Key principles
• Exclude pelvic tumours, large bowel carcinoma and inflammatory bowel • Consider non-operative or banding options for Grade I/II
I would perform an open haemorrhoidectomy with diathermy based on the Milligan and Morgan technique leaving appropriate mucosal bridges to minimise post-operative complications
Operation Details
- Positioning
- Lithotomy, head down
- Eisenhammer retractor to locate haemorrhoids
- Commence left lateral haemorrhoid
- Mark apex of haemorrhoidectomy with diathermy
- Grasp external component and excise it with electrocautery using cutting diathermy on skin and coagulating for haemorrhoidectomy
- Dissect onto internal sphincter lifting haemorrhoid complex off
- Narrow pedicle as dissect towards apex
- Suture ligate apex with braided absorbable suture
- Proceed to right anterior haemorrhoid and then right posterior haemorrhoid
- Pudendal nerve block
- Spongostat
Other operative options • Closed o No advantage • Stapled o Circular staplers reduce short term operative pain o Higher major complication rate including fistula, tenesmus, and urgency • HALO o Doppler guided haemorrhod artery ligation o Does not deal with external factors
Relative anatomy
• Haemorrhoids are normal vascular tissue within the submucosa of the anal canal • Left lateral, right anterior and right posterior (4,7,11) • Proximal to dentate line
Intraoperative complications & challenges
• Additional haemorrhoid o Leave it and return if proves troublesome or o Fillet it out by undermining skin bridge or o Divide skin bride above dentate line reflect it out of anus and trim haemorrhoids with back of pair of scissors, excising redundant mucosa and stitching the trimmed flap back in • Circumferential o Consider Whithead haemorrhoidectomy, a tubular circumferential excision with mucosal cutaneous reanastomosis o Perform standard three-quadrant and return at later date • Bleeding o Pressure with gauze o Suture ligation
Post-operative complications
• Urinary retention 30% • Faecal incontinence 2% • Infection 1% • Delayed bleeding 1% • Stricture 1% • Recurrence
Specific post-operative care
• Educate re: increasing pain 3-5 days • NSAIDs • Lactulose • Metrondiazole • Topical GTN if required