 hours and drinking clear liquids (e.g. water or tea without milk) for two hours before the operation.

The Surgery

You will usually not be aware of your positioning during the surgery as this will be done once after the anesthetic 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 hemorrhoidectomy include:

Open hemorrhoidectomy (Milligan-Morgan)
Closed hemorrhoidectomy (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 hemorrhoid 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 hemorrhoid 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 hemorrhoid, and scissors are used to dissect into the subcutaneous space surrounding the hemorrhoid.
The dissection of the hemorrhoid begins from the pedicle (base), and portion of the hemorrhoid 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).

Post-Operation

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.

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

Caring for yourself 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:

Maintaining a high fiber 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 hemorrhoids (8).
If the above approach does not aid in passing stool, you can also use a stool softener to reduce strain when emptying your bowel.
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.

The total time to recover from hemorrhoidectomy 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.