Open (Milligan–Morgan) hemorrhoidectomy. a External hemorrhoids grasped with forceps and retracted outward. b Internal hemorrhoids grasped with forceps and retracted outward with external hemorrhoids. c External skin and hemorrhoid excised with scissors. d Suture placed through proximal internal hemorrhoid and vascular bundle. e Ligature tied. f Tissue distal to ligature is excised. Insert depicts completed three bundle hemorrhoidectomy
Modified Ferguson excisional hemorrhoidectomy. a Double elliptical incision made in mucosa and anoderm around hemorrhoidal bundle with a scalpel. b The hemorrhoid dissection is carefully continued cephalad by dissecting the sphincter away from the hemorrhoid. c After dissection of the hemorrhoid to its pedicle, it is either clamped, secured, or excised. The pedicle is suture ligated. d The wound is closed with a running stitch. Excessive traction on the suture is avoided to prevent forming dog ears or displacing the anoderm caudally
Whitehead hemorrhoidectomy. a Suture placed through proximal internal hemorrhoid for orientation. Excision started at dentate line and continued to proximal bundle. b Internal hemorrhoidal tissue excised above ligated bundle. c Vascular tissue excised from underside of elevated anoderm. d End of anoderm reapproximated with sutures to original location of dentate line. (E) Completed procedure
Excisional hemorrhoidectomy is usually reserved for patients with symptomatic mixed component (internal and external) hemorrhoids who have either failed or are not candidates for nonoperative treatment.
One of the most significant consequences of undergoing excisional hemorrhoidectomy is postoperative pain. Although one can argue as to whether pain is a complication versus an expected consequence of excisional hemorrhoidectomy, it is nonetheless, probably the most significant factor that patients have to contend with postoperatively. Unfortunately, despite newer alternatives and multimodal approaches, pain control postoperatively remains one of the major challenges for patient and surgeon. Despite the widespread adoption of performing excisional hemorrhoidectomy as an ambulatory procedure, it still remains the most common reason for delaying discharge after ambulatory surgery . Additionally, increased pain can also contribute to the development of urinary retention in patients that is another cause of unplanned admission to the hospital after day case surgery. In a study looking at predictive factors for postoperative pain in the ambulatory setting Gramke  found that the presence of pain preoperatively, the age of the patient, the patient’s fear of their surgery, and the expectations of patient and physician regarding postoperative pain were the strongest predictors in the outpatient setting.
The process of dealing with postsurgical pain management for excisional hemorrhoidectomy begins preoperatively. When the patient is seen in the office a candid discussion regarding pain expectations and strategies to control it are essential to the outcome and satisfaction of the procedure. Unfortunately, obtaining a balance of adequate pain control while preventing opioid-related side effects can sometimes be easier said than done. Nevertheless, when the patient is educated preoperatively as to the multimodal approach to analgesia they realize that the physician can target their pain from a number of different angles. This stepwise multidrug approach to pain management will lead to fewer intolerable adverse events, increased efficacy, and improved patient satisfaction.
Perianal Infiltration of Local Anesthetics
Probably one of the most important pillars in the multimodal approach is the intraoperative administration of local analgesics. The use of locally infiltrated anesthetics in conjunction with intravenous sedation is safe and may even have fewer complications than other anesthetic techniques for excisional hemorrhoidectomy. This technique has been shown to be the most cost effective anesthetic technique when compared to spinal anesthesia and general anesthesia . This randomized clinical trial compared these three anesthetic techniques in 93 patients undergoing ambulatory anorectal surgery. The local anesthetic infiltration consisted of a mixture of 15 mL of 2% lidocaine and 15 mL of 0.5% bupivacaine with 1:200,000 of epinephrine. The intravenous sedation consisted of propofol. There was a 30–50% cost savings over the other anesthetic techniques in the ambulatory setting. In addition to the increased cost savings with this technique, there was also no difference in postoperative side effects and unanticipated hospitalizations when utilizing local perianal infiltration. The need for pain medication was also less in comparison to general anesthesia. An anal block is performed by infiltrating circumferentially either in a field block subcutaneously and submucosally or by infiltrating into the intersphincteric groove in a four- or eight-quadrant manner. Additionally, local infiltration to the proposed site of excision is needed in order to ensure adequate anesthesia during the case. Since pain is the most common reason for delaying discharge after ambulatory surgery, significant attention must be given to good analgesia for effective postsurgical pain management. Most of these agents are short acting however, and can block noxious stimuli and pain intensity for at most 8–12 h after which the patient must take other analgesics to control pain.
Approved by the FDA in 2011, Exparel® is a liposome injection of the amide local anesthetic bupivacaine encapsulated in a proprietary DepoFoam® delivery technology that is infiltrated into the local site for postoperative analgesia. The DepoFoam® consists of multivesicular liposomes that encapsulate the bupivacaine and release it over an approximately 96-h period. These properties are beneficial in prolonging the time to first narcotic use and in decreasing overall narcotic use. The drug is infiltrated locally at the end of surgery. Gorfine et al.  published a randomized multicenter, double-blind placebo controlled trial in 189 adults undergoing excisional hemorrhoidectomy (2- or 3-column). Those patients who received a bupivacaine liposome injectable suspension had a 30% statistically significant reduction in pain scores at 72 h. In addition, this led to a significant reduction in opioid consumption. Haas et al. reported a randomized clinical trial using liposomal bupivacaine for post-hemorrhoidectomy pain management compared to standard bupivacaine HCL . They found that the liposomal bupivacaine significantly reduced postsurgical pain and opioid consumption in comparison to bupivacaine HCL. This in turn led to decreased opioid-related adverse events.
Of note, the injection of bupivacaine liposomal injectable suspension should not be admixed with lidocaine or other non-bupivacaine-based local anesthetics, which can lead to the immediate release of bupivacaine from the suspension.
Catheter Delivery Systems
These pumps were developed to provide a continuous infusion of nonnarcotic pain relief in the form of local anesthetics directly to or near the surgical site through specially designed catheters. This delivery method can provide patients with days of targeted pain relief after surgery thereby minimizing narcotic usage and the side effects that go along with increased narcotic usage such as nausea, emesis, constipation, and over sedation. In theory, the use of catheter delivery systems, which provide a continuous administration of local anesthetics to the site of surgery through a locally placed catheter, seems intuitive. However, this has been significantly limited by difficulty in maintaining correct catheter position, the cost of the delivery device, and the resources needed to manage patients in the outpatient setting. These catheter delivery systems (STA cath®, On-Q®) are not used widely for excisional hemorrhoidectomy for the reasons listed above.
NSAIDS and Cox-2 Inhibitors
Nonsteroidal anti-inflammatory drugs (NSAIDS) are peripherally acting analgesics utilized worldwide. These drugs provide pain relief and an alternative to opioid-based analgesia. They play a key role in the multimodal approach to pain relief in the perioperative setting providing analgesic, anti-inflammatory, and antipyretic benefits. The use of NSAIDS in the perioperative period has been shown to provide improved analgesia, lower rates of urinary retention, and decreased narcotic usage [7–9]. Additionally, it is not associated with excessive sedation, respiratory depression, or cognitive dysfunction. This drug is indicated for the management of moderate to moderately severe postsurgical pain. NSAIDS can be delivered orally, transdermally, intramuscularly, intravenously, and through direct local infiltration at the surgical site. Ketoralac tromethamine was the first injectable NSAID approved for use in the USA. The combined duration of oral, intramuscular, and intravenous administration should not exceed 5 days. When utilized in a multimodal fashion a 30 mg loading dose followed by 15–30 mg doses every 6 h can be a potent adjunct and opioid sparing modality to control postoperative pain. However, analgesic effects must be balanced and weighed against the potential for adverse effects especially GI bleeding, platelet dysfunction, and renal failure [7, 8].
Another injectable NSAID formulation approved in the USA in 2006 was injectable ibuprofen (Caldolor®). This medication can be used to treat mild to moderate pain by itself or as an adjunct to opioid analgesics (Ibuprofen Injection (Caldolor®). Nashville, TN: Cumberland Pharmaceuticals, Inc. . Recommended dosing for ibuprofen injection are 800 mg every 6 h with a maximum dose of 3200 mg over a 24 h period. Patients weighing less than 50 kg and elderly patients may achieve effective analgesia with 400 mg doses. Its lower selectivity for Cox-1 isoenzymes in comparison to Ketoralac may reduce the risk of adverse side effects such as GI bleeding or platelet dysfunction. Unlike Ketoralac, this drug should be diluted with 250 mL of sterile saline or lactated Ringer’s solution and infused slowly over 7–15 min in order to achieve maximal plasma concentrations more rapidly and at the site of tissue injury.
Cox-2 inhibitors were developed to improve GI safety while providing effective analgesia. Approved by the FDA in 1998, the only Cox-2 inhibitor available for perioperative pain management is celecoxib (Celebrex®). This subclass of NSAIDS is more selective for the Cox-2 isoenzyme, which is induced following tissue injury. Unfortunately, other Cox-2 inhibitors were withdrawn from the US market and the FDA mandated a black box warning for celecoxib with respect to its risks regarding cardiovascular and cerebrovascular thrombosis with long-term use.
This is a centrally acting analgesic for mild to moderate acute as well as chronic pain that is one of the most widely administered over the counter analgesics. Since it does not act peripherally it has no anti-inflammatory effects locally at the site of surgery. Modes of administration include oral, rectal, and intravenous. It has been shown to significantly reduce postsurgical pain versus placebo . Additionally, acetaminophen lacks the adverse side effects of NSAIDS and opioids. The intravenous formulation (Ofirmev®) gained FDA approval in the United States in 2010. In addition to its antipyretic benefits, it is indicated for the treatment of mild to moderate pain by itself or as an adjunct to opioid analgesics in the treatment of moderate to severe pain. The touted benefits over the oral or rectal formulations are a higher analgesic efficacy, a higher maximum plasma concentration, and a more rapid onset of action. The medication comes in a 1000 mg solution that should be infused over a 15-min period every 4–6 h not to exceed 4 g/day in adults less than 70 years of age. Dosing should be adjusted for children, adolescents, and the elderly. There are some data to suggest that the analgesic effectiveness of intravenous acetaminophen is enhanced when administered prior to making the surgical incision although this was in patients undergoing abdominal hysterectomy and not excisional hemorrhoidectomy . Because of acetaminophen’s narrow therapeutic window great care should be taken to adhere to recommended dosing by the manufacturer in order to minimize potential hepatotoxicity. Additionally, acetaminophen should not be used in patients with severe hepatic impairment or severe active liver disease.
Nitroglycerin ointment has been studied looking at its analgesic efficacy, its effect on wound healing, and its adverse effects with respect to headache. Glyceryl trinitrate has been shown to decrease muscle spasm and increase anodermal blood flow. A meta-analysis looking at 333 patients from 5 randomized trials demonstrated analgesic efficacy on days three and seven compared to placebo . Additionally, wound healing was reported to be better at 3 weeks compared to placebo and the side effect of headache was not statistically increased over placebo. Another meta-analysis of 12 randomized controlled trials by Liu and colleagues looked at a total of 1095 patients. That meta-analysis found that there was a significant pain reduction on days 1, 3, 7, and 14. There also seemed to be a benefit with respect to improved wound healing three weeks postoperatively but this came at a cost of increased headache .
Joshi and Neugebauer reported a study on behalf of the PROSPECT Collaboration working group evaluating the available literature on the management of pain after hemorrhoid surgery . The collaborative group was formulated to provide evidence-based recommendations for specific surgical procedures. Of 207 randomized studies identified, only 106 met inclusion criteria and of these 41 were excluded leaving a total of 65 studies for evaluation. Although quantitative analyses were not performed, the conclusion was that local anesthetic infiltration either as a sole technique or in conjunction with a multimodal approach to pain (NSAIDS, Acetaminophen, Opiates) is recommended in the management of pain after hemorrhoidectomy. The following algorithm can be utilized in the management of postoperative pain after excisional hemorrhoidectomy (Fig. 4.4) (Pain management algorithm).
Pain management algorithm for excisional hemorrhoidectomy
Postoperative urinary retention after excisional hemorrhoidectomy is the most frequent complication after pain. This is especially evident after multiple-quadrant excisions or the performance of other concomitant anorectal procedures performed at the time of excisional hemorrhoidectomy. A number of studies have shown that limiting perioperative fluids to less than 1000 mL can lower the incidence of urinary retention from approximately 20% to less than 10% [19, 20]. Bailey lowered the incidence of urinary catheterization from 14.9 to 3.5% with fluid restriction . Additionally, multimodal analgesia has been shown to decrease urinary retention from 25 to 8% . Toyonaga et al. found that female sex, presence of preoperative urinary symptoms, diabetes mellitus, need for postoperative analgesics, and more than three hemorrhoids resected were independent risk factors for urinary retention as assessed by multivariate analysis . The most recent practice parameters published by the American Society of Colon and Rectal Surgeons gives a strong recommendation with level 1B evidence stating that “urinary retention after ambulatory surgery may be reduced by limiting perioperative fluid intake.”  Since the vast majority of hemorrhoidectomies are performed on an ambulatory basis it is not very practical to mandate voiding prior to discharge. Patients are encouraged to minimize fluid intake until voiding. Warm sitz baths or warm showers the following day usually promote voiding.
Massive hemorrhage after excisional hemorrhoidectomy requiring operative treatment occurs in less than 1–2% of patients. Hemorrhage occurs either early (immediate in PACU or within 48 h) or late (72 h or greater). Although it is usually not difficult to identify bleeding internally, it can be potentially masked if there is an anal pack in place and some surgeons advocate not placing an anal pack after hemorrhoidectomy for this reason.
Hemorrhage in the early postoperative period is almost always secondary to a technical issue likely from inadequate ligation of the internal hemorrhoid pedicle. Although bleeding from the external portion of the wound is unusual, it can occur and can potentially be managed at the bedside in the PACU. Bleeding from the external wound may be managed with simple injection of 1% lidocaine with 1:100,000 epinephrine. This may control the bleeding alone and at the very least allows the surgeon the ability to assess the outer wound carefully. Occasionally, suture ligation of a bleeding point on the external skin may be needed. If there is severe bleeding from the anal canal while the patient is in the post anesthesia care unit (PACU) or within 48 h they should be brought back to the operating room immediately. This will allow optimal visualization and management with suture ligation.
Late or Delayed Hemorrhage
Late or delayed hemorrhage can occur up to several weeks after excisional hemorrhoidectomy although the majority occurs within the first week. The delayed hemorrhage frequently requires admission to the hospital for observation and management. Delayed hemorrhage is usually due to bleeding from the sloughed hemorrhoidectomy wound where there is a granulating tissue base possibly with an exposed vessel. The incidence of late bleeding is similar in open Milligan–Morgan hemorrhoidectomies versus closed Ferguson hemorrhoidectomies . Delayed hemorrhage can be managed through a variety of treatments. Once the patient is resuscitated in the emergency department, an assessment is made to determine the extent of bleeding through a thorough history and physical examination. If the patient is hemodynamically unstable despite resuscitation then they should be brought to the operating room immediately for an examination under anesthesia and possible suture ligation. If the patient is stable, then an attempt can be made to perform rectal tap water irrigation with a large three-way foley catheter. This usually does not require anesthetics or narcotics but can be used on a selective basis. If fresh blood is persistent throughout the rectal irrigation then the patient should be brought to the operating room for an examination under anesthesia. If the rectal irrigation becomes clear then the patient can be admitted for close observation. Chen et al. performed a prospective study comparing rectal irrigation with immediate examination under anesthesia. They found that rectal irrigation was well tolerated and bleeding stopped in 88% of patients. In comparison to surgery patients undergoing rectal irrigation had a higher satisfaction, lower length of stay and more cost effective treatment .
Another minimally invasive approach is proctoscopic or anoscopic inspection followed by injection of 1% lidocaine with 1:100,000 epinephrine. This may require the use of local anesthesia and narcotics for patient tolerance. Additionally, good lighting is essential for appropriate visualization .
Anal packing has been described with a variety of materials including Surgicel, and gelfoam soaked with thrombin or epinephrine. This usually requires anesthesia and narcotics for patient tolerance and may lead to other complications such urinary retention . An alternative to packing is Foley catheter tamponade of the bleeding. Once the catheter is inserted the balloon is inflated with 20–40 mL of fluid and placed on gentle traction. The balloon can then be deflated and removed within 24 h. This technique can also be utilized as a temporizing procedure prior to going to the operating room if it is not immediately available [27, 28]. Lastly, in patients with significant ongoing bleeding, suture ligation in the operating room provides the best means for a thorough and painless examination so that suture ligation can be performed.
Although the rate of bacteremia has been reported to be as high as 8.5% following sigmoidoscopic examination, the incidence of local infectious complications and or systemic sepsis is surprisingly low following excisional hemorrhoidectomy. This has been attributed in part to the excellent blood supply of the anorectal region as well as effective clearance of portal bacteremia by the reticuloendothelial system of the liver . There is definitely a paucity of reported wound infections following hemorrhoidectomy. The reported rate of local infection following excisional hemorrhoidectomy in most cases is less than 1–2%. In a report by Bouchard et al. in over 600 patients undergoing hemorrhoidectomy the incidence of local infection was 1.4% . Chen et al. reported 1 infection in 666 patients undergoing excisional hemorrhoidectomy with the LigaSure device . Qarabaki et al. reported zero wound infections in a comparative study looking at 688 patients undergoing either circumferential excisional hemorrhoidectomy versus three-quadrant Ferguson hemorrhoidectomy .
Anal stenosis following excisional hemorrhoidectomy is usually a preventable complication that results from excessive excision of perianal skin and or anoderm. Its incidence is typically less than 5% but has been reported as high as 10%. The best treatment for anal stenosis is prevention. If adequate skin bridges and anoderm are preserved during excisional hemorrhoidectomy, the risk of anal stenosis will be decreased. Excisional hemorrhoidectomy is best performed with a large Hill-Ferguson retractor in place during the entire procedure. If disease is circumferentially extensive then you are better off leaving enough skin/anoderm bridges in situ even though the patient may complain about some residual disease. This can be taken care of at a subsequent operation if needed once there is complete healing of the initial wounds. Although the surgeon has the option of performing more extensive excision with a concomitant anoplasty, it is my preference to leave sufficient skin bridges and anoderm in situ to avoid postoperative anal stenosis. The timeline for presentation of anal stenosis may be anywhere from weeks to several months after excisional hemorrhoidectomy . Medical and or surgical treatment should be tailored to the severity of anal stenosis. Patients usually report painful or difficult bowel movements, rectal bleeding, and or narrow caliber stools. Visual inspection and attempted digital rectal examination usually establishes the diagnosis of anal stenosis. However, some patients may require examination under anesthesia in order to make an adequate assessment. If the etiology of the stenosis is unclear then the patient should undergo endoscopy to rule out malignancy and or inflammatory bowel disease. Crohn’s disease must also be in the differential diagnosis. Stenoses can be classified as either mild, moderate or severe . A mild stenosis is characterized by the ability to perform a digital rectal examination on the patient or to be able to insert a medium Hill-Ferguson retractor into the anus without forceful dilatation. A moderate stenosis requires forceful dilatation in order to perform a digital rectal examination or to insert a medium Hill-Ferguson retractor. A severe stenosis is defined as one in which the 5th digit or a small Hill-Ferguson retractor can only be inserted with forceful dilatation. Stenoses can also be classified as to their level of involvement as low, middle, and high . Low involves at least 0.5 cm distal to the dentate line, middle 0.5 cm distal and proximal to the dentate line and high as involving 0.5 cm above the dentate line. Mild stenosis can frequently be treated with stool softeners or bulking agents . Some patients may require daily self-digital dilation or mechanical dilation with dilators 2–3 times per day. Mechanical dilators can be quite costly and may be replaced with a well-lubricated tapered candle for significantly less money. The patient is instructed to bring the candle to the office and then observed in its use for dilation. The candle can also be marked to provide limits of insertion for the patient. These patients are best seen in the office on a weekly basis to assess progress and to perform dilation or digital rectal examination. Moderate stenosis should be treated initially with conservative management with fiber supplements and dilation. If adequate results are not obtained patients may benefit from incision of a constricting band and concomitant lateral internal sphincterotomy. The lateral internal sphincterotomy should be performed in an open fashion in order to incise the scarred anoderm at the same time. The sphincterotomy wound should be left open to heal by secondary intention and then the patient placed on bulk forming fiber immediately after surgery. Some patients may require more than one sphincterotomy in order to allow appropriate dilation. In Milsom’s series of 212 patients greater than 50% were treated with a sphincterotomy . More severe stenosis usually requires surgical intervention in the form of anoplasty. Figure 4.5 is a simplified algorithm for the treatment of anal stenosis post-hemorrhoidectomy. Anoplasty essentially treats the loss of anoderm that resulted from the excisional hemorrhoidectomy. A variety of advancement flaps have been developed in order to deliver new healthy, pliable tissue that replaces the scarred and missing anal canal tissue. Occasionally, more than one flap may be needed in order to correct the deformity. In common to virtually almost all flaps for the correction of anal stenosis secondary to excisional hemorrhoidectomy is that they should be based laterally in either the left or right lateral positions away from the midline where there is more tension and where healing can be impaired. Although not all-inclusive the following is a list of the more common anoplasty procedures utilized for treating severe anal stenosis secondary to excisional hemorrhoidectomy (Figs. 4.6, 4.7, 4.8 and 4.9).
Management of anal stenosis post excisional hemorrhoidectomy
Y-V Anoplasty. a Anal canal with stenosis. b. Line of incision for Y-V anoplasty. Note that the base of the incision from superior to inferior (i.e., the distance between the arms of the Y) should be equal or greater to the length of the Y. c Completed Y-V anoplasty with all wounds closed. Adapted from Blumetti and Abcarian 
Diamond flap anoplasty. a Line of incision for diamond flap anoplasty. The leading edge of the flap should be the same size as the defect in the anal canal. b The fully mobilized flap is brought into the wound. Adapted from Blumetti and Abcarian 
U-Flap anoplasty. a Outline of incision for bilateral U-flap anoplasty. b The fully mobilized flap is brought into the wound. c The flap sutured in place. Note the lateral donor site is left open to heal by secondary intention. Adapted from Blumetti and Abcarian 
S-Plasty. a Line of excision of stenosis and ectropion. b Line of incisions for S-Plasty. The distance from A to the left lateral edge is the base of the superior flap. Note that this distance is longer than the height of the flap from superior to inferior. c Mobilization of the inferior flap is demonstrated. The superior flap has already been completed d final appearance after completion. Note that the tip of the superior flap (a) has been rotated and sutured to the inferior aspect of the wound, and the tip of the inferior flap (b) now lies at the superior aspect. The donor sites are left open, but may also be closed primarily. Adapted from Blumetti and Abcarian 
Patients usually undergo full mechanical bowel preparation as well as intravenous antibiotics preoperatively. In order to facilitate sphincter muscle relaxation, patients should have either regional or general anesthesia. Infiltration with local anesthetics is also utilized in order to help with postoperative pain. Flaps are created in full thickness with its underlying adipose tissue that includes its blood supply. Care needs to be taken not to undermine the flap in order to prevent ischemia. Of the flaps listed all include closure of the primary donor site except the U-flap that leaves the donor site partially open to heal by secondary intention .
In a 1-year follow-up in 488 patients, Bouchard et al. reported a 4.7% incidence of anal stenosis . Nienhuijs and de Hingh performed a Cochrane review looking at conventional versus LigaSure hemorrhoidectomy . Twelve randomized controlled studies with 1142 patients met the inclusion criteria. Data for anal stenosis was reported in only 931 patients. Of the 931 patients undergoing either LigaSure or conventional hemorrhoidectomy, the reported incidence of anal stenosis was 0.86% (8/931).
In a literature review by Brisinda et al. they reported an overall healing rate ranging from 60 to 100% in 29 reports with a total of more than 700 patients. In 26 of the 29 reports the healing rate was greater than or equal to 90% . Of note however, some of these anoplasty procedures were not performed for anal stenosis and some patients underwent bilateral anoplasties. Unfortunately, it is quite difficult to compare results of anoplasty procedures as there are no prospective randomized trials available. Nonetheless, results have been reported to be successful in the majority of patients.
This condition may arise occasionally when the mucosa is incorrectly sutured distal to the dentate line. The defect results in mucosa visible at the level of the anal verge. This can lead to a “wet anus” secondary to mucous discharge where the patient complains of persistent moisture and irritation in the anal region. This complication more often occurs after an improperly performed Whitehead hemorrhoidectomy  (Fig. 4.3). If there is no associated anal stenosis and the ectropion is confined to a small quadrant of the anus then local excision can be performed. After excising the ectropion, the rectal mucosa is sutured to the internal sphincter in a transverse fashion at the level of the dentate line and the skin is allowed to heal by secondary intention. If anal stenosis is present or if the mucosal ectropion is extensive or a Whitehead deformity exists then an anoplastic procedure is indicated.
Patients being considered for hemorrhoidectomy must undergo a thorough history that includes episodes of fecal soiling, gross incontinence, or incontinence to flatus. This is particularly important in the elderly patient who may have impaired continence. This may be particularly difficult to sort out when minor fecal soiling or incontinence is present in patients complaining of mucosal prolapse. Although the presence of new postoperative incontinence is rare, it is not unusual for patients to experience temporary difficulty controlling flatus for several weeks postoperatively . Whether this is secondary to removal of internal hemorrhoidal cushions that contribute to flatus continence versus removal of transitional zone tissue that contributes to sensation is unclear. This problem may be of particular concern in women. Anal incontinence after hemorrhoidectomy has been reported in up to 12% of patients . Additionally, concomitant internal sphincterotomy must be avoided in patients with disturbed continence. It has been reported that anal retractors can also disturb continence in patients after anorectal surgery [43, 44]. As in many complications prevention is the best treatment. One should avoid excisional hemorrhoidectomy in patients with disturbed continence. In addition to appropriate patient selection, careful use of the anal retractor and avoidance of concomitant internal sphincterotomy will minimize this postoperative complication.
Although constipation is not uncommon after excisional hemorrhoidectomy, it is best prevented by placing the patient on an appropriate bowel management program postoperatively. Patients should be instructed on the use of bulk fiber laxatives immediately postoperatively as well as stimulant laxatives should they not have a proper bowel movement by postoperative day three. Fecal impaction occurring in approximately 1–3% of patients should be avoided at all costs as this will typically require a trip to the operating room for correction .
Bulk laxatives have been shown to decrease pain with bowel movements as well as lead to decreased soiling .
Complications of Stapled Hemorrhoidopexy
Ariane M. Abcarian and Herand Abcarian
Stapled hemorrhoidopexy or PPH (Procedure of Prolapse and Hemorrhoids) was originally designed by Antonio Longo in 1995 and reported as a new procedure to the 6th World Congress of Endoscopic Surgery in Rome, Italy in 1998 . In this novel concept and operation, Longo proposed that excision of all hemorrhoidal tissue practiced in Europe (Milligan–Morgan procedure) or in the US (Ferguson procedure) is unnecessary, and all that is needed is elevation and fixation of the prolapsing hemorrhoid and rectal mucosa to the rectal wall at the level of the anorectal ring. This could be accomplished by a circular stapler which he designed and Ethicon Endosurgery (Cincinnati, Ohio) produced and marketed . In essence, this was the ultimate extension of all “Nonoperative treatments” of hemorrhoids, e.g., injection sclerotherapy, rubber band ligation, infrared coagulation, etc., which succeeded in alleviating hemorrhoidal symptoms of prolapse and bleeding by promoting fixation of the tissue to the anorectal wall. It is important to note at the onset that many European surgeons continued to use the term “stapled hemorrhoidectomy” instead of hemorrhoidopexy.
This operation gained rapid popularity in Europe especially in Italy and Germany due to the simple nature of the procedure and minimal pain experienced by the patient due to avoidance of incising the anoderm and placement of the staple line well (2–3 cm) above the dentate line. As any new procedure, its rapid expansion in the hands of surgeons, many of whom were noncolorectal specialists, led to a series of complications some new and others common to all previous hemorrhoidectomies. Ultimately, an international working party was assembled in France with representation from many countries (including the US) to establish guidelines for the use of this new instrument and procedure recommending lectures, videos, application in animal models, etc., leading to a formal credentialing by each practitioner’s surgical department .
The early experience with stapled hemorrhoidopexy in the US was quite favorable and the results of this procedure performed at the University of Illinois at Chicago and Washington University in St. Louis were reported by Singer and colleagues . Since then numerous publications have confirmed significant reduction in postoperative pain, early resumption of normal activity and greater patient satisfaction [48, 49]. Randomized controlled trials comparing “stapled hemorrhoidectomy” with other conventional techniques all favored the former in regards to postoperative pain and patient satisfaction [50–53]. With further experience, long-term results of stapled hemorrhoidectomy confirmed the earlier favorable results [54, 55].
In an attempt to validate the results of the European studies, a prospective randomized controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy was carried out in the United States . Perioperative and 1-year results confirmed the advantage of hemorrhoidopexy in decreasing postoperative pain, time off work and similar if not better results at the end of 1-year follow-up . Among the detailed data collected were the postoperative complications which are summarized in Table 4.1 under Adverse Events (AE).
Adverse events (AE)
Pts ≥ 1AE
Return to OR due to AE
Micturition disorder (dysuria)
Temporary fecal incontinence
Postoperative wound infection
Temporary flatus incontinence
The authors concluded that: (a) PPH and Ferguson have similar safety profile, (b) PPH results in less postoperative pain, a faster recovery and fewer patients requiring analgesics and (c) PPH and Ferguson had similar rate of control of hemorrhoidal symptoms. Also, PPH patients required fewer additional anorectal procedures within the first postoperative year .
The complications of stapled hemorrhoidopexy and their management will be grouped as best as possible and discussed under the following headings.
Usual postoperative pain is best managed with nonnarcotic analgesics to prevent added side effects of opioid-related constipation. Narcotics are rarely prescribed in Europe for postoperative pain. Administration of 1000 mg intravenous acetaminophen in the operating room is a valuable adjunct for postoperative pain control. Warm sitz baths 10–15 min t.i.d or q.i.d is very helpful. Compared with Ferguson hemorrhoidectomy, pain after stapled hemorrhoidopexy is much less in severity, lasts for shorter period, and requires lower doses of analgesics . “Persistent pain” or fecal urgency of unknown etiology has been reported . If severe pain persists beyond 3–4 weeks an examination under anesthesia is advisable.
Pelvic Floor Spasm May cause intense deep burning pain in the rectum which may radiate to the pubis. This is usually a brief postoperative episode, lasting no more than a few days and can be managed by addition of a nightly dose of striated muscle relaxant (e.g., 10 mg oral cyclobenzaprine) in addition to frequent sitz baths.
Low staple line It is essential that the purse string for stapled hemorrhoidopexy be placed 3–4 cm cephalad to the dentate line to prevent irritation of the somatic sensory nerves which stop at the dentate line but may diffuse at least 5–6 mm cephalad (analogous preventing pain during rubber band ligation of hemorrhoids). Generally, if the staple line can be visualized with simple eversion of the buttocks, it is safe to conclude that it is too low, abutting the dentate line.
Chronic pain is poorly understood but could be related to low staple line. After 3–4 weeks, the patient may be returned to the operating room and if no other causes for pain can be identified, the surgeon may attempt to remove as many readily easily visible staples as possible with no risk of staple line dehiscence or bleeding. If an anal stenosis is found, it should be managed appropriately with simple dilation, division of scar, or even partial lateral internal sphincterotomy.
Anal Fissure may occur after dilation of the anal canal for insertion of the circular anal dilator (CAD). Manual dilation of the anus should be avoided. The lubricated obturator of the CAD should be inserted 2–3 times to allow safe placement of CAD. If the patients complain of typical postcibal pain of anal fissure, a simple eversion of the buttocks without digital examination will allow visualization of the fissure. This can be managed with topical application of nitroglycerine (NTG) or calcium channel blockers (CCB), but may require lateral internal sphincterotomy if the fissure does not respond to topical medications.
Thrombosed External Hemorrhoids may occur if the external hemorrhoids are large preoperatively and are not excised during the procedure. Prolonged “conservative” treatment with analgesics, anti-inflammatory, steroid topical analgesic creams should be condemned. Excision of the hemorrhoid with its thrombosis under local anesthesia provides immediate relief.
Perianal Abscess/Fistula is rarely seen after stapled hemorrhoidopexy due to avoidance of incision through the anoderm. If a deep (intraanal) abscess is suspected (pain, fever, swelling, tenesmus), an urgent examination under anesthesia will allow prompt diagnosis and treatment (drainage).
Perianal Burning, Itching, and Irritation are all mild forms of pain expressed as troublesome symptoms. Proper hygiene, mild steroid creams, and maintaining dryness will help resolve the symptoms quickly.
Bacteremia may occur after all rectal operations. This is usually inconsequential and causes temporary low grade fever and chills lasting less than 24 h . The incidence is low and conservative treatment with sitz baths and antipyretics suffice [56–58]. It is unclear whether preoperative use of antibiotic prophylaxis decreases the incidence of bacteremia due to rarity of the condition and lack of evidence-based data or prospective randomized trails.
Retroperitoneal Sepsis Secondary to breakdown of the staple line has been reported. Seow-Choen and colleagues published in a case report and review of literature . Other reports of septic complications resulting from hemorrhoidectomy has been reported [60, 61]. If the patient develops fever, leukocytosis, and severe pain or dysuria, immediate workup including CT scan should be initiated. Due to the potential lethal nature of this complication, emergency surgery, external drainage of sepsis, and fecal diversion must be undertaken without delay. After the patient recovers a careful endoscopy and contrast enema will guide the surgeon toward appropriate surgical intervention addressing the abscess cavity, stricture and ultimately utilizing coloanal anastomosis if indicated.
Anorectal Abscess fistula has already been addressed (vide supra)
Dysuria after stapled hemorrhoidopexy is more often seen in male patients. Although the etiology is not clearly understood, it may be related to pelvic floor spasm and or reflex bladder neck contraction secondary to postoperative pain. Empiric use of cyclobenzaprine, 10 mg and tamsulosin HcL (Flomax®) 0.4 mg qhs for 3–4 nights after surgery is greatly helpful.
Urinary Retention Urinary retention is the most common postoperative complication after any type of hemorrhoidectomy. Overzealous intravenous fluid administration during and immediately after surgery especially when regional anesthesia is used is most often at fault. In an old study of 610 patients with anorectal surgery, hemorrhoidectomy stood out among all other operations for benign anorectal disease as a risk factor or urinary retention . In the study by Senagore and colleagues, the incidence of urinary retention after stapled hemorrhoidopexy was 11.7% versus 7.6% for Ferguson hemorrhoidectomy (p = 0.382 ns) . Bladder decompression, fluid restriction, warm sitz baths, and use of tamsulosin HcL (Flomax®) 0.4 mg daily help prevent need for repeat catherization.
Sexual Dysfunction Temporary impotence in men almost always resolves in time. Occasional dyspareunia has been reported by women. The very close proximity of the staple line to the posterior vaginal wall is a possible etiologic factor. I have personal experience with a case of small hematoma in the rectovaginal septum which caused deep vaginal pain and dyspareunia. One month after surgery, the hematoma began draining spontaneously through a minute defect in the staple line. Under local anesthesia, the opening was enlarged with a hemostat resulting in further drainage of “old blood” and resolution of symptoms in 2 weeks.
Penile Laceration in sexual partner of an individual after stapled hemorrhodiopexy has been reported . It is safe to say that a careful history especially in men, should alert the surgeon to counsel the patient against opting for stapled hemorrhoidopexy for the treatment of symptomatic hemorrhoidal disease. Women can be counseled to avoid anal receptive intercourse for 6–12 moths until all staples are extruded.
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Constipation and fecal urgency constipation is related to dehydration, decreased physical activity, dietary change, and most often injudicious use of narcotic analgesics. This was reported in 5.2% of patients with stapled hemorrhoidopexy and 12.7% of the patients following Ferguson hemorrhoidectomy . Patients should be placed on high fiber diet, increased oral fluid/water intake and stool softeners. Patients with history of chronic constipation should be started on this regimen plus daily dose of polyethylene glycol (PEG) powder for 1–2 weeks before surgery. Fecal urgency and sense of incomplete evacuation is related to the inverting type of staple line which does functionally somewhat narrow the anorectal outlet. With proper bowel management and reassurance, the urgency abates gradually and resolves in 3–4 weeks postoperatively.
Fecal Impaction after stapled hemorrhoidopexy is usually related to overuse of narcotic analgesic. After 5–6 days of “constipation,” patients have tenesmus and pass liquid stool which many mistake for diarrhea. Using Loperamide or other constipating agents at this stage greatly aggravate the condition. Even though this is rare, patients with postoperative fecal impaction should be disimpacted under anesthesia or deep sedation followed by use of PEG or lactulose laxatives.
Fecal Incontinence Temporary fecal incontinence was reported in 3.9% of patients following stapled hemorrhoidopexy and 5.2% of the patients after Ferguson hemorrhoidectomy . It is more commonly seen in elderly patients who do not tolerate anal stretch for any rectal surgery. In general the fecal incontinence is temporary and resolves in 2–4 weeks. If the patient complains of prolonged periods of fecal incontinence, EAUS can be useful to pinpoint a sphincter injury, even though this could have been present for years prior to the operation in an occult asymptomatic state. If a sphincter defect is found, a course of biofeedback should be recommended, and if this fails, an overlapping sphincter repair should be attempted.
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