Chapter 26. Benign Anorectal Procedures

Hemorrhoidectomy

• Internal hemorrhoids: grade III and IV hemorrhoids, symptomatic combined internal and external hemorrhoids, bleeding, incarceration, or failure of conservative management.
• External hemorrhoids: acute thrombosis < 72 hours post-onset.

Pilonidal Cyst Excision and Marsupialization

• Recurrent acute pilonidal infections.
• Chronic pilonidal sinus.

Anorectal Abscess and Fistula

• Acute perirectal abscess.
• Anorectal fistula.

Hemorrhoidectomy

Absolute

• Anorectal Crohn's disease or Crohn's proctitis.
• Acquired immunodeficiency syndrome.

Relative

• Portal hypertension.
• Pregnancy.
• Coagulopathy.

Pilonidal Cyst Excision and Marsupialization

• The presence of cancer requires additional treatment.

Anorectal Abscess and Fistula

• Multiple fistulous tracts in a patient with Crohn's disease may require additional studies of the colon and sphincter mechanism prior to definitive surgical treatment.

Hemorrhoidectomy

Expected Benefits

• Resolution of hemorrhoids and symptoms.

Potential Risks

• Common complications include significant postoperative pain, urinary retention, bleeding, incontinence, infection, and anal stenosis.
• Risk of bleeding is increased with emergent hemorrhoidectomy, during pregnancy, and in patients with portal hypertension or coagulopathy.
• Rectal perforation, rectovaginal fistula, and retroperitoneal and pelvic sepsis are rare risks of circular stapled hemorrhoidopexy and may be avoided with proper technique.

Pilonidal Cyst Excision and Marsupialization

Expected Benefits

• Resolution of cyst and infection.
• Prevention of recurrence.

Potential Risks

• Primary cyst excision with marsupialization requires daily wound scrubbing and strict attention to shaving hair in wound proximity.
• Time to healing may be several months.
• Rate of recurrence is approximately 6%.
• Rate of wound breakdown is 2–3%.

Anorectal Abscess and Fistula

Expected Benefits

• Resolution of abscess or fistula.

Potential Risks

• Common complications of surgery include:
  • Fistula in ano.
  • Abscess.
  • Incontinence due to iatrogenic sphincter injury.

• No special equipment is required for hemorrhoidectomy, pilonidal cyst excision, or the treatment of anorectal abscess and fistula.

Circular Stapled Hemorrhoidopexy

• 33-mm hemorrhoidal circular stapler.

Hemorrhoidectomy

• Thorough preoperative workup to confirm diagnosis, hemorrhoid grade, and symptomatic status is essential before recommending hemorrhoidectomy.
• If bleeding is the indication for hemorrhoidectomy, examination of the colon and rectum for other potential sources of bleeding may be indicated.
• In patients with portal hypertension, hemorrhoids must be distinguished from anorectal varices.
• The rectum may be evacuated with an enema immediately before the operation.

Pilonidal Cyst Excision and Marsupialization

• Digital rectal examination ...