If the patient requires colonoscopy for any of the standard indications, it can most conveniently be performed on the morning of the surgery. Colonoscopy can exclude any serious pathology within the colon and can confirm that any rectal bleeding is indeed from the hemorrhoids and not from a second unrecognized source.

Although mechanical bowel preparation does not rise to “standard of care” prior to a Harmonic Scalpel® hemorrhoidectomy, it may be a sensible and safe precaution. First, the mechanical bowel preparation effectively prevents the constant oozing of stool into the surgical field during the surgery itself. Suctioning and irrigation stool out of the surgical field simply adds additional time to the procedure, and is an unpleasant inconvenience. Second, the mechanical bowel preparation postpones the patient’s first bowel movement for a few days, allowing some degree of healing to occur before this sentinel event.

The patient should be thoroughly informed of the risks of Harmonic Scalpel® hemorrhoidectomy. These risks include anorectal incontinence; postoperative bleeding; persistent pain/discomfort; posthemorrhoidectomy fissure or fistula.

Aside from preanesthetic requirements, a complete blood count usually suffices to exclude a dangerously low hemoglobin and hematocrit from prolonged severe hemorrhoidal bleeding or a dangerously low white blood count from an unrecognized immunosuppression. Both of these conditions require correction prior to an elective Harmonic Scalpel® hemorrhoidectomy.

The Harmonic Scalpel® consists of cutting shears that vibrate at 55,500 Hz, at amplitudes of 60–100 microns. The vibratory energy results in disruption of hydrogen bonds that cause denaturing of intracellular proteins. This mechanism results in shearing of the coapted tissue and creation of a sticky coagulum that further assists in hemostasis.

The principles of cutting tissue lie in two main modalities:

Pressure results from compression (coaptation) of the “active” blade onto a “pressure pad” on the opposite blade of the shears. The pressure pad focuses pressure and vibratory energy to optimize cutting of the coapted tissue.

The hemostatic coagulum is formed from denatures intracellular proteins. Because of these nonthermal modalities, the tissue is divided at a lower temperature than electrocautery, and lateral thermal injury is minimized.

The reduction in lateral thermal injury results in less postoperative pain after Harmonic Scalpel® hemorrhoidectomy compared to electrocautery (1). Furthermore, the hemostatic coagulum, and coapting hemostatic properties result in minimal, if any, blood loss during hemorrhoidectomy.

The Harmonic Scalpel® generator transmits energy to the hand piece at energy levels of 1–5. The lower the setting, the less the excursion of the blades and conversely, higher settings increase blade excursion.

The hand piece has two available energy settings: MIN and MAX. The MIN setting (1,2,3,4) results in more effective hemostasis, and is therefore used to divide the proximal pedicle of the internal hemorrhoid, ensuring complete hemostasis of the internal hemorrhoidal arteries. The MAX setting (defaults to level 5) results in more effective and faster cutting, and is therefore used on the tougher and less vascular external hemorrhoidal tissue.

Harmonic Scalpel® hemorrhoidectomy is most conveniently performed in the prone-jackknife position, and under these circumstances, maintenance of the patient’s airway is the most immediate and primary concern. Harmonic Scalpel® hemorrhoidectomy may be performed under local monitored anesthesia care (MAC) (usually propofol (3)), but requires very close coordination and cooperation between the surgeon and anesthetic team. Oversedation may easily compromise the patient’s airway, especially in obese individuals.

A useful and successful compromise between local MAC anesthesia and general anesthesia with endotracheal intubation is general anesthesia using laryngeal mask anesthesia (LMA) technique (4). This technique allows the patient to be positioned awake in prone position. The LMA is inserted whilst still prone, and the table is then positioned in jackknife prior to starting the surgery (Figs. 3.1 and 3.2). After the procedure, the table is flattened, the patient rolled supine onto a stretcher, and the LMA removed from the airway. This technique avoids having to perform endotracheal intubation, avoids having to “roll” the patient from supine to prone prior to the surgery, but still maintains a safe and secure airway.