Hemorrhoidectomy

Hemorrhoids are a problem that affects over 1 million Americans each year. It affects both sexes and
is more common in the more prosperous societies, perhaps related to exercise, diet and bowel
habits.
Anatomy
The anal canal is a little over one inch in length ( cm! and extends from the lowest part of
the rectum to the anus ("igure 1!
The anal canal is surrounded by an internal (inside! and external (outside! venous plexus
(interconnection of veins!
In the anal canal these plexuses form #cushions# of mucosa (inner lining of tissue! filled with
veins and muscle fibers. These hemorrhoidal cushions fill up with blood during the act of
straining while passing stool, and serve to protect the anus from in$ury. The muscle fibers
help support the cushions
There are three cushions one each in the left lateral, right posterior and right anterior
positions (loo%ing from behind at &, ' and ( o)cloc%!
Two muscular sphincters (internal, inside* external, outside! surround the anal canal and
control the passage of stool. The sphincters tends to contract to hold in stool when pressure
in the abdomen increases and relaxes when a person strains at the stool
"igure 1 + Anatomy of the lower rectum and anus
showing the muscle sphincters that control bowel
movements and the internal and external plexuses.
, -. .calici
Pathology
It is believed that abnormal distension of blood vessels in the hemorrhoidal cushions leads
to the development of hemorrhoids
This may be caused by increased sphincter pressure (people who strain excessively while
passing stool!, by pressure on the drainage of blood from the hemorrhoidal veins (a
pregnant women may have the uterus compressing the venous drainage!, or by
abnormalities in the vessel walls
/atients with liver failure may develop abnormal venous connections in the rectum causing
similar blood vessel congestion
Another cause may be the wea%ening of the muscle support of the hemorrhoidal cushions,
which may occur with age or poor bowel habits
These factors tend to cause the cushions to prolapse (bulge! downwards. Hemorrhoids may
be classified by their location or by degree of prolapse (downward bulging!
0y location, hemorrhoids may be external (outside the anal canal! or internal (inside the anal
canal!
1. 1xternal hemorrhoids are distended vascular cushions that occur $ust outside the
margin of the anus and under the s%in ("igure '!
'. Internal hemorrhoids are the more common variety and occur from within the anal
canal and prolapse outside ("igure !
0y degree of prolapse, there are four grades
1. The vessels of the hemorrhoid are increased in number and si2e and may bleed on
passing stool, but they do not prolapse outside of the anus
'. The hemorrhoids prolapse outside of the anus while passing stool but
spontaneously return after
. The hemorrhoids protrude out of the anus but need to be reduced (pushed in! by
hand
3. The hemorrhoids are unable to be reduced to within the anal canal

"igure ' + 4arious degrees of external
hemorrhoids. , -. .calici
"igure + 4arious degrees of internal
hemorrhoids. , -. .calici

History and Examination
The most common complaint associated with hemorrhoids is bleeding. This usually occurs
during a bowel movement and in some cases can be significant. 0lood may be chec%ed to
determine anemia due to blood loss
5ther complaints include itching, discomfort and discharge in the anal area
A detailed history of diet, exercise and bowel habits is ta%en, as well as a physical exam to
find other causes that may be cause this condition
/atients may notice prolapse of the hemorrhoids. 6hen this occurs the patient may reduce
the hemorrhoids
There may be pain if the hemorrhoid is thrombosed (the blood within is clotted! or ulcerated
(open on the surface!. /ainful hemorrhoids may cause the patient to become constipated
and worsen the condition
Hemorrhoids are usually examined with an anoscope, which is a small tube that is inserted
into the anus and rectum to see the hemorrhoidal cushions. The doctor will usually as% the
patient to strain during the exam to see the effect this has on the hemorrhoids. If the patient
is more than (7 years old, an examination of the colon with a colonoscopy is a good idea to
rule out colon cancer, which may also cause bleeding in the stool
Indications for Surgery
Treatment for early symptoms is directed towards improving bowel habits, including
increasing fiber in the diet, regular bowel movements and improvement in anal hygiene.
.urface medications serve to soothe s%in irritation and itching. /ain from hemorrhoids may
be from thrombosis of the blood vessels or ulceration and surgery is usually indicated, but
the use of warm .it2 baths may be helpful
.urgery may be necessary for hemorrhoids that do not improve with conservative means.
The following methods are for uncomplicated hemorrhoids (grades 1 and '!. Treatment is
usually by sclerosant (solution that causes scarring! in$ection, rubber band ligation (tie off! or
cryotherapy (free2ing!. Advantages to these methods are that they are usually painless and
can be performed as an outpatient
1. .clerotherapy ("igure 3! + 6ith the patient in the bent $ac%%nife position, an
anoscope is inserted to see the hemorrhoids. A syringe with a long hemorrhoid
needle is used to in$ect. About cc of a sclerosant solution, usually phenol in
vegetable oil or sodium morrhuate, is in$ected under the mucosa at each
hemorrhoid site. In$ection causes scarring of the tissues with shrin%age. 8ore than
one treatment may be necessary. -ontraindications to this method are external,
infected or thrombosed hemorrhoids
'. 9ubber 0and :igation ("igure (! + The hemorrhoidal mass is pulled down with a
grasper and a special instrument called a ligator is passed around the mass. The
ligator passes a small rubber band around the nec% of the mass to bloc% the blood
supply. The mass usually falls off and passes out harmlessly in the stool a few days
. -ryosurgery + 6ith this method, a probe through which li;uid nitrogen or li;uid
nitrous oxide at temperatures below +177(- is applied to the hemorrhoidal mass.
This free2es and destroys the mass. The probes are usually applied for about ' min.
/atients may experience drainage for a few days and the destroyed mass passes in
the stool a wee% or two later. 1xternal hemorrhoids may also be treated this way

"igure 3 + In$ection of a sclerosing agent into an
internal hemorrhoid. , -. .calici
"igure ( + Tying off of a hemorrhoid with a rubber
band., -. .calici

.urgical hemorrhoidectomy should be considered for grade and 3 hemorrhoids, combined
internal and external hemorrhoids, ulceration or thrombosis ("igure <!
1. 8ost patients are given a laxative or enema the morning of the operation to empty
the rectum of stool
'. The operation is usually performed with local anesthetic with sedation (relaxing
medication! given by the anesthesiologist. 5ccasionally, some patients may re;uire
a spinal anesthesia or even general anesthesia. The patient is usually positioned in
the prone $ac%%nife position, with buttoc%s taped apart, although some surgeons
may prefer the patient in the lithotomy position (lying on the bac% with legs up in
stirrups!
. The hemorrhoidal mass is held with a clamp and the tissue around it excised (cut
out! with a %nife. The incision extends to the s%in out of the anus to also control any
external hemorrhoids. The incision then goes into the anal canal up to the highest
most part of the mass, which is then sutured and tied off. The dissection of the mass
leaves behind the underlying muscle sphincters
3. The mass is then cut away and the open edges are sutured closed with absorbable
sutures that do not need to be removed. In a similar fashion all hemorrhoidal tissue
is excised. Antibiotic ointment or pac%ing may be left in the anus
Thrombosed hemorrhoids may be treated differently
1. .ome surgeons treat this condition with in$ection of local anesthetic and
hyaluronidase (an en2yme which brea%s down fibrous tissue!. This causes the
hemorrhoid to shrin%, and the patient may be then ta%en to the operating room later
for a hemorrhoidectomy
'. If seen in the emergency room, the hemorrhoidal mass may be opened and excised
under local anesthesia. 9emoval of the blood clots reduces the pain from pressure
within the mass. The wound is left open and the patient may be sent home and a
hemorrhoidectomy later carried out in the operating room. /atients are told to
perform .it2 baths at home to help with the pain and reduce the si2e of the mass
=ew treatments of hemorrhoids
.ome newer methods that are being tried for treatment of hemorrhoids include>
1. ?se of an ultrasonic scalpel to excise the hemorrhoidal tissue. This techni;ue may
be faster, and re;uire no suturing
2. ?se of a stapler (similar to the stapler used to divide bowel!, which is inserted into
the rectum and the hemorrhoidal tissue stapled across and divided

"igure < + .urgical excision of an internal
hemorrhoid., -. .calici
Complications
.evere pain
?rinary retention
-onstipation
@elayed bleeding
Infection
.tricture of the anus
Incontinence of stool
Anal fissure or fistula
9ecurrent hemorrhoids
.loughing of the mucosa and thrombosis of the vessels with the use of sclerosing solution
.lippage of the ligature
Postoperative Care
/atients are usually discharged the same day after having passed urine in the recovery
room
/atients are usually discharged with pain medication, stool softeners to help with bowel
movements, and some dressings for the wound
The dressing is usually removed the evening of the operation, with warm .it2 baths advised
@ressings are advised for the first few days to absorb drainage
/atients are usually able to return to wor% in a few days and the wounds should have healed
in ' + wee%s
-opyright, '771 Aour.urgery.-om All 9ights 9eserved