Plate 226

Indications

This is an office procedure generally reserved for grade 1 or 2 hemorrhoids with minimal symptoms. The anatomy of internal and external hemorrhoids is shown in Figure 1.

Preparation

Fleets enema. No anesthetic is necessary.

Position

The patient is usually placed in a standard kneeling position on a Ritter table, although this may also be done in the left lateral position.

Details of Procedure

The hemorrhoidal bander is prepared with two rubber bands loaded. After digital examination, a Hirschman anoscope is inserted in the anal canal, the obturator removed, and the internal hemorrhoids are evaluated. After evaluation, which includes inspection of the internal hemorrhoids in their cardinal positions (right anterior, right posterior, and lateral), a decision is made as to which hemorrhoid is the most suitable for banding. This is usually the largest hemorrhoid. The Hirschman anoscope is positioned over the target hemorrhoid to allow prolapsed into the anoscope. Care must be taken to ensure that the site of the banding is above the dentate line. An Allis clamp is first placed through the Hirschman anoscope to test the area (Figure 2A). The hemorrhoid in question is grabbed with the Allis clamp. If the patient has significant discomfort, the clamp is too far distal and needs to be moved more proximal. Once the correct position of the clamp is determined, the bander is placed through the Hirschman anoscope, and the hemorrhoid is prolapsed with the Allis clamp into the bander (Figure 2B). If there is no discomfort, the bander is fired, and the band is placed on the hemorrhoid. The instruments are then removed.

It is generally unsafe to place more than one or two bands at any one sitting. If more than two hemorrhoids are banded, they should be done at two or more office visits over the course of a couple of months. It is not unusual for the symptoms to improve after a single banding. Banding the largest hemorrhoid involved will sometimes resolve the patient's symptoms for a significant period of time.

Postoperative Care

The patient will usually report some bleeding when the hemorrhoid sloughs in four to seven days, which is entirely normal. However, the patient should be instructed to call immediately if he or she develops urinary retention or fever, as these may be early indications of pelvic sepsis.

Indications

Hemorrhoidectomy is usually an elective procedure performed in good-risk patients with persistent symptoms referable to proven hemorrhoids. Bleeding, protrusion, pain, pruritus, and infection are the more common indications when palliative medical measures have failed. Large external skin tags may require removal because of local pruritus. In the female, a pelvic examination is made to eliminate tumor or pregnancy as the etiology. In the male, the status of the prostate gland must be thoroughly evaluated. In older patients, a thorough colonoscopy or sigmoidoscopy and barium enema are mandatory. The presence of a serious systemic disease, such as cirrhosis of the liver, or a probable short life expectancy from advanced age or any other cause should be a general contraindication to operation unless anal symptoms are marked.

Simple internal hemorrhoids that prolapse may be treated by rubber banding using the technique shown in Figure 2A and B. After insertion of an anoscope, the internal hemorrhoid is grasped with an Allis-like clamp inserted through the banding instrument, which has been preloaded with two rubber bands. The area is pinched to be sure it is pain free. As the forceps or suction draws the hemorrhoid into the instrument, it is fired. The constricting rubber bands strangulate the hemorrhoid and both are then silently passed a few days later.

Preparation

A thorough cleaning enema is given the night before or early the morning of operation, preferably several hours before operation, since residual enema fluid is more disturbing than the presence of a small amount of dry fecal material.

Anesthesia

Spinal, epidural, or local anesthesia is satisfactory. If an inhalation anesthesia is given, it should be remembered that dilatation of the anus stimulates the respiratory centers. Spinal anesthesia must be used with caution because it may so completely relax the anal sphincter such that it cannot be properly identified by palpation.

Position

The positioning of the patient depends on the type of anesthesia used. With spinal anesthesia, the prone jackknife position affords the surgeon the best exposure. If general anesthesia is used, an exaggerated dorsal lithotomy position is preferred, with the buttocks extending beyond the edge of the table and the legs held in stirrups.

Operative Preparation

Extensive dilatation of the anus before hemorrhoidectomy is undesirable because it distorts the anatomy, making it impossible to remove all hemorrhoids at one operation without fear of stenosis. Gentle dilatation may be used if no more than three hemorrhoids are removed at one time.

Details of Procedure

Anoscopy is done, and any associated pathology is identified so that hypertrophied papillas or deep crypts may be removed.

The anal canal may be gently dilated to about two fingers' width to permit adequate exposure. A suitable self-retaining retractor is inserted into the canal, and further inspection is made. A gauze sponge is introduced into the rectum, and the retractor is withdrawn (Figure 3). The surgeon makes gentle traction on the sponge, reproducing, in effect, the passage of a bolus through the canal. As the sponge is withdrawn, the prolapsing hemorrhoids may be identified and are picked up with hemorrhoid clamps (Figure 4). Clamps are placed on all the prolapsing hemorrhoids and left in place as markers during the operation. Opposite the hemorrhoid a straight hemostatic forceps is placed on the anal verge, which is the external boundary of the anal canal. The hemorrhoid is placed under tension by simultaneous traction on the forceps and the hemorrhoid clamp (Figure 5). A triangular incision is made from the anal verge to the pectinate line (Figure 6). By traction on the two clamps and careful blunt and sharp dissection with the scalpel, it is possible to dissect off the triangular area of skin and the hemorrhoidal tissue from the outer edge of the external sphincter muscle. Many small fibrous bands will be found running upward into the hemorrhoidal mass. These represent the continuation downward of the longitudinal muscle and may be divided with impunity (Figure 7). Dissection is carried to the outer edge of the external sphincter. The anal skin must be divided to and slightly beyond the pectinate line. There now remain mucosa and the deep veins entering the hemorrhoidal mass. The tissue is secured with a straight clamp and a transfixing suture is placed at the apex of the hemorrhoidal mass (Figure 8). The hemorrhoidal tissue is removed with a knife, and an over-and-over continuous suture is made in the mucosa (Figure 9). The clamp is removed and a continuous suture approximates the mucosa, including the two edges of the pectinate line. As the suture is continued externally, small bites are taken in the external sphincter muscle (Figure 10). The deep portion of the skin is closed by a subcutaneous approximation (Figure 11), and the skin edges are left open to provide for better drainage and prevent postoperative edema (Figure 12).

Each hemorrhoidal mass is similarly removed. All possible mucosal tissue must be preserved to prevent stenosis. However, relatively large areas of skin may be safely removed in the triangular incision.

With extensive hemorrhoids it may be necessary to excise one-half of the mucosa of the entire canal in this fashion. The triangular incision may extend from the anal verge and reach the pectinate anteriorly and posteriorly. The mucosa is divided horizontally, taking small bites of tissue in a series of hemostats (Figure 13). This mucosal flap is sutured into the external sphincter horizontally to prevent stenosis (Figure 14). All redundant incisional skin margins should be excised to minimize the subsequent development of potentially damaging perianal skin tabs.

Postoperative Care

A sterile protective dressing is applied to the anus. Petrolatum may be applied locally. The diet is restricted for the first 2 or 3 days, but by the third day the patient may be allowed a full diet. Mineral oil (30 mL) is given. The patient is encouraged to have a bowel movement and usually will do so by the third day. Local application of heat is useful in alleviating discomfort. The patient may take sitz baths as desired. Weekly anal dilatation may be needed postoperatively until healing is complete.

Indications

Thrombosed hemorrhoids usually occur from straining or significant downward pressure. Often, individuals who have done heavy lifting or women late in their pregnancy may experience thromboses. These patients usually complain of significant pain. Diagnosis is made by inspection. The thrombosed hemorrhoid will generally be located in either the right lateral or the left lateral position. Depending upon the size of the hemorrhoid, removal might be accomplished successfully in the office. If the thrombosed hemorrhoid has been present for more than a couple of weeks, it may be unnecessary to do anything, as these will usually resolve with time. Occasionally, thrombosed hemorrhoids will present with extrusion of the clot and possible contamination, and in cases such as this, they should be removed.

Procedure

Once the decision is made to remove the thrombosed hemorrhoid in the office, the patient should be placed on the Ritter examination table in the standard kneeling position. With an assistant, hold the buttock apart to expose the anal canal and the thrombosed hemorrhoid. The area is first painted with betadine, and then injected with 2 to 3 mL of 1.0% xylocaine with epinephrine. This will provide both good analgesia and allow the patient comfort on the way home. The hemorrhoid is then grasped with a small hemostat and using dissecting scissors, excised using an elliptical incision (Figure 15). It is important to excise, and not to simply incise, the hemorrhoid as much as possible, to prevent further clot re-accumulation. This may be facilitated by using a small curette (Figure 16). The open wound is not closed. It is treated with silver nitrate and a pressure dressing placed. The patient is instructed to keep the dressing on until the next morning or bowel movement and to begin sitz baths the next day.