Hemorrhoidectomy
Massarat Zutshi
Perioperative Considerations
The mere presence of hemorrhoids is not an indication for hemorrhoidectomy. Symptoms should be directly related to the hemorrhoids.
Many patients with “hemorrhoids” are not hemorrhoids, and a thorough evaluation for other anorectal pathology should be performed.
Excisional hemorrhoidectomy should be reserved for those patients with external or grade III/IV hemorrhoids that have failed conservative management.
Patients should be appropriately counseled as to the risk of pain, bleeding, open wounds, recurrence, and resulting skin tags prior to hemorrhoidectomy.
Anal stenosis following hemorrhoidectomy should be a rare occurrence and is minimized by keeping >1 cm of anoderm between resected columns.
Similarly, new incontinence following hemorrhoidectomy should be rare, and all efforts to identify and preserve the sphincter should be done.
For appropriate patients, or those with more concerning symptoms, ensure the colon has been evaluated with a colonoscope to rule out more proximal pathology.
Sterile Instruments/Equipment
Betadine solution for skin preparation
Lighted Hill-Ferguson anal retractor
Hemostats: Straight and curved
Needle driver
Assorted forceps (eg, Adson-DeBakey)
Metzenbaum scissors
Electrocautery
Lidocaine with epinephrine 0.5% and injection equipment for anal block
Surgical Approach
Preoperative preparation: two-fleet enemas
Anesthesia: general/laryngeal mask airway
Position: lithotomy or prone depending on surgeon/anesthesia preference (Fig. 8-1)
 FIGURE 8-1 ▪ Lithotomy positioning exposing the perineum. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
MILLIGAN-MORGAN (OPEN)
Technique
With the patient in the lithotomy position, examine the perineum to look for other pathology and evaluate the hemorrhoidal columns (Fig. 8-2A and B).
Hemorrhoids are rarely the same size and anoscopy can confirm the largest or most problematic. Begin with that one and proceed sequentially.
Sometimes one or two of the three columns can be successfully managed by elastic ligation.
FIGURE 8-2 ▪ A. Traditional three column external hemorrhoids in the right anterior, right posterior, and left lateral positions. B. Circumferential hemorrhoidal prolapse. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Clean the inside of the anal canal first with a gauze soaked in betadine solution.
Clean the skin over the perineum up to the scrotum or the vagina anteriorly and the tailbone posteriorly. On the lateral side, the preparation should go beyond the ischial tuberosity.
Perform an anal examination by placing a finger in the anal canal, and sweep the anal canal for any abnormalities.
Insert a Hill-Ferguson anal retractor, perform a visual examination, and record any abnormalities and location of the hemorrhoids.
To plan the procedure accordingly, make sure that there are enough skin bridges (>1 cm of anoderm) between the excision of the three pedicles. Mark areas of possible excision, if needed.
Inject 0.5% Marcaine with epinephrine under the hemorrhoid pedicles using a small-gauge needle using about 5 mm at every pedicle (Fig. 8-3).Related posts:
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