Hemorrhoidectomy and Hemorrhoidopexy

Background

For the most part, symptomatic hemorrhoids are a quality-of-life issue. All patients should initially receive conservative management If this fails to improve symptoms, an office-based or operative procedure may be offered. Office-based treatments include sclerotherapy, rubber-band ligation, and infrared coagulation, Operative treatments include excisional hemorrhoidectomy, stapled hemorrhoidopexy (procedure for prolapse and hemorrhoids [PPH]), and hemorrhoid artery ligation (HAL). (See Technique.)

Despite several years of study, the main etiology of hemorrhoidal disease is still largely unknown. Many theories have been proposed, but the most common, and perhaps most accurate, theory 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. [1]

It is useful to classify hemorrhoids as external or internal (see Technical Considerations below).

Symptoms

Bleeding is the most common presenting symptom of hemorrhoidal disease. 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. [2]

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.

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. [32]

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. [3]

Complications

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. [2]

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

Indications

External hemorrhoids

Thrombosed external hemorrhoids diagnosed within 72 hours of symptom onset may undergo surgical excision with excellent results. Often, such excision can be done in the office setting; however, in the event of extensive hemorrhoids, the physician may prefer to perform the procedure in the operating room. Simple incision and drainage should be avoided because there is a high risk of reaccumulation, which may worsen symptoms. Overall, management should be based on the severity of the patient's symptoms at the time of diagnosis. [34]

Internal hemorrhoids

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; thus, the authors offer HAL or stapled hemorrhoidopexy (PPH). The authors prefer HAL in women, on the grounds that there is less dilation of the sphincter complex and no cutting of tissue. They believe that this provides a safe and effective treatment without posing a 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 hemorrhoidal disease 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

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 with local anesthesia.

Relative contraindications include the following:

  • Fecal incontinence
  • Rectoceles
  • Bleeding disorders
  • Portal hypertension with rectal varices
  • Crohn disease

Because hemorrhoids contribute to overall fecal continence, excision or removal may worsen a patient with borderline sphincter function. Women with rectoceles can develop obstructed defecation syndrome postoperatively if any stenosis occurs; use of a stapler is discouraged because of the 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 morbidity is high in these patients. [3]

Technical Considerations

Anatomy

Anal vascular cushions are present in everyone and are believed to contribute, in small part, to overall anal continence. When these cushions become enlarged and symptomatic, they are referred to as hemorrhoids. [3]

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. [1 Anatomically, these major vascular cushions are typically located in the following three main positions:

  • Left lateral
  • Right anterolateral
  • Right posterolateral

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 (anatomic anal canal). (See the image below.) For more information about the relevant anatomy, see Anal Canal Anatomy.

Anatomy of anal transition zone and surrounding muAnatomy of anal transition zone and surrounding muscles.

Classification

When hemorrhoids are symptomatic, smaller, secondary cushions may be present between the main cushions.

External hemorrhoids originate below the dentate line and are covered by squamous epithelium. They are in sensitive anal canal skin and are painful. Internal hemorrhoids are located above the dentate line and are covered by transitional or columnar epithelium. They are in insensitive anal canal mucosa and are painless (unless complicated).

Internal hemorrhoids can further be divided into four categories on the basis of 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 (see the first image below)
  • Grade 3 - Hemorrhoids prolapse with straining or defecation and have to be reduced manually (see the second and third images below)
  • Grade 4 - Hemorrhoids are permanently prolapsed and irreducible (see the fourth image below)
Grade 2 hemorrhoids. Grade 2 hemorrhoids.
Grade 3 hemorrhoids. Grade 3 hemorrhoids.
Grade 3 hemorrhoids. Grade 3 hemorrhoids.
Grade 4 hemorrhoids. Grade 4 hemorrhoids.

Although this grading system has limitations, it is beneficial for determining the efficacy of various forms of treatment. [21]

Outcomes

Early experience with stapled hemorrhoidopexy (also referred to as stapled hemorrhoidectomy, circumferential mucosectomy, or PPH) found it to be safe and effective. Because 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, quicker recovery and earlier return to work, and a low incidence of complications (see the images below).

Stapled hemorrhoidopexy vs excisional hemorrhoidecStapled hemorrhoidopexy vs excisional hemorrhoidectomy: postoperative pain scores. Source: Roswell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled hemorrhoidectomy): randomized, controlled trial. Lancet. 2000 Mar 4:355:779-81.
Stapled hemorrhoidopexy vs excisional hemorrhoidecStapled hemorrhoidopexy vs excisional hemorrhoidectomy: time to return to work. Source: Hetzer N, Demartines N, Handschin AE. Stapled vs. excision hemorrhoidectomy, long-term results of a prospective randomized trial. Arch Surg. 2002 Mar;137(3):337-40.

Long-term studies suggested that recurrence rates may be higher than with conventional hemorrhoidectomy; however, a 2015 study comparing long-term outcomes of closed hemorrhoidectomy with those of stapled hemorrhoidopexy found that patient satisfaction, resolution of symptoms, quality of life, and functional outcome appeared to be similar. [53216]

In a prospective, randomized trial that included 180 patients with hemorrhoids who were treated with open hemorrhoidectomy (n = 60), semiclosed hemorrhoidectomy (n = 60), or stapled rectal mucosectomy (ie, stapled hemorrhoidopexy; n = 60), Ripetti et al found that patients in the second and third groups resumed work earlier, experienced less pain, and had fewer complications. [7]

Aytac et al assessed circular stapled hemorrhoidopexy (mean follow-up, 6.3 ± 2.9 years) against Ferguson hemorrhoidectomy (mean follow-up, 7.7 ± 3.4 years) with respect to long-term outcomes and quality of life in 217 patients who underwent surgical treatment of hemorrhoids. [6 They found the two approaches to be similar over the long term with regard to patient satisfaction, resolution of symptoms, quality of life, and functional outcome.

A prospective randomized study by Carvajal López et al compared the outcomes of HAL with rectoanal repair (HAL-RAR) and  those of excisional hemorrhoidectomy. [8The primary measure was postoperative pain; secondary measures were symptom resolution rates, postoperative morbidity, recurrence rates, and changes in quality of life. Compared with excisional hemorrhoidectomy, HAL-RAR was found to evoke less postoperative pain during a shorter period and to achieve resolution of hemorrhoidal symptoms with less postoperative complaints. At 12 months' follow-up, however, there were no significant differences in morbidity or recurrence rate.

The LigaLongo trial, a randomized trial comparing transanal Doppler-guided HAL (either HAL-RAR or transanal hemorrhoidal dearterialization [THD]) with mucopexy and circular stapled hemorrhoidopexy in patients with grade 2 or 3 hemorrhoidal disease, found that postoperative morbidity and outcome at 1 year were similar, regardless of the type of device used. [9These findings suggested that device type has little impact on the results of therapy for hemorrhoidal disease.

A review and meta-analysis by Emile et al examined six randomized trials that included 554 patients with internal hemorrhoids to determine whether either THD or stapled hemorrhoidopexy was superior to the other in terms of recurrence of hemorrhoids, complications, and postoperative pain. [10 The primary end point was persistence or recurrence of disease; secondary end points were postoperative pain, complications, readmission, return to work, and patient satisfaction. THD was associated with a significantly higher persistence/recurrence rate, but there were no significant differences in the other end points.


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.

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.


Approach Considerations

In the management of hemorrhoids, it is extremely important to isolate the predominant symptom. Patients may have external tags and complain of bleeding, and thus, a simple rubber-band ligation may suffice. The therapy must always be tailored to the specific symptoms; hemorrhoids are a quality-of-life issue.

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

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 high-fiber diet over the long term. If compliance is problematic, doctors may prescribe psyllium seed extract or methylcellulose to facilitate consumption of fiber in a more convenient way. Adequate hydration must be encouraged as well. This is generally a good initial approach for reducing hemorrhoidal bleeding and is ideal for grade 1 and some grade 2 hemorrhoids. [31]

When conservative management is inadequate, surgical treatment is necessary. The classic operative approach is excisional hemorrhoidectomy. This procedure is indicated for patients who do not improve after multiple attempts of nonoperative management or office-based procedures and for patients who have markedly prolapsed hemorrhoidal disease (grade 3 and 4). Other surgical procedures that may be considered are stapled hemorrhoidopexy (sometimes referred to as stapled hemorrhoidectomy or circumferential mucosectomy) and hemorrhoid artery ligation (HAL).

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

Office-Based Procedures

Nothing is worse for a patient than undergoing a procedure of the anorectum. Ensuring patient comfort is the key to success. 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 (eg, a second rubber-band ligator) at hand. 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.

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 as other, more effective modalities have increasingly been employed. [31]

Rubber-band ligation

Rubber-band ligation is a quick and effective office procedure for the treatment of internal hemorrhoids. The principle underlying rubber-band ligation is similar to that underlying sclerotherapy, in that the procedure results in fixation of the mucosa. The band leads to ischemic necrosis and finally ulceration of the mucosa. The procedure is performed by using an anoscope and a rubber-band ligator. The bands should be placed on the rectal mucosa above the hemorrhoidal group. No special bowel preparation is required, and multiple groups can be banded during a single session.

The success rate of rubber-band ligation is variable in the literature but has been reported to be as high as 75%. [32More than one banding session may be required. A meta-analysis by MacRae et al found rubber-band ligation to be superior to sclerotherapy and infrared coagulation for the treatment of grade 1-3 hemorrhoids but determined that pain was slightly greater. [11]

Infrared coagulation

The infrared coagulator uses heat to induce coagulation of an internal hemorrhoid. As with sclerotherapy and rubber-band ligation, the goals are to induce fibrosis and scarring of the hemorrhoids, preventing future bleeding and prolapse. [3This procedure is more expensive than rubber-band ligation and requires specialized equipment. As with rubber-band ligation, repeat procedures are often required.

Excisional Hemorrhoidectomy

Excisional hermorroidectomy may be broadly classified as open or closed; the distinction is made according to whether the anorectal mucosa is closed with sutures after the excision. (See the video below.)

Excisional hemorrhoidectomy. Procedure performed by Daniel L. Feingold, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors. https://www.columbiadoctors.org/

Closed technique

Position the patient in the prone jackknife position. Apply adhesive tape to the buttocks, and retract the buttocks 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. 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 that the sphincter is not clamped during the hemorrhoidectomy.

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 for visualizing the internal anal sphincter and ensuring that they are not too deep. Place a 2-0 chromic suture in a figure-eight manner above the pedicle first; 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 cauterization for hemostasis. Finally, close the wound with a continuous 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. The authors often close the incision in an inverted-T shape to ensure that there is no stenosis of the anal canal. (See the image below.)

Surgical excision of hemorrhoids. Surgical excision of hemorrhoids.

Open technique

Place the patient in the lithotomy or prone position, and prepare and drape the area. Inject a local anesthetic 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.

Alternative energy devices

The LigaSure (Covidien), a bipolar cauterizing device, and the Harmonic Scalpel (Ethicon), an ultrasonic energy device, have gained popularity in the performance of hemorrhoidectomy. 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 in comparison with the standard techniques.

Randomized trials have shown that in comparison with conventional hemorrhoidectomy, hemorrhoid excision with the LigaSure is faster and generally produces less blood loss and pain. Information on long-term follow-up is not yet available. [1]

Stapled Hemorrhoidopexy

Stapled hemorrhoidopexy involves removing a ring of mucosa and submucosa approximately 4-5 cm from the dentate line with a specific PPH (procedure for prolapse and hemorrhoids) circular stapler. The distal mucosa is surgically fixed 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.

Procedure

The preparation of the patient is the same as for conventional hemorrhoidectomy. Position the patient either in the prone jackknife or the lithotomy position. General anesthesia is typically used, though the procedure may also be done with monitored anesthesia care (MAC) and local anesthesia. Inject a local anesthetic as previously described.

Evert the anal canal with four silk sutures before placing the dilator. This brings the dentate line closer to the anal verge, reducing 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 so as to allow better visualization of the operative field. Insert a circular anal dilator and anoscope, reducing 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.

Apply an anal retractor, and place a 2-0 polypropylene 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 1 minute for hemostasis and vessel compression. If this procedure is being performed on a woman, a vaginal examination should be performed before the stapler is fired so as to make sure that 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. [21Do not pack. Place dry gauze on the anal verge, and keep it in place with mesh underwear. (See the images below.)

PPH stapled hemorrhoidectomy: anatomy of anal canaPPH stapled hemorrhoidectomy: anatomy of anal canal.
PPH stapled hemorrhoidectomy: prolapsed internal hPPH stapled hemorrhoidectomy: prolapsed internal hemorrhoids.
PPH stapled hemorrhoidectomy: purse-string suture PPH stapled hemorrhoidectomy: purse-string suture placed 4-5 cm above dentate line.
PPH stapled hemorrhoidectomy: retracting and operaPPH stapled hemorrhoidectomy: retracting and operating anoscopes.
PPH stapled hemorrhoidectomy: placing purse-stringPPH stapled hemorrhoidectomy: placing purse-string suture.
PPH stapled hemorrhoidectomy: schematic of circumfPPH stapled hemorrhoidectomy: schematic of circumferentially excised mucosa.
PPH stapled hemorrhoidectomy: schematic of approxiPPH stapled hemorrhoidectomy: schematic of approximated mucosa.
PPH stapled hemorrhoidectomy: completed procedure.PPH stapled hemorrhoidectomy: completed procedure.
PPH device through purse-string suture. PPH device through purse-string suture.
PPH stapled hemorrhoidectomy: (A) stapler insertedPPH stapled hemorrhoidectomy: (A) stapler inserted through purse-string and (B) excised mucosa and stapler.
PPH stapled hemorrhoidectomy: completed procedure.PPH stapled hemorrhoidectomy: completed procedure.

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. Doppler-guided HAL was introduced as one means of dealing with these potential problems.

Two platforms for HAL are currently available in the United States, transanal hemorrhoidal dearterialization (THD) and one from the Agency for Medical Innovations (AMI; ie, HAL with rectoanal repair [HAL-RAR]). The authors have been using THD for the past several years. The procedure involves Doppler-guided ligation of the arteries supplying the hemorrhoidal cushions, which decreases 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 by Morinaga in 1995, several reviews of this therapy have been completed. The technique has evolved over the past couple of decades, and it is being recognized as both a safe and an effective means of treating symptomatic grade 2-4 hemorrhoids.

Procedure

Place patients either in the prone jackknife or lithotomy position. Patient preference and comorbidities dictate the anesthetic plan. Provide local anesthesia to all patients.

The THD 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, then use the suture to ligate the artery with two 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. It is essential to make sure that the hemorrhoidopexy is not too close to the dentate line; a margin of at least 1 cm must be left to help decrease postoperative discomfort. [12]

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. (See the images below.)

Hemorrhoid artery ligation device from THD AmericaHemorrhoid artery ligation device from THD America.
THD America slide. Needle is premeasured to ligateTHD America slide. Needle is premeasured to ligate hemorrhoidal arteries.

Postoperative Care

Excisional hemorrhoidectomy

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. Nonnarcotic analgesics may be given to alleviate pain. Pain is usually mild during the initial days after the procedure but is exacerbated by bowel movements. Sitting in a warm bath immediately after having a bowel movement may decrease pain. Topical glyceryl nitrate may reduce pain, but there is a substantial incidence of headache with its use. [13]

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.

Stapled hemorrhoidopexy

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 nonnarcotic analgesics. Pain is not exacerbated by bowel movements.

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

Hemorrhoid artery ligation

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 nonnarcotic analgesics. Pain is not exacerbated by bowel movements.

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

Complications

Complications of 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, or 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 who 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 highly dependent on the individual patient. Therefore, it is natural for surgeons to want to use a procedure that produces as little pain as possible. [2Newer techniques such as PPH and HAL have been shown to cause significantly less pain than the conventional techniques do.

Urinary retention

Urinary retention can occur in as many as 15% of patients after hemorrhoidectomy. [2Many factors are thought to contribute to posthemorrhoidectomy urinary retention, 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 one catheterization. Men with enlarged prostates may require an indwelling Foley catheter for as long as 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 postoperative complications

Poor wound healing

An anal fissure or ulceration, though 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. [2Stools 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, though some patients experience leakage and soiling from the anus that usually resolves by 6 weeks to 2 months. [2Further data will be required for meaningful commentary to be made 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.

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