Hemorrhoids Surgery


Hemorrhoids Surgery

Most hemorrhoidal flareups stop hurting within two weeks without treatment. Eating a high-fiber diet and drinking eight to 10 glasses of water per day can usually manage the symptoms. You may also need to use stool softeners to reduce straining during bowel movements. Your doctor may recommend over-the-counter topical ointments to ease occasional itching, pain, or swelling.

Hemorrhoid Surgery Highlights

  1. Hemorrhoids are swollen blood vessels that can be painful and irritated.
  2. Most people don’t need hemorrhoid surgery, but surgical removal is required for severe cases that don’t resolve with home treatment.
  3. There are five types of surgery you and your doctor might consider.

Hemorrhoids are swollen veins that can be internal, which means they’re inside the rectum, or external, which means they’re outside the rectum.

Sometimes, hemorrhoids can lead to other complications. External hemorrhoids may develop painful blood clots. If this happens, they’re called thrombosed hemorrhoids. Internal hemorrhoids may prolapse, which means they drop through the rectum and bulge from the anus. External or prolapsed hemorrhoids can become irritated or infected and may require surgery. The American Society of Colon and Rectal Surgeons (ASCRS) estimates that less than 10 percent of hemorrhoid cases require surgery.

Types of Hemorrhoid Surgeries

Some types of hemorrhoid surgery can be done in your doctor’s office without anesthetic. Other types of surgery need to be performed in a hospital.

Banding

Banding is an office procedure used to treat internal hemorrhoids. Also called rubber band ligation, this procedure involves using a tight band around the base of the hemorrhoid to cut off its blood supply. Banding usually requires two or more procedures that take place about two months apart. It’s not painful, but you may feel pressure or mild discomfort. Banding is not recommended for those taking blood thinners because of the high risk of bleeding complications.

Sclerotherapy

This procedure involves injecting a chemical into the hemorrhoid. The chemical causes the hemorrhoid to shrink and stops it from bleeding. Most people experience little or no pain with the shot.

Sclerotherapy is done at the doctor’s office. There are few known risks. This may be a better option if you’re taking blood thinners because your skin is not cut open. Sclerotherapy tends to have the best success rates for small, internal hemorrhoids.

Coagulation Therapy

Coagulation therapy is also called infrared photocoagulation. This treatment uses infrared light, heat, or extreme cold to make the hemorrhoid retract and shrink. It’s another type of procedure that’s done at your doctor’s office, and it’s usually performed along with an anoscopy. An anoscopy is a visualization procedure where a scope is inserted several inches into your rectum. The scope allows the doctor to see. Most people experience only mild discomfort or cramping during treatment.

Hemorrhoidectomy

A hemorrhoidectomy is used for large external hemorrhoids and internal hemorrhoids that have prolapsed. This procedure usually takes place in a hospital. You and your surgeon will decide on the best anesthesia to use during the surgery. Choices include:

  • general anesthesia, which puts you into a deep sleep throughout the surgery
  • regional anesthesia, which involves medication that numbs your body from the waist down being delivered by a shot in the back
  • local anesthesia, which numbs only your anus and rectum

You may also be given a sedative to help you relax during the procedure if you receive local or regional anesthesia.

Once the anesthesia takes effect, your surgeon will cut out the large hemorrhoids. When the operation is over, you’ll be taken to a recovery room for a brief period of observation. Once the medical team is sure that your vital signs are stable, you’ll be able to return home. Pain and infection are the most common risks associated with this type of surgery.

Hemorrhoidopexy

Hemorrhoidopexy is sometimes referred to as stapling. It’s usually handled as a same-day surgery in a hospital, and it requires general, regional, or local anesthesia. Stapling is used to treat prolapsed hemorrhoids. A surgical staple fixes the prolapsed hemorrhoid back into place inside your rectum and cuts off the blood supply so that the tissue will shrink and be reabsorbed. Stapling recovery takes less time and is less painful than recovery from a hemorrhoidectomy.

Anal Surgery for Hemorrhoids

Hemorrhoids result from disruption of the anchoring of the anal cushions. They occur most commonly in the right anterior position and are associated with straining and irregular bowel habits. During defecation, straining engorges the cushions, resulting in their displacement. Repeated displacement of these cushions results in stretching and eventual prolapse of the cushions, known as hemorrhoids (see the image below).

Constipation and all conditions that result in abnormal anal pressure and compliance predispose to the formation of hemorrhoids. Acquired conditions such as portal hypertension cause engorgement of these venous plexuses, which can also contribute to anal cushion displacement. Pregnancy can also cause or aggravate symptoms; direct pressure may play a role, but other factors like hormonal fluctuations may contribute.

Inflammatory bowel disease (IBD) and consistent diarrhea can cause hemorrhoidal disease. Any patient with a combination of hemorrhoidal and IBD should be viewed with caution.

Hemorrhoid classification

Hemorrhoids may be broadly classified as external or internal. External hemorrhoids are located distal to the dentate line and cause pain when they thrombose. This area is covered with sensate squamous epithelium, so the patient typically reports pain, swelling, itching, or a combination of these symptoms.

Internal hemorrhoids are located proximal to the dentate line. This area is composed of insensate columnar-glandular epithelium. Internal hemorrhoids bleed, prolapse, or both. Patients typically present with sudden painless bleeding, usually after a bowel movement. Patients should undergo anoscopic examination or colonoscopy to rule out malignancy or diverticular disease.

Internal hemorrhoids may be graded as follows:

  • Grade I (primary) – These slide below the dentate line with strain but retract with relaxation; patients are typically treated with dietary changes, including increased fiber intake; if hemorrhoids persist, sclerotic therapy or rubber banding ligation may be offered
  • Grade II (secondary) – These prolapse past the anal verge but reduce spontaneously; patients are typically treated with sclerotic therapy or rubber banding
  • Grade III (tertiary) – These prolapse past the anal verge and must be reduced manually; depending on the size of the hemorrhoids and the symptoms noted, patients may be treated with sclerotic therapy, rubber banding ligation, or surgery
  • Grade IV (quaternary) – These prolapse past the anal verge and are not reducible; treatment with surgical hemorrhoidectomy is indicated

Indications

Depending on the severity of the symptoms, hemorrhoids are managed either medically or surgically.

For grade I and II hemorrhoids, medical treatment is indicated as first-line management. Medical treatment consists of dietary changes and bulk-forming agents. Dietary management is the first line of therapy. Patients are advised to ingest adequate fiber and water and avoid straining. This conservative management is effective for hemorrhoids with lesser prolapse.

For grade I and II hemorrhoids—as well as some prolapsed grade II hemorrhoids and some grade III hemorrhoids—and for cases in which medical management is not adequate, an office procedure may be indicated. Such procedures include the following:

  • Rubber band ligation
  • Infrared photocoagulation
  • Electrocoagulation
  • Sclerotherapy
  • Cryotherapy

Surgery is reserved for cases in which conservative management is not adequate—for instance, hemorrhoids refractory to office procedures, large external hemorrhoids, hemorrhoids with significant bleeding, and prolapsed internal hemorrhoids. The following surgical procedures may be indicated:

  • Open vs closed hemorrhoidectomy
  • Stapled hemorrhoidopexy

Contraindications

Contraindications to office treatments include the following:

  • Anal stenosis
  • Bleeding hemorrhoids
  • Grades III or IV hemorrhoids
  • Patient taking nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners

Technical considerations

Anatomic considerations

Hemorrhoidal cushions are anal cushions of tissue composed of blood vessels, smooth muscle, and connective tissue. These cushions are located in the upper anal canal at three different sites: left lateral, right anterolateral, and right posterolateral quadrant. They are separate structures rather than a continuous ring of vascular tissue and therefore allow the anal canal to dilate during defecation without tearing.

Anal cushions are thought to aid in anal continence, though their function is not entirely understood. During the act of defecation, the anal cushions become engorged and tense with blood, cushioning the anal canal lining.

The anal canal above the dentate line is supplied by the terminal branches of the superior rectal (hemorrhoidal) artery, which is the terminal branch of the inferior mesenteric artery. The middle rectal artery (a branch of the internal iliac artery) and the inferior rectal artery (a branch of the internal pudendal artery) supply the lower anal canal.

Treating Hemorrhoids With Surgery

  • If you notice that the hemorrhoids become quite large, bleed a lot, cause excessive pain, interfere with bowel movements or become swollen and hard, surgery might be necessary
  • Before having surgery for hemorrhoids, consult a physician or surgeon first to determine the procedure that’s right for you

While there are homemade treatment protocols that patients with hemorrhoids can follow, there are cases that persist despite being treated. If you notice that the hemorrhoids become quite large, bleed a lot, cause excessive pain, interfere with bowel movements or become swollen and hard, surgery might be necessary.

Before having surgery for hemorrhoids, consult a physician or surgeon first to determine the procedure that’s right for you, or if there are other homemade solutions that you haven’t tried yet that could help with your case. There are three different surgical treatments for hemorrhoids:

Hemorrhoidectomy: in this procedure, the surgeon cuts out the large hemorrhoids.

Prior to the operation, you and your surgeon will choose from three types of anesthesia: general (sends you into a deep sleep throughout the operation), regional (delivered via a shot on your back and numbs your body from the waist down) or local (numbs your anus or rectum).

While hemorrhoidectomy is effective at treating recurrent hemorrhoid cases and lowering the risk of the hemorrhoids returning, there are potential and painful complications.

Bleeding, urinary tract infections and temporary difficulty in emptying bladder and stools are common problems after this procedure. Plus, recovery time can take up to a week, and even you still might experience post-surgery pain.

Hemorrhoid stapling or hemorrhoidopexy: this is often performed on prolapsed hemorrhoids because of its effectivity. Just like hemorrhoidectomy, you and your surgeon will decide first whether to use general, regional or local anesthesia.

This process uses a surgical staple to fix the prolapsed hemorrhoid and return it into its place inside your rectum. This blocks blood supply, causing the tissue to shrink and be reabsorbed. Compared to hemorrhoidectomy, hemorrhoid stapling is less painful and involves a shorter recovery period.

However, there is a chance that hemorrhoids will still return post-surgery. There is also a risk for rectal prolapse, wherein a part of your rectum may stick out from your anus. In some cases, the surgery might result in a blockage or hole in your anus or rectum, or even an infection in these areas.

Hemorrhoidal artery ligation: also called a hemorrhoid artery ligation operation or HALO, the procedure uses an instrument called a modified proctoscope containing a Doppler probe. This will be placed in your anus, allowing your surgeon to have a good view of the hemorrhoids. The Doppler probe will then locate the blood vessels that cause the hemorrhoids.

Once these blood vessels are located, a small window inside the proctoscope allows your surgeon to place a suture or stitch around the artery. This cuts off the blood supply to your hemorrhoids and causes them to shrink. Hemorrhoidal artery ligation also brings the hemorrhoids higher up the anal canal.

Hemorrhoidal artery ligation is effective for patients with bleeding and/or prolapsing hemorrhoids. The procedure also causes less pain post-surgery, although there might be slight discomfort in the process. Unfortunately, there is a possibility that the hemorrhoids will return and you might experience difficulty or inability urinating. Having open bowels may also result in pain.