Hemorrhoidectomy

Definition

A hemorrhoidectomy is the surgical removal of a hemorrhoid, which is an enlarged, swollen and inflamed cluster

Hemorrhoids can occur inside the rectum, or at its opening (A). To remove them, the surgeon feeds a gauze swab into the anus and removes it slowly. A hemorrhoid will adhere to the gauze, allowing its exposure (B). The outer layers of skin and tissue are removed (C), and then the hemorrhoid itself (D). The tissues and skin are then repaired (E). (

Illustration by GGS Inc.

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Purpose

The primary purpose of a hemorrhoidectomy is to relieve the symptoms associated with hemorrhoids that have not responded to more conservative treatments. These symptoms commonly include bleeding and pain. In some cases the hemorrhoid may protrude from the patient's anus. Less commonly, the patient may notice a discharge of mucus or have the feeling that they have not completely emptied the bowel after defecating. Hemorrhoids are usually treated with dietary and medical measures before surgery is recommended because they are not dangerous, and are only rarely a medical emergency. Many people have hemorrhoids that do not produce any symptoms at all.

As of 2003, inpatient hemorrhoidectomies are performed significantly less frequently than they were as recently as the 1970s. In 1974, there were 117 hospital hemorrhoidectomies performed per 100,000 people in the general United States population; this figure declined to 37 per 100,000 by 1987.

Demographics

Hemorrhoids are a fairly common problem among adults in the United States and Canada; it is estimated that ten million people in North America, or about 4% of the adult population, have hemorrhoids. About a third of these people seek medical treatment in an average year; nearly 1.5 million prescriptions are filled annually for medications to relieve the discomfort of hemorrhoids. Most patients with symptomatic hemorrhoids are between the ages of 45 and 65.

Risk factors for the development of symptomatic hemorrhoids include the following:

• hormonal changes associated with pregnancy and childbirth
• normal aging
• not getting enough fiber in the diet
• chronic diarrhea
• anal intercourse
• constipation resulting from medications, dehydration, or other causes
• sitting too long on the toilet

Hemorrhoids are categorized as either external or internal hemorrhoids. External hemorrhoids develop under the skin surrounding the anus; they may cause pain and bleeding when the vein in the hemorrhoid forms a clot. This is known as a thrombosed hemorrhoid. In addition, the piece of skin, known as a skin tag, that is left behind when a thrombosed hemorrhoid heals often causes problems for the patient's hygiene. Internal hemorrhoids develop inside the anus. They can cause pain when they prolapse (fall down toward the outside of the body) and cause the anal sphincter to go into spasm. They may bleed or release mucus that can cause irritation of the skin surrounding the anus. Lastly, internal hemorrhoids may become incarcerated or strangulated.

Description

There are several types of surgical procedures that can reduce hemorrhoids. Most surgical procedures in current use can be performed on an outpatient level or office visit under local anesthesia.

Rubber band ligation is a technique that works well with internal hemorrhoids that protrude outward with bowel movements. A small rubber band is tied over the hemorrhoid, which cuts off the blood supply. The hemorrhoid and the rubber band will fall off within a few days and the wound will usually heal in a period of one to two weeks. The procedure causes mild discomfort and bleeding. Another procedure, sclerotherapy, utilizes a chemical solution that is injected around the blood vessel to shrink the hemorrhoid. A third effective method is infrared coagulation, which uses a special device to shrink hemorrhoidal tissue by heating. Both injection and coagulation techniques can be effectively used to treat bleeding hemorrhoids that do not protrude. Some surgeons use a combination of rubber band ligation, sclerotherapy, and infrared coagulation; this combination has been reported to have a success rate of 90.5%.

Surgical resection (removal) of hemorrhoids is reserved for patients who do not respond to more conservative therapies and who have severe problems with external hemorrhoids or skin tags. Hemorrhoidectomies done with a laser do not appear to yield better results than those done with a scalpel. Both types of surgical resection can be performed with the patient under local anesthesia.

Diagnosis/Preparation

Diagnosis

Most patients with hemorrhoids are diagnosed because they notice blood on their toilet paper or in the toilet bowl after a bowel movement and consult their doctor. It is important for patients to visit the doctor whenever they notice bleeding from the rectum, because it may be a symptom of colorectal cancer or other serious disease of the digestive tract. In addition, such other symptoms in the anorectal region as itching, irritation, and pain may be caused by abscesses, fissures in the skin, bacterial infections, fistulae, and other disorders as well as hemorrhoids. The doctor will perform a digital examination of the patient's rectum in order to rule out these other possible causes.

Following the digital examination, the doctor will use an anoscope or sigmoidoscope in order to view the inside of the rectum and the lower part of the large intestine to check for internal hemorrhoids. The patient may be given a barium enema if the doctor suspects cancer of the colon; otherwise, imaging studies are not routinely performed in diagnosing hemorrhoids. In some cases, a laboratory test called a stool guaiac may be used to detect the presence of blood in stools.

Preparation

Patients who are scheduled for a surgical hemorrhoidectomy are given a sedative intravenously before the procedure. They are also given small-volume saline enemas to cleanse the rectal area and lower part of the large intestine. This preparation provides the surgeon with a clean operating field.

Aftercare

Patients may experience pain after surgery as the anus tightens and relaxes. The doctor may prescribe narcotics to relieve the pain. The patient should take stool softeners and attempt to avoid straining during both defecation and urination. Soaking in a warm bath can be comforting and may provide symptomatic relief. The total recovery period following a surgical hemorrhoidectomy is about two weeks.

Risks

As with other surgeries involving the use of a local anesthetic, risks associated with a hemorrhoidectomy include infection, bleeding, and an allergic reaction to the anesthetic. Risks that are specific to a hemorroidectomy include stenosis (narrowing) of the anus; recurrence of the hemorrhoid; fistula formation; and nonhealing wounds.

Normal results

Hemorrhoidectomies have a high rate of success; most patients have an uncomplicated recovery with no recurrence of the hemorrhoids. Complete recovery is typically expected with a maximum period of two weeks.

Morbidity and mortality rates

Rubber band ligation has a 30–50% recurrence rate within five to 10 years of the procedure whereas surgical resection of hemorrhoids has only a 5% recurrence rate. Well-trained surgeons report complications in fewer than 5% of their patients; these complications may include anal stenosis, recurrence of the hemorrhoid, fistula formation, bleeding, infection, and urinary retention.

Alternatives

Doctors recommend conservative therapies as the first line of treatment for either internal or external hemorrhoids. A nonsurgical treatment protocol generally includes drinking plenty of liquids; eating foods that are rich in fiber; sitting in a plain warm water bath for five to 10 minutes; applying anesthetic creams or witch hazel compresses; and using psyllium or other stool bulking agents. In patients with mild symptoms, these measures will usually decrease swelling and pain in about two to seven days. The amount of fiber in the diet can be increased by eating five servings of fruit and vegetables each day; replacing white bread with whole-grain bread and cereals; and eating raw rather than cooked vegetables.

Resources

BOOKS

"Hemorrhoids." Section 3, Chapter 35 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

PERIODICALS

Accarpio, G., F. Ballari, R. Puglisi, et al. "Outpatient Treatment of Hemorrhoids with a Combined Technique: Results in 7850 Cases." Techniques in Coloproctology 6 (December 2002): 195-196.

Peng, B. C., D. G. Jayne, and Y. H. Ho. "Randomized Trial of Rubber Band Ligation Vs. Stapled Hemorrhoidectomy for Prolapsed Piles." Diseases of the Colon and Rectum 46 (March 2003): 291-297.

Thornton, Scott, MD. "Hemorrhoids." eMedicine , July 16, 2002 [June 29, 2003]. http://www.emedicine.com/med/topic2821.htm .

ORGANIZATIONS

American Gastroenterological Association. 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055; Fax: (301) 652-3890. http://www.gastro.org .

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Road, Suite 550, Arlington Heights, IL 60005. http://www.fascrs.org .

National Digestive Diseases Information Clearinghouse (NIDDC). 2 Information Way, Bethesda, MD 20892-3570. http://www.niddk.nih.gov .

OTHER

National Digestive Diseases Information Clearinghouse (NDDIC). Hemorrhoids . Bethesda, MD: NDDIC, 2002. NIH Publication No. 02-3021. http://www.niddk.nih.gov/health/digest/pubs/hems/hemords.htm .

Laith Farid Gulli, M.D.,M.S.
Bilal Nasser, M.D.,M.S.
Nicole Mallory, M.S.,PA-C

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A board certified general surgeon who has completed one additional year of advanced training in colon and rectal surgery performs the procedure. Specialists typically pass a board certification examination in the diagnosis and surgical treatment of diseases in the colon and rectum, and are certified by the American Board of Colon and Rectal Surgeons. Most hemorrhoidectomies can be performed in the surgeon's office, an outpatient clinic, or an ambulatory surgery center.

QUESTIONS TO ASK THE DOCTOR

• How many of your patients recover from hemorrhoids without undergoing surgery?
• How many hemorrhoidectomies have you performed?
• How many of your patients have reported complications from surgical resection of their hemorrhoids?
• What are the chances that the hemorrhoids will recur?