Editing Haemorrhoidectomy


== Choice of procedure ==

* Open preferred, no benefit to     closing in terms of pain or outcome
* Probably no indication for     peri-operative metronidazole - useful in immunocompromised, high-risk, or     patients with cellulitis
* Should have a perianal LA     block
* Can be done entirely under LA     + sedation in some cases, or just spinal

== Positioning ==

* Can do lithotomy
* Prone jack-knife is supposed     to be best
* Lateral would work for small     external haemorrhoids

== Closed haemorrhoidectomy (Ferguson) ==

* Bilateral pudendal block     (half-way between anus and ischial tuberosity)
* Insert anal retractor (Pratt     or Eisenhammer)
* Start with the posterior-most     haemorrhoid
* Grasp top of the haemorrhoid     with two Allis/Kelly clamps or arteries and score out the intended     resection path with diathermy
* Use scissors, diathermy or     other energy device to remove the haemorrhoid
** Easier to see the plane with      scissors
** If big and inflamed, maybe      easier to use diathermy
** Pay close attention to      keeping clear of muscle fibres of the internal sphincter - seen as      transverse subcutaneous whitish fibres
* When near the apex, tie the     pedicle off with 2-0 Vicryl (which can also act to fix the haemorrhoid in     place), then cut off the haemorrhoid
* Close the haemorrhoid using     the same stitch in continuous fashion, taking care to close the submucosal     cavity
** Cris Cuthbertson does      'partially closed' haemorrhoidectomies - just closing the mucosa - to      attempt to reduce bleeding
* Repeat for other     haemorrhoids, but leave at least 1cm between adjacent excisions, and     classically do a maximum of three per session (Situ only does a maximum of     two)
* Place a spongostan (although     Sabiston's advises against this, as it is unlikely to prevent major     bleeding, but can delay recognition, as blood will be trapped above the     packing)


== Open haemorrhoidectomy (Milligan-Morgan technique) ==

* Exactly the same, but wounds     are not closed

== Stapled haemorrhoidectomy ==

* Mucosa to mucosa anastomosis,     while removing redundant mucosa proximal to the dentate line
* Does not treat external     haemorrhoids
* Blind procedure
* Can get wonderful results in     majority of patients, but risky since you can't see what you're stapling,     and can cause things like rectovaginal fistula. Not recommended.

== Doppler-guided haemorrhoid artery ligation (DH-HAL) ==

* Use proprietary device to     identify haemorrhoidal artery
* Suture ligate the vessel

== Post-op: ==

* Soft, bulked stools - fibre     and softeners
* Analgaesia likely to be a     problem
* Sitz baths
* Oral metronidazole

== Complications ==

* Anal stenosis
* Bleeding
** Prevention
*** Placing a solid apical       suture to the haemorrhoid pedicle
*** Use energy device rather       than knife
** First 24 hours - reactionary      haemorrhage - probably a bleeding vessel
** Later - secondary      haemorrhage - probably will need takeback to OT
* Incontinence
* Pain
* Pelvic sepsis
** Early symptoms non-specific      - urinary dysfunction, worsening anal pain, fever
* Wound breakdown - treat with     topical nitrates or diltiazem

[[Category:Colorectal]]