Treatments

• Symptomatic grade III / IV, or mixed internal and external hemorrhoids
• Where there are additional anorectal conditions that require surgery
• Strangulated internal hemorrhoids
• Thrombosed external hemorrhoids
• Patients cannot tolerate or fail minimally invasive procedures

Types of haemorrhoidectomies:

• Closed Haemorrhoidectomy
• Open Haemorrhoidectomy
• Stapled Haemorrhoidectomy (Procedure for Prolapse and Haemorrhoids – PPH)
• Rubber band Ligation

Symptoms

• Bleeding – Bleeding is the most common presenting symptom. It usually manifests as bright red blood, recognized first on the toilet paper with defecation and later becoming heavier and noticed in the toilet. With time, bleeding may be unrelated to defecation.
• Prolapse – Prolapse of internal hemorrhoids is highly characteristic of more advanced and chronic hemorrhoidal disease. The prolapsed internal hemorrhoids may reduce spontaneously or may need to be reduced manually. In rare cases, they may prolapse through the anal canal and become incarcerated.
• Pain/discomfort – In the absence of thrombosis or incarceration, hemorrhoids are usually painless. Dull pain after defecation is common with prolapsed hemorrhoids and is relieved by reducing the prolapse. If someone is experiencing severe pain, a complication of hemorrhoids or another diagnosis, such as anal fissure, abscess, or rectal ulceration, must be considered.
• Discharge/Pruritus – Patients may experience mucoid anal discharge or fecal soilage as internal hemorrhoids prolapse through the anal canal. This irritation of the perianal skin can result in significant pruritus.

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.

Closed Haemorrhoidectomy

Closed hemorrhoidectomy is the surgical procedure most commonly used to treat internal hemorrhoids.

It consists of the excision of hemorrhoidal bundles using a sharp instrument, such as a scalpel, scissors, electrocautery, or even laser followed by complete wound closure with absorbable suture. Typically all three hemorrhoidal columns are treated at one time. Postoperative care includes frequent sitz baths, mild analgesics, and avoidance of constipation. Closed hemorrhoidectomy is successful 95% of the time.

Potential complications include pain, delayed bleeding, urinary retention/urinary tract infection, fecal impaction, and very rarely, infection, wound breakdown, fecal incontinence, and anal stricture. Although this technique has the most postoperative discomfort and pain, it does have the best long term results with the lowest recurrence rates. New methods are being devised to decrease the pain associated with the surgery and should allow for a better patient experience.

Open Haemorrhoidectomy

In an open hemorrhoidectomy, hemorrhoidal tissue is excised in the same manner as in a closed procedure, but here the incision is left open. Surgeons may opt for open hemorrhoidectomy when the location or amount of disease makes wound closure difficult or the likelihood of postoperative infection high. Often, a combination of open and closed technique is utilized. Complications following open hemorrhoidectomy are similar to those that occur after closed hemorrhoidectomy.

Stapled Haemorrhoidectomy for Prolapsing Haemorrhoids :

Stapled hemorrhoidectomy is the newest addition to the armamentarium of surgical internal hemorrhoid procedures. It has several aliases, including Longo’s procedure, the procedure for prolapse and hemorrhoids (PPH, Ethicon Endo-surgery, Inc., Cincinnati, OH), stapled circumferential mucosectomy, and circular stapler haemorrhoidopexy.

Stapled hemorrhoidectomy is mostly used in patients with grade III and IV hemorrhoids and those who fail prior minimally invasive treatments. During stapled hemorrhoidectomy, a circular stapling device is used to excise a circumferential ring of excess hemorrhoid tissue, thereby lifting hemorrhoids back to their normal position within the anal canal.

Stapling also disrupts hemorrhoid blood supply. Studies have suggested that stapled hemorrhoidectomy results in less postoperative pain and shorter recovery compared with conventional surgery, but a higher rate of recurrence. Frequency of complications is similar to that following standard hemorrhoidectomy.

Rubber Band Ligation

A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.

Aftercare

You can expect rectal and anal pain after undergoing hemorrhoid surgery. Your doctor will probably prescribe a painkiller to ease the discomfort.

You can aid in your own recovery by:

• eating a high-fiber diet
• staying hydrated by drinking eight to ten glasses of water each day
• using a stool softener so you won’t have to strain during bowel movements

Avoid any activities that involve heavy lifting or pulling.

Some people find that sitz baths help ease post-surgical discomfort. A sitz bath involves soaking the anal area in a few inches of warm water several times a day.

You can expect to make a full recovery within about 14 days.

When you follow up with your doctor, he or she will probably recommend:

• diet changes, such as eating foods high in fiber
• making lifestyle changes, such as losing weight
• adopting a regular exercise program

These adjustments will reduce the likelihood of hemorrhoids recurring.

Prognosis

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.