Hemorrhoidectomy

Overview

Hemorrhoidal disease is a frequent illness that necessitates surgical intervention in around 10% of patients. Because asymptomatic people are less likely to seek medical attention, the overall prevalence is unknown. According to some studies, the incidence of symptomatic patients in the United States is 4.4 percent, with individuals aged 45 to 65 years old being the most affected.

When medical management fails, when there is a significant bulging external component, or when imprisoned internal hemorrhoids require prompt medical treatment, surgical hemorrhoidectomy is required for large third- and fourth-degree hemorrhoids.

Hemorrhoidectomy definition

Hemorrhoids are bulging veins in the lower abdomen. Internal hemorrhoids are typically painless but bleed. External hemorrhoids can be painful. Hemorrhoids (HEM-uh-roids), often known as piles, are bulging veins in the anus and lower rectum that resemble varicose veins. Because asymptomatic people are less likely to seek medical attention, the overall prevalence is unknown.

Hemorrhoids are columns of vascular connective tissue within the anal submucosa that help to maintain anal canal continence and mass. The pathogenesis of hemorrhoids is mostly unknown, but one theory holds that hemorrhoids form as a result of varicose veins in the anal canal; however, most healthcare experts disagree with this explanation. Instead, hemorrhoids are hypothesized to form as a result of vascular cushion erosion or deterioration.

The three principal hemorrhoidal columns are located in the anal canal's left lateral, right anterolateral, and right posterolateral regions and can be internal or external depending on their location relative to the dentate line. Internal hemorrhoids are further classified on a scale of I to IV based on the degree of prolapse, which aids in determining treatment options.

Patients with symptomatic internal hemorrhoids report painless, brilliant red bleeding, described as streaks of blood in the stool, anal itching, pain, concerning grape-like tissue protrusion, or a combination of these symptoms. Except for thrombosed external hemorrhoids, which produce severe discomfort due to somatic nerve innervation, most individuals have asymptomatic external hemorrhoids.

Depending on the degree of prolapse and whether they are internal or external, hemorrhoids can be treated with both medicinal and surgical procedures. Surgical excision is the most effective treatment for recurrent, symptomatic grade III or IV hemorrhoids. The most prevalent surgical methods in the United States are closed, also known as Ferguson hemorrhoidectomy, or open, also known as Milligan-Morgan hemorrhoidectomy, which is used in the United Kingdom and Europe.

Anatomy and Physiology

Hemorrhoids are nonpathological vascular tissue cushions in the anal canal. Because they lack muscle and veins, they have been classified as sinusoids under the microscope. Several anatomic studies have verified the presence of arteriovenous links between vessels, explaining why hemorrhoidal bleeding is brilliant red and has the same pH as arterial blood.

In adults, the anal canal is about 4 cm long, with the dentate line indicating it's halfway. Internal hemorrhoids form above the dentate line and are painless because they are innervated by the viscera. Columnar epithelium covers them, and they are classed based on the degree of prolapse.

Grade 1 hemorrhoids are distinguished by prominent vessels and the absence of prolapse. Grade 2 hemorrhoids prolapse with Valsalva but resolve on their own. Grade 3 hemorrhoids prolapse with Valsalva as well but must be manually reduced. Grade 4 hemorrhoids are chronically prolapsed and cannot be reduced manually. External hemorrhoids are anoderm-covered and located below the dentate line. Because of somatic nerve innervation, they are sensitive to touch, stretch, and temperature.

Indications

Depending on the degree of prolapse and whether they are external or internal, hemorrhoids can be treated medically or surgically. A high-fiber diet is one of the first and most important conservative suggestions. Garg suggests adding 4 to 5 teaspoons of fiber per day, which translates to 20 to 25 grams of supplementary fiber.

To be successful and avoid abdominal discomfort, a suitable amount of water (500 ml) must be drunk at the same time as the fiber supplement in order for the water to be absorbed and result in soft stools. This method has been shown to halt progression and aid reduce the size of the prolapse.

Rubber band ligation and infrared coagulation are recommended for grade one and two hemorrhoids that have not responded to medical treatment. The reported number of rubber banding sessions is one, occasionally two, with a four-week interval between visits. When comparing the two, rubber banding has a higher long-term success rate, whereas infrared coagulation is associated with less pain due to the lack of mucopexy during the surgery. Rubber band ligation has a fourfold lower failure rate than infrared coagulation.

Operative hemorrhoidectomy is necessary for large third- and fourth-degree hemorrhoids in the following situations:

1. Failed non-operative management
2. Advanced disease process unlikely to respond to conservative management
3. Mixed hemorrhoids with a bulging external component
4. Incarcerated internal hemorrhoids needing urgent intervention
5. Coagulopathic patients requiring management of hemorrhoidal bleeding

Contraindications

Relative contraindications include the following:

1. Patients unable to undergo general anesthesia due to medical comorbidities
2. Baseline fecal incontinence
3. Rectocele
4. Presence of inflammatory bowel diseases such as Crohn disease or ulcerative colitis
5. Portal hypertension with rectal varices
6. Uncontrolled bleeding disorder

Surgical Technique

Equipment

The scalpel, with or without the use of scissors for dissection, is the standard instrument for an excisional hemorrhoidectomy. This method is both effective and inexpensive.

Ligasure and Harmonic scalpels are new energy gadgets that have progressively made their way into the medical world. In the current reimbursement environment, the additional expense may have a detrimental influence on economic efficiency. Ligasure is a bipolar cautery device that is used for both tissue division and blood vessel coagulation. The Harmonic scalpel generates heat for tissue division and coagulation by using a reciprocating blade. The proposed clinical benefits of employing energy devices in comparison to their cost have not been established.

When compared to a scalpel, monopolar electrocautery provides improved hemostasis. It enables for hemorrhoidal complex excision without suture closure but at the expense of damaging neighboring tissues due to lateral thermal spread. 

Preparation

Bowel preparation is not required; however, an enema may be required to evacuate stool from the distal rectum. Antibiotics are not required prior to surgery. A discussion between the anesthesiologist, the operating surgeon, and the patient should take place before selecting an anesthetic. The patient should be informed that a spinal anesthetic increases the risk of urine retention. Most American surgeons favor a prone jack-knife position with the buttocks taped apart. A lithotomy position is another possibility.

Technique

Closed hemorrhoidectomy (Ferguson technique) or open hemorrhoidectomy (Milligan-Morgan technique), which is more frequent in the United Kingdom and Europe, is the most common method of surgical excision. The Ferguson approach, on which this article concentrates, is the most often employed technique in the United States.

To evaluate all three hemorrhoidal columns, the Hill Ferguson retractor is placed into the anal canal. The excision can be limited to one column, but if clinically necessary, all three can be removed at the same time. The clinician should begin by addressing the greatest pathogenic column.

To guarantee that the anoderm is tension-free, the expanded column should be squeezed at the base with DeBakey forceps. An oval incision around the hemorrhoidal column is made with a 10-scalpel blade. Using Mayo scissors, the pedicle is dissected from the surface of the internal anal sphincter up to the level of the pedicle.

The pedicle is grabbed with a big Kelly and suture ligated with a CT 2 needle with 3-0 Vicryl. Deeper 3-0 Vicryl suture fixation is employed at the top of the anorectal ring to lessen the likelihood of recurrent prolapse. The suture is then utilized in a running fashion to close the rectal mucosa, anoderm, and perianal skin.

In addition to these traditional procedures, stapled hemorrhoidopexy is a surgical procedure. The hemorrhoidal columns are not removed during this treatment, but rather elevated over the anal margin and joined to each other. According to studies, there is a high rate of recurrence as well as microscopic integration of sphincter muscle in resection specimens, resulting in transitory flatus incontinence.

Clinical Significance

Hemorrhoidal columns are a normal aspect of anorectal anatomy that must be treated if they become symptomatic. For adequate outcomes, the first-line treatment includes cautious management, and the patient should be educated on fiber supplements.

When medicinal care fails and the degree of prolapse worsens, surgical excision is the chosen treatment option. Removal success rates are excellent, with low recurrence rates. When open and closed procedures are compared, they both have comparable rates of postoperative pain, the requirement for analgesics, and complications.

SURGICAL OPTIONS FOR HEMORRHOIDS

The majority of randomized controlled trials conducted to date compare the various surgical methods available for hemorrhoids, however, they frequently offer a mixed sample or fail to specify disease stage. This research has concentrated on the technique rather than how to personalize the option to the individual. Because hemorrhoid presentation and symptomatology are so diverse, a surgeon cannot assume that one approach is appropriate for all patients.

As our research and experience with each surgical procedure grows, we now recognize that the grade of hemorrhoids has a significant impact on result evaluation. One technique that works well for one grade of hemorrhoids may have a high recurrence rate with another.

When weighing surgical options, we believe that each grade of hemorrhoids should be treated as a unique entity. Aside from the grade, the size and circumferential nature of the hemorrhoids, as well as the patient's major symptoms, must be considered. Only then can surgical management be genuinely matched to the demands of the patients.

GRADE I HEMORRHOIDS

Grade I hemorrhoids are those that bleed but do not prolapse. Surgery is rarely recommended for grade I hemorrhoids, with therapy consisting of lifestyle changes, medication, and office-based procedures.

A high fiber diet and appropriate fluid consumption are two examples of lifestyle changes. Micronized, pure flavonoids have been found in randomized controlled trials to be safe and efficacious, with quick cessation of bleeding.

In the absence of lifestyle changes and medical therapy, grade I hemorrhoids are candidates for office-based procedures, the most effective of which is rubber band ligation. Sclerotherapy, cryotherapy, infrared photocoagulation, and BICAP coagulation are among other office-based techniques.

GRADE II HEMORRHOIDS

Grade II hemorrhoids account for 18.4% of all hemorrhoids. Surgery is not the first line of therapy for grade II hemorrhoids because most are treatable with less invasive methods such as medication and rubber band ligation (RBL). RBL has an 86.6 percent cure rate one month after treatment and an 11 percent recurrence rate after two years, with 7.5 percent requiring additional surgical therapy. When less invasive techniques fail, surgery is recommended. The size of the hemorrhoidal tissue mass may be related to the failure of less invasive therapies treating grade II hemorrhoids.

DGHAL has been demonstrated to be effective, with a recurrence rate of 5.3 percent -6.7 percent at less than 12 months of follow-up and a recurrence rate of 12 percent at more than 12 months of follow-up. DGHAL problems are comparable to, if not fewer than, those associated with other techniques. There were no serious complications observed.

GRADE III HEMORRHOIDS

While DGHAL is effective for grade II hemorrhoids, it has a recurrence rate of 18%-31% when administered for grade III hemorrhoids and followed up for more than 12 months. The only predictor associated with recurrence was the severity of hemorrhoids, with repeat prolapse being the most common symptom in individuals who failed DGHAL.

DGHAL was demonstrated to have a shorter operating time, significantly lower mean pain scores at 24 h and one-week post-operation, significantly less postoperative discomfort, and less post-operative complications in a randomized controlled trial of DGHAL vs SH for grade III hemorrhoids.

GRADE IV HEMORRHOIDS

Hemorrhoids of grade IV are symptomatic, prolapsed, and irreducible piles. DGHAL does not treat prolapse and is woefully insufficient for grade IV hemorrhoids, as evidenced by the high rate of recurrent prolapse when DGHAL is used alone. DGHAL has been used in conjunction with mucopexy to elevate and secure projecting hemorrhoids in piles with substantial prolapse. DGHAL and rectoanal repair (RAR) were demonstrated to be both safe and efficacious for grade IV hemorrhoids, with recurrence occurring in 9% of the research group after a 34-month mean follow-up.

What to Expect After Surgery?

Recovery takes about 2 to 3 weeks.

Going home after surgery

You will be given a long-acting local anesthetic right after the surgery while you are still under anesthesia. It should continue 6 to 12 hours following surgery to give pain relief. If you are not planning to stay in the hospital overnight after surgery, you will leave once the anaesthetic has worn off and you have urinated. Urinary retention can occur as a result of swelling (edema) in the tissues or a spasm of the pelvic muscles.

Care after surgery

• You should expect some discomfort following surgery. If your doctor has recommended a pain reliever, take it exactly as directed. Inquire with your doctor about which over-the-counter medications are appropriate for you.
• Some bleeding is usual, especially after the first bowel movement following surgery.
• Drink liquids and eat a bland diet for a few days after surgery (plain rice, bananas, dry toast or crackers, applesauce). Then you can gradually return to ordinary foods and increase the amount of fiber in your diet.
• To reduce pain, administer numbing medications before and after bowel motions.
• Applying ice packs to the anal area may help to minimize swelling and soreness.
• Warm water soaks (sitz baths) on a regular basis can help reduce pain and muscular spasms.
• Some doctors may advise you to take an antibiotic (such as metronidazole) after surgery to avoid infection and pain.
• Stool softeners containing fiber are recommended by doctors to help with smooth bowel movements. Hemorrhoids can reappear if you strain during bowel motions.
• Follow-up checks with the surgeon are normally scheduled 2 to 3 weeks after surgery to check for complications.

Complications

Within the first week after hemorrhoidectomy and hemorrhoidopexy, the patient should expect pain and anal fullness. In the postoperative period, adequate pain control and the use of stool softeners are priorities.

Early complications include:

• Bleeding
• Urinary retention
• Thrombosed external hemorrhoids

Rare but life-threatening complications that must be recognized early include sepsis, abscess formation, massive bleeding, and peritonitis.

• Late complications include:
• Anal stenosis
• Skin tags
• Recurrent hemorrhoids
• Delayed hemorrhage
• Fecal incontinence

Conclusion 

Hemorrhoids are common in society, and while they are easy to diagnose, the treatment is not always effective. An interprofessional team focused to anorectal disorders is best suited to treating the issue.

Depending on the intensity and severity of the disease, all members of the healthcare team see patients with hemorrhoids in different venues. Understanding the degree of internal hemorrhoid prolapse assists the healthcare provider in selecting the appropriate treatment and providing relevant instruction. Correct diagnosis of an acutely thrombosed external hemorrhoid results in rapid treatment, which improves overall patient safety and satisfaction.

Because hemorrhoids are avoidable, patient education is essential. The nurse, nutritionist, and pharmacist should counsel the patient to avoid constipation, drink plenty of water, stay physically active, incorporate fiber into the diet, and avoid overuse of pain drugs (which cause constipation). The overall results of surgery range from satisfactory to bad. After practically every procedure, residual pain and recurrence are common. Better patient outcomes can be achieved by interprofessional team management comprising doctors, nurses, and pharmacists.