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Hemorrhoidectomy
Removal of hemorrhoids

Hemorrhoids are a problem that affects over 1 million Americans each year. It affects both sexes and is more common in the more prosperous societies, perhaps related to exercise, diet and bowel habits.

Anatomy

  • The anal canal is a little over one inch in length (3 cm) and extends from the lowest part of the rectum to the anus (Figure 1)
  • The anal canal is surrounded by an internal (inside) and external (outside) venous plexus (interconnection of veins)
  • In the anal canal these plexuses form "cushions" of mucosa (inner lining of tissue) filled with veins and muscle fibers. These hemorrhoidal cushions fill up with blood during the act of straining while passing stool, and serve to protect the anus from injury. The muscle fibers help support the cushions
  • There are three cushions one each in the left lateral, right posterior and right anterior positions (looking from behind at 9, 2 and 5 o'clock)
  • Two muscular sphincters (internal, inside; external, outside) surround the anal canal and control the passage of stool. The sphincters tends to contract to hold in stool when pressure in the abdomen increases and relaxes when a person strains at the stool
Figure 1 - Anatomy of the lower rectum and anus showing the muscle sphincters that control bowel movements and the internal and external plexuses. © C. Scalici

Pathology

  • It is believed that abnormal distension of blood vessels in the hemorrhoidal cushions leads to the development of hemorrhoids
  • This may be caused by increased sphincter pressure (people who strain excessively while passing stool), by pressure on the drainage of blood from the hemorrhoidal veins (a pregnant women may have the uterus compressing the venous drainage), or by abnormalities in the vessel walls
  • Patients with liver failure may develop abnormal venous connections in the rectum causing similar blood vessel congestion
  • Another cause may be the weakening of the muscle support of the hemorrhoidal cushions, which may occur with age or poor bowel habits
  • These factors tend to cause the cushions to prolapse (bulge) downwards. Hemorrhoids may be classified by their location or by degree of prolapse (downward bulging)
  • By location, hemorrhoids may be external (outside the anal canal) or internal (inside the anal canal)
    1. External hemorrhoids are distended vascular cushions that occur just outside the margin of the anus and under the skin (Figure 2)
    2. Internal hemorrhoids are the more common variety and occur from within the anal canal and prolapse outside (Figure 3)
  • By degree of prolapse, there are four grades
    1. The vessels of the hemorrhoid are increased in number and size and may bleed on passing stool, but they do not prolapse outside of the anus
    2. The hemorrhoids prolapse outside of the anus while passing stool but spontaneously return after
    3. The hemorrhoids protrude out of the anus but need to be reduced (pushed in) by hand
    4. The hemorrhoids are unable to be reduced to within the anal canal

     

Figure 2 - Various degrees of external hemorrhoids. © C. Scalici Figure 3 - Various degrees of internal hemorrhoids. © C. Scalici

History and Examination

  • The most common complaint associated with hemorrhoids is bleeding. This usually occurs during a bowel movement and in some cases can be significant. Blood may be checked to determine anemia due to blood loss
  • Other complaints include itching, discomfort and discharge in the anal area
  • A detailed history of diet, exercise and bowel habits is taken, as well as a physical exam to find other causes that may be cause this condition
  • Patients may notice prolapse of the hemorrhoids. When this occurs the patient may reduce the hemorrhoids
  • There may be pain if the hemorrhoid is thrombosed (the blood within is clotted) or ulcerated (open on the surface). Painful hemorrhoids may cause the patient to become constipated and worsen the condition
  • Hemorrhoids are usually examined with an anoscope, which is a small tube that is inserted into the anus and rectum to see the hemorrhoidal cushions. The doctor will usually ask the patient to strain during the exam to see the effect this has on the hemorrhoids. If the patient is more than 50 years old, an examination of the colon with a colonoscopy is a good idea to rule out colon cancer, which may also cause bleeding in the stool

Indications for Surgery

  • Treatment for early symptoms is directed towards improving bowel habits, including increasing fiber in the diet, regular bowel movements and improvement in anal hygiene. Surface medications serve to soothe skin irritation and itching. Pain from hemorrhoids may be from thrombosis of the blood vessels or ulceration and surgery is usually indicated, but the use of warm Sitz baths may be helpful
  • Surgery may be necessary for hemorrhoids that do not improve with conservative means. The following methods are for uncomplicated hemorrhoids (grades 1 and 2). Treatment is usually by sclerosant (solution that causes scarring) injection, rubber band ligation (tie off) or cryotherapy (freezing). Advantages to these methods are that they are usually painless and can be performed as an outpatient
    1. Sclerotherapy (Figure 4) - With the patient in the bent jackknife position, an anoscope is inserted to see the hemorrhoids. A syringe with a long hemorrhoid needle is used to inject. About 3 cc of a sclerosant solution, usually phenol in vegetable oil or sodium morrhuate, is injected under the mucosa at each hemorrhoid site. Injection causes scarring of the tissues with shrinkage. More than one treatment may be necessary. Contraindications to this method are external, infected or thrombosed hemorrhoids
    2. Rubber Band Ligation (Figure 5) - The hemorrhoidal mass is pulled down with a grasper and a special instrument called a ligator is passed around the mass. The ligator passes a small rubber band around the neck of the mass to block the blood supply. The mass usually falls off and passes out harmlessly in the stool a few days
    3. Cryosurgery - With this method, a probe through which liquid nitrogen or liquid nitrous oxide at temperatures below -100(C is applied to the hemorrhoidal mass. This freezes and destroys the mass. The probes are usually applied for about 2 min. Patients may experience drainage for a few days and the destroyed mass passes in the stool a week or two later. External hemorrhoids may also be treated this way

     

Figure 4 - Injection of a sclerosing agent into an internal hemorrhoid. © C. Scalici Figure 5 - Tying off of a hemorrhoid with a rubber band.© C. Scalici
  • Surgical hemorrhoidectomy should be considered for grade 3 and 4 hemorrhoids, combined internal and external hemorrhoids, ulceration or thrombosis (Figure 6)
    1. Most patients are given a laxative or enema the morning of the operation to empty the rectum of stool
    2. The operation is usually performed with local anesthetic with sedation (relaxing medication) given by the anesthesiologist. Occasionally, some patients may require a spinal anesthesia or even general anesthesia. The patient is usually positioned in the prone jackknife position, with buttocks taped apart, although some surgeons may prefer the patient in the lithotomy position (lying on the back with legs up in stirrups)
    3. The hemorrhoidal mass is held with a clamp and the tissue around it excised (cut out) with a knife. The incision extends to the skin out of the anus to also control any external hemorrhoids. The incision then goes into the anal canal up to the highest most part of the mass, which is then sutured and tied off. The dissection of the mass leaves behind the underlying muscle sphincters
    4. The mass is then cut away and the open edges are sutured closed with absorbable sutures that do not need to be removed. In a similar fashion all hemorrhoidal tissue is excised. Antibiotic ointment or packing may be left in the anus
  • Thrombosed hemorrhoids may be treated differently
    1. Some surgeons treat this condition with injection of local anesthetic and hyaluronidase (an enzyme which breaks down fibrous tissue). This causes the hemorrhoid to shrink, and the patient may be then taken to the operating room later for a hemorrhoidectomy
    2. If seen in the emergency room, the hemorrhoidal mass may be opened and excised under local anesthesia. Removal of the blood clots reduces the pain from pressure within the mass. The wound is left open and the patient may be sent home and a hemorrhoidectomy later carried out in the operating room. Patients are told to perform Sitz baths at home to help with the pain and reduce the size of the mass
  • New treatments of hemorrhoids
  • Some newer methods that are being tried for treatment of hemorrhoids include:
    1. Use of an ultrasonic scalpel to excise the hemorrhoidal tissue. This technique may be faster, and require no suturing
    2. Use of a stapler (similar to the stapler used to divide bowel), which is inserted into the rectum and the hemorrhoidal tissue stapled across and divided

       

      Figure 6 - Surgical excision of an internal hemorrhoid.© C. Scalici

Complications

  • Severe pain
  • Urinary retention
  • Constipation
  • Delayed bleeding
  • Infection
  • Stricture of the anus
  • Incontinence of stool
  • Anal fissure or fistula
  • Recurrent hemorrhoids
  • Sloughing of the mucosa and thrombosis of the vessels with the use of sclerosing solution
  • Slippage of the ligature

Postoperative Care

  • Patients are usually discharged the same day after having passed urine in the recovery room
  • Patients are usually discharged with pain medication, stool softeners to help with bowel movements, and some dressings for the wound
  • The dressing is usually removed the evening of the operation, with warm Sitz baths advised
  • Dressings are advised for the first few days to absorb drainage
  • Patients are usually able to return to work in a few days and the wounds should have healed in 2 - 3 weeks