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