Hemorrhoidectomy

Hemorrhoids are a collection of blood in the venous system (engorged veins) that occurs in the anal region either internally or externally.
Hemorrhoidectomy is normally reserved for the failed outpatient treatment but factors such as the patient’s preference, the extent of the clinical signs and symptoms and the anatomy of the hemorrhoid are also considered when considering surgery.
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Hemorrhoidectomy

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Hemorrhoids are a collection of blood in the venous system (engorged veins) that occurs in the anal region either internally or externally.
Hemorrhoidectomy is normally reserved for the failed outpatient treatment but factors such as the patient’s preference, the extent of the clinical signs and symptoms and the anatomy of the hemorrhoid are also considered when considering surgery.
Haemorrhoidectomy can be done using the open or the closed techniques in which both involve ligation and excision of hemorrhoid but in the open technique, the anal mucosa and the skin are left open to heal through secondary intention while in the closed technique, the wound is sutured.
Haemorrhoidectomy can be done using the open or the closed techniques in which both involve ligation and excision of hemorrhoid but in the open technique, the anal mucosa and the skin are left open to heal through secondary intention while in the closed technique, the wound is sutured.

Indications for haemorrhoidectomy

The indications for a haemorrhoidectomy include:
  • Fibrosed haemorrhoids
  • When the haemorrhoids are both internal and external with the external haemorrhoid being well defined.
  • Second-degree haemorrhoids that have not been cured by non-operative treatments
  • 3 rd – 4 th degree haemorrhoids
  • Surgery is done to alleviate the symptoms especially if the haemorrhoidal bleeding is too much to cause anaemia, haemorrhoidectomy is also strongly indicated.

How is this procedure done?

The procedure is usually performed under general or regional anesthesia with the patient in the lithotomy or the jack-knife position. This position helps in the easy accessibility of the piles during surgery. The perianal skin is shaved and a formal examination is performed to assess the progression of the piles as per the moment.
Haemorrhoidectomy can be performed using the open (Milligan-Morgan technique) or the closed technique.

Open technique

  • The hemorrhoids are usually identified and they are injected with diluted adrenaline to minimize the bleeding during the surgery by vasoconstriction. The areas surrounding the hemorrhoids should also be injected with the dilute adrenaline.
  • The hemorrhoids are pulled away with a forceps and the diathermy is used to cut them out while ensuring minimal blood loss prevails.
  • The wound is left open for self-healing. Aim to ensure that there is no bleeding after the surgical excision is done.
  • A pad of gauze and cotton wool is firmly applied and well bandaged.

Closed technique

  • In this technique, the hemorrhoid should be excised together with the overlying mucosa. Then the wound is sutured with an absorbable suture completely. This technique is mainly used for internal hemorrhoids.

Risk of this procedure

Haemorrhoidectomy is normally a well-done procedure but sometimes it can be associated with complications which are as follows:
  • Incontinence
  • Secondary haemorrhage local use of adrenaline to constrict the blood vessels with blood transfusion and injection of morphine is indicated. After the replacement of blood, the ligation and excision of the piles is required.
  • Anal strictures
  • Acute retention of urine- this is seen especially in men which may require catheterisation so as to relieve the problem.
  • Reactionary haemorrhage
  • Very painful anal wound

Getting ready for the procedure

The patient should have gotten adequate antibiotic cover before the surgical procedure to avoid the risk of portal pyaemia.
The use of rectal enema preoperatively is advised so as to clear the rectum before the surgery. Stool softeners are also taken days before the surgery.
You are required to show up to the health care facility about a day to the surgery. This will give the care givers enough time to run the lab blood tests required and other tests that might be required prior to the surgery. This will give a clear picture of the current status of the patient.
The caregivers will still assess if you are fit for the surgery particularly to prevent the adverse effects of the anesthesia.
As of any surgical procedure that you’ll be required to be under general anesthesia, the patient is required to fast for about 8-12 hours to avoid complications of the anesthesia.
An intravenous line is required to feed the required drugs into the body system of the patient. A water drip may or may not be employed.
Because of the nature of the surgery, the patient is required to have a temporary urinary catheter to deliver the formed urine from the urinary bladder to prevent the bladder from becoming over full during the surgery.

Recovery after surgery

The recovery is normally good in most patients. The wound heals faster in the closed technique compared to the open one with a high 95% success rate. The open technique is often prone to infections.
Stool softeners and bulking agents are used to enhance defecation to avoid straining postsurgery. Appropriate pain medication and antibiotics postoperatively are also given.
The patient needs to be reassessed after 3-4 weeks after discharge to assess if the piles are healing well or are well healed.
A diet limitation for the recovery period is advised.
The patient is also required to take two warm baths each day.

Outcomes

A patient is normally discharged a day or two after surgery with a median of about 4 weeks of recovery.
On review, if there is evidence of stenosis, the patient is encouraged to use a dilator