Anal vascular cushions are present in everyone and are believed to contribute, in small part, to overall anal continence.

The
term hemorrhoids is used to refer to these cushions when they become enlarged and symptomatic. [1]
These anal cushions are composed of plexuses of vessels within the anal canal that connect arterioles to veins without
intervening capillaries. They are also normally supported by smooth muscle fibers (Treitz muscle) and connective tissues in the
submucosa that help maintain their position in the upper half of the canal. Repeated stretching of these attachments causes
disruption and results in prolapse.[2] Anatomically, these major vascular cushions are typically located in 3 main positionsleft
lateral, right anterolateral, and right posterolateral. When hemorrhoids are symptomatic, smaller, secondary cushions may be
present between the main cushions. Hemorrhoids present above the dentate line are classified as internal hemorrhoids.
Hemorrhoids occurring below the dentate line are classified as external hemorrhoids. See the image below.

Anatomy of the anal transition zone and surrounding muscles.

External hemorrhoids are in sensitive anal canal skin and are painful, while internal hemorrhoids are in insensitive anal canal
mucosa and are painless (unless complicated).
The anal canal is completely extraperitoneal. The length of the (surgical) anal canal is about 3-5 cm, with two thirds of this being
above the dentate line and one third below the dentate line (anatomical anal canal). For more information about the relevant
anatomy, see Anal Canal Anatomy.

Development of hemorrhoids
Despite several years of study, the main etiology of hemorrhoidal disease is still largely unknown. Many proposed theories exist,
but the most common, and perhaps most accurate, pertains to the abnormal sliding of the vascular cushions that is associated
with straining and irregular bowel habits. Hard, bulky stools promote straining, which is more likely to push the cushions out of
the anal canal. Furthermore, straining may cause engorgement of the cushions during defecation, making their displacement
more likely. Congestion and hypertrophy of the anal cushions ensue, making them more prone to developing edema and
bleeding.[2]

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. [3]
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. [1, 3]
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. [1]

Complications
Thrombosis and infection
Thrombosis is the most painful complication of internal or external hemorrhoids. The pain is often severe enough to affect
routine daily activities. While it can occur in large, prolapsed hemorrhoids, thrombosis is more common in external hemorrhoids.
If the epithelium overlying the thrombosed hemorrhoid breaks down and allows invasion of bacteria, it may lead to infection,
which is rare.[3]
Anemia
The incidence of hemorrhoidal bleeding that results in anemia is low.

Classification of hemorrhoids
External hemorrhoids originate below the dentate line and are covered by squamous epithelium.
Internal hemorrhoids are located above the dentate line and are covered by transitional or columnar epithelium.
Internal hemorrhoids can further be divided into 4 categories determined by the extent of prolapse, as follows:

Grade 1: Hemorrhoids bulge into the lumen of the anal canal but do not descend below the dentate line.
Grade 2: Hemorrhoids prolapse below the dentate line with straining but reduce spontaneously. See the image below.

Grade 3: Hemorrhoids prolapse with straining or defecation and have to be reduced manually. See the images below.

Grade 2 hemorrhoids.

Grade 3 hemorrhoids.

Grade 3 hemorrhoids.

Grade 4: Hemorrhoids are permanently prolapsed and irreducible. See the image below.

Grade 4 hemorrhoids.

Although this grading system has limitations, it is beneficial to determine the efficacy of various forms of treatment.

Indications
External hemorrhoids
Thrombosed external hemorrhoids diagnosed within 72 hours of symptom onset may undergo excision of thrombus with
excellent results. Certain patients with thrombosis longer than 72 hours who still have maximal pain may see some relief, but the
clot is usually beginning to resorb and expectant management is appropriate. Overall, base the management on the severity of
the patient's symptoms at the time of diagnosis.[1]

Internal hemorrhoids
For the most part, symptomatic hemorrhoids are a quality of life issue. Start all patients with conservative management as
described below. If this fails to improve the patients' symptoms, offer a procedure.
Failed medical management is the primary indication for surgery. The authors usually offer escalating treatments, from least
invasive to most invasive. For bleeding hemorrhoids refractory to dietary modification, rubber band ligation is their preferred
treatment. Sclerotherapy and infrared coagulation are also options.
With prolapse of tissue, rubber band ligation requires multiple applications, so the authors offer hemorrhoid artery ligation (HAL)
or stapled hemorrhoidopexy (procedure for prolapse and hemorrhoids [PPH]). The authors prefer HAL in women, as there is less
dilation of the sphincter complex and no cutting of tissue. They believe that this provides a safe and effective treatment without
significant risk to the sphincter complex. With large prolapsing hemorrhoids, they offer PPH or excision. In patients with a large
external component, excision is the most effective option.
Symptomatic hemorrhoids affecting quality of life is the general indication for intervention. Symptoms include pain, bleeding, and
difficulty with hygiene. In some cases of patients on antiplatelet or anticoagulation therapy or patients with hemophilia, surgical
intervention is needed to prevent hemorrhage.

Anesthesia
Office procedures
The authors use lidocaine 1% with epinephrine for office excision of a clot from a thrombosed hemorrhoid. A standard bilateral
pudendal nerve block is used followed by injecting the perianal skin and mucosa. The authors do not use anesthetic for
sclerotherapy, rubber band ligation, or infrared coagulation.

Operative procedures
The authors prefer monitored anesthesia care (MAC) with local anesthetic. Most procedures are less than 25 minutes and they
can achieve moderate sedation until the block is complete and then lighten the sedation to reduce the risk of apnea.General
anesthesia with an endotracheal tube is required in patients at risk for apnea. If the patient is to be in lithotomy position, a
laryngeal mask airway (LMA) is preferred.
All patients should receive local anesthesia with lidocaine and bupivacaine with epinephrine before any incision, unless
contraindicated.

Bupivacaine liposome
A liposomal form of the local anesthetic bupivacaine (Exparel) was approved by the US Food and Drug Administration (FDA) in
October 2011. A single dose infiltrated into the surgical site produces postsurgical analgesia for hemorrhoidectomy. A total dose
of 266 mg (20 mL) diluted with 10 mL of saline (for a total of 30 mL) is used once for hemorrhoidectomy. The mixture is divided
into 6 aliquots (5 mL each). Perform the anal block by visualizing the anal sphincter as a clock face and slowly infiltrating 1
aliquot into each of the even numbers.

Equipment
Office equipment
The most common office procedures performed are sclerotherapy and rubber band ligation. In addition to whatever agent is
required for sclerotherapy, good lighting and anal retractors are required. The authors use Buie-Hirschmann anoscopes
(Hirschmann Rectal Specula) for office procedures. They prefer lighted retractors because they improve visualization. They do
not anesthetize for office procedures because they are working above the dentate line.
For rubber band ligation, use a grasping or suction technique. If using the grasping technique, the equipment needed includes a
McGivney ligator, grasping forceps, a loading cone, and rubber bands. If using a suction ligator, the equipment needed include a
suction apparatus, the suction ligator, and rubber bands.

Operating room equipment

The standard hemorrhoidectomy tray has basic instruments as well as basic retractors and a Bovie cautery. Standard excision
with open or closed technique requires no other specialized equipment. Again, the authors prefer lighted retractors because they
improve visualization; these are ordered separately.
If using other techniques such as LigaSure, Harmonic, THD, and PPH, these items and the appropriate supplies are purchased
separately.

Positioning
The patient can be treated in several positions. Choose the position in which the patient is the most comfortable.
In the office, the authors use a tilt table and do all office procedures in the prone-jackknife position. In their opinion this affords
the best lighting, is tolerated well by most patients, and allows excellent visualization of the anal canal. If a tilt table is
unavailable, the left lateral position, with the knee to chest and buttocks over the edge of the table is the most effective.
In the operating room, the authors also prefer the prone jackknife position. The authors routinely use this technique with MAC
and sedation. Place the patient in the prone jackknife position and give light sedation. Use a pudendal block and local analgesia
and then perform the procedure. In patients who are obese or have airway issues, either general anesthesia or lithotomy
position may be used. When the authors use lithotomy, they use Candy Cane stirrups as opposed to yellow fins or Allen stirrups,
as they provide better eversion of the perineum.

Technique
Medical management
Lifestyle and diet modification are best suited for patients with only minor symptoms and should be attempted before more
aggressive treatment is undertaken. In general, topical creams and suppositories are not effective.
Diet modification
Adding bulking agents in the form of fiber is the recommended first-line therapy, and a high-fiber diet should be encouraged.
However, compliance is an issue because many people are not motivated to adhere to a long-term, high-fiber diet. In this case,
doctors may prescribe psyllium seed extract or methylcellulose to facilitate the consumption of fiber in a more convenient way.
Adequate hydration must be encouraged as well. This is generally a good initial approach to reduce hemorrhoidal bleeding and
is most ideal for the treatment of grade 1 and some grade 2 hemorrhoids. [1, 2]

Office-based procedures
Sclerotherapy

The goal of sclerotherapy is to produce submucosal fibrosis so that prolapse is less likely to occur. The solutions commonly
injected are phenol, quinine urea, and sodium morrhuate. The popularity of sclerotherapy has gradually diminished in favor of
the more effective modalities.[1, 2]
Rubber band ligation
Rubber band ligation is a quick and effective office procedure for the treatment of internal hemorrhoids. The principle behind
rubber band ligation is similar to that of sclerotherapy, in that it results in fixation of the mucosa. The band leads to ischemic
necrosis and finally ulceration of the mucosa. The procedure is performed using an anoscope and a rubber band ligator. The
bands should be placed on the rectal mucosa above the hemorrhoidal group. No special bowel prep is required and multiple
groups can be banded during one session. The success rate of rubber band ligation is variable in the literature but has been
reported to be as high as 75%.[1, 3] More than one banding session may be required.
Infrared coagulation
The infrared coagulator uses heat to induce coagulation of an internal hemorrhoid. Like sclerotherapy and rubber band ligation,
the goals are to induce fibrosis and scarring of the hemorrhoids, preventing future bleeding and prolapse. [1] This procedure is
more expensive than rubber band ligation and requires specialized equipment. Like rubber band ligation, repeat procedures are
often required.

Operative treatment of hemorrhoidal disease

The classic operative approach, or criterion standard, is excisional hemorrhoidectomy. Excisional hemorrhoidectomy is broadly
classified as open or closed. The distinction is made by whether the anorectal mucosa is closed with sutures after the excision.
These procedures are indicated for patients who fail to improve after multiple attempts of nonoperative management or officebased procedures and patients who have markedly prolapsed hemorrhoidal disease (grade 3 and 4). Other procedures include
stapled hemorrhoidopexy and HAL.
All patients are told to take 2 Fleets enemas 2 hours before the procedure.
Excisional hemorrhoidectomy - closed technique
Position the patient in the prone jackknife position. Apply adhesive tape to the buttocks and to retract it laterally to aid in
exposure. Perform a bilateral pudendal nerve block and infiltrate the perianal skin and mucosa with lidocaine 1% or bupivacaine
0.5% with epinephrine. Insert a Hill-Ferguson retractor for inspection of the anal canal and distal rectum. Grasp the prolapsed
hemorrhoid in a Kelly clamp and retract toward the center of the anal canal. The authors prefer the Kelly clamp to visualize the
internal anal sphincter and ensure they are not too deep. Place a 2-0 chromic suture in a figure eight manner above the pedicle
first as this decreases blood loss. Mark an elliptical incision with the knife from the external component of the hemorrhoid group
to the proximal end of the clamp. Excise the hemorrhoid with scissors or electrocautery.
This technique allows excision without injury to the underlying internal sphincter muscle. Complete the excision with cautery for
hemostasis. Finally, close the wound with a running, absorbable 2-0 suture, beginning at the apex of the wound with a locking
stitch. The authors usually use the original stitch from ligating the pedicle. Small bites of internal sphincter muscle are included in
the closure to decrease dead space. They often close the incision in an inverted T-shape to ensure no stenosis of the anal canal.
See the image below.

Surgical excision of hemorrhoids.

Excisional hemorrhoidectomy - open technique

Place the patient in the lithotomy or prone position and prep and drape the area. Inject local anesthesia as described above.
Place a lighted Hill-Ferguson retractor. Grasp the component of hemorrhoidal tissue that is covered by skin with a Kelly clamp.
Pull the hemorrhoid downward, prolapsing the hemorrhoid tissue completely out of the anus, making visible the rectal mucosa
superior to the hemorrhoid. Use a 2-0 chromic suture to ligate the vascular pedicle as described above.
Excise the hemorrhoid from the underlying sphincter muscle proximally to its apex. Leave the wound open and apply a
nonadherent dressing.
The patient is advised to change the outer gauze daily as needed. The packing may be removed in 24 hours. Stool softeners
can be used to ensure a more comfortable first bowel movement. Non-narcotic analgesics can be used to alleviate pain. Pain is
usually mild during the initial days following the procedure but is exacerbated by bowel movements. Sitting in a warm bath
immediately after having a bowel movement may decrease pain.
The patient should be seen for a postoperative visit 4-6 weeks after the procedure; at this point they can tolerate a rectal
examination, which is necessary to ensure that there is no stenosis. If stenosis is present, the daily use of an anal dilator is
recommended.
Alternative energy devices
Recently, the LigaSure (Coviden), a bipolar cauterizing device, and the Harmonic Scalpel (Ethicon), an ultrasonic energy device,
have gained popularity. These techniques use bipolar diathermy and ultrasound energy, respectively, to completely coagulate
the vessels while limiting thermal spread and excess tissue injury. The risk of infection and postoperative pain may be reduced
when compared with the standard techniques.
Randomized trials have shown that the LigaSure technique is faster and generally produces less blood loss and pain when
compared with the conventional hemorrhoidectomy. Information on long-term follow-up is not yet available. [2]
Stapled hemorrhoidopexy
During stapled hemorrhoidopexy, remove a ring of mucosa and submucosa approximately 4-5 cm from the dentate line using a
specific PPH circular stapler. "Pexy" the distal mucosa to the proximal mucosa with the stapling device. The procedure also
interrupts the arterial blood supply to the hemorrhoids, allowing involution of the hemorrhoidal plexus. The early experience with
this technique found it to be safe and effective. Since all the work is done above the dentate line, there is less pain than with
conventional excision. Studies have shown significant reduction in postoperative pain, a quicker recovery and earlier return to
work, and few complications. Long-term studies suggest that recurrence may be higher relative to conventional
hemorrhoidectomy.[1, 3, 2] See the images below.

Source: Roswell M, Bello M, Hemingway DM. Circumferential

mucosectomy (stapled hemorrhoidectomy): randomized, controlled trial. The Lancet, Vol. 355, Mar 4, 2000;779-781.

Source: Hetzer N, Demartines N, Handschin AE. Stapled vs.

excision hemorrhoidectomy, long-term results of a prospective randomized trial. Archives of Surgery. 2002.

Stapled hemorrhoidopexy - technique

The preparation of the patient is the same as conventional hemorrhoidectomy. Position the patient either in the prone jackknife
or lithotomy position. General anesthesia is typically used, although the procedure may also be done with MAC and local
anesthesia as described above. Inject local anesthesia as described. Evert the anoderm slightly and insert a circular anal dilator
and anoscope, which reduces the prolapse. Remove the dilator and the mucosa that was prolapsed falls into the lumen of the
anoscope, which is transparent to facilitate easy visualization of the dentate line.
Place an anal retractor and place a 2-0 Prolene purse string suture in the mucosal layer at least 4-5 cm proximal to the dentate
line. Assess the complete purse string via digital examination. Feel the mucosa circumferentially as the string is pulled. No
suture should be felt. Open the dedicated 33-mm hemorrhoidal circular stapler fully and introduce it into the anal canal proximal
to the purse string, which is then tied. Pull the threads through the holes on the sides of the stapler and knot or hold with forceps.
Close the stapler while holding traction on the sutures and gently pull outward.
Once the stapler is completely closed, wait one minute for hemostasis and vessel compression. If this procedure is being
performed on a woman, a vaginal examination should be performed before firing the stapler to make sure there is no vaginal
entrapment in the device. After firing and removing the stapler, use the retractor to examine the staple line, and if there is any
bleeding or gaps, place sutures at this time. [3, 2] Do not pack. Place dry gauze on the anal verge and keep it in place with mesh
underwear. See the images below.

PPH stapled hemorrhoidectomy: anatomy of the anal canal.

PPH stapled hemorrhoidectomy: prolapsed internal hemorrhoids.

PPH stapled hemorrhoidectomy: purse-string suture placed 4-5 cm

above dentate line.

PPH stapled hemorrhoidectomy: retracting and operating

anoscopes.

PPH stapled hemorrhoidectomy: placing pursestring suture.

PPH stapled hemorrhoidectomy: schematic of circumferentially

excised mucosa.

PPH stapled hemorrhoidectomy: schematic of approximated

mucosa.

PPH stapled hemorrhoidectomy: completed procedure.

PPH device through purse string suture.

PPH stapled hemorrhoidectomy: A) stapler inserted through purse string and B) excised mucosa and
stapler.

PPH stapled hemorrhoidectomy: completed procedure.

Stapled hemorrhoidopexy - postoperative management

Advise the patient to change the outer gauze daily as needed. Stool softeners can be used to ensure a more comfortable first
bowel movement. Pain is usually most severe in the first 72 hours after the procedure and can be alleviated with non-narcotic
analgesics. Pain is not exacerbated by bowel movements.
See the patient for a postoperative visit 4-6 weeks after the procedure, as at this point they can tolerate a rectal examination.
Hemorrhoid artery ligation
Excision of anal tissue by any means requires a good deal of prudence. The anal sphincter is at risk for being damaged if the
depth of the excision is too great. A technique recently introduced is known as Doppler-guided hemorrhoid artery ligation (HAL).
Two platforms are currently available in the United States, transanal hemorrhoidal dearterialization (THD) and one from the
Agency for Medical Innovations (AMI). The authors have been using THD for the past 4 years. The procedure involves Doppler-

guided ligation of the arteries supplying the hemorrhoidal cushions, thereby decreasing the pressure within the plexus
hemorrhoidalis. A hemorrhoidopexy can then be performed if there is redundant mucosa. Since the introduction of endorectal
Doppler-guided THD in 1995 by Morinaga, several reviews of this therapy have been completed. This technique has evolved
over the past decade, and it is being recognized as both a safe and effective means to treat symptomatic grade 2-4
hemorrhoids.
Hemorrhoid artery ligation - technique
Place patients either in the prone jackknife or lithotomy position. Patient preference and comorbidities dictate the anesthetic
plan. Give local anesthetic to all patients. The kit includes a lighted anal retractor with Doppler, needles, and a needle driver.
Place the THD device into the anal canal. Use the Doppler probe to identify pulsatile arterial segments. Load the provided
absorbable suture to the appropriate marks on the needle driver and then use the suture to ligate the artery with 2 bites until the
Doppler signal is obliterated. If there is redundant hemorrhoidal tissue, remove the Doppler slide and perform a
hemorrhoidopexy using the same suture running distally. Never come closer than 1 centimeter from the dentate line. [4]
Duplicate the procedure circumferentially until all signals are obliterated. Six to seven separate bites are commonly required. Do
not pack or place gauze. Patients are discharged the same day. See the images below.

Hemorrhoid artery ligation device from THD America.

THD America slide: The needle is premeasured to ligate the

hemorrhoidal arteries.

Hemorrhoid artery ligation - postoperative management

Stool softeners can be used to ensure a more comfortable first bowel movement. Pain is usually most severe in the first 72
hours after the procedure and can be alleviated by non-narcotic analgesics. Pain is not exacerbated by bowel movements.
See the patient for a follow-up visit 4-6 weeks after the procedure.

Pearls
Overview
When dealing with patients with hemorrhoids, isolating the predominant symptom is extremely important. Patients may have
external tags and complain of bleeding, so a simple rubber band ligation may suffice. Always tailor the therapy to the specific
symptoms, as hemorrhoids are a quality of life issue.

Office procedures
Patient comfort is the key to success. Nothing is worse for a patient than undergoing a procedure of the anorectum. Lidocaine
ointment is good to use for a rectal examination and allows some local analgesia. Placing the anoscopes slowly and allowing the
anorectal inhibitory reflex to initiate allows for easier placement. Always have all the equipment ready and have back-up
materials (second rubber band ligator) ready. After the procedure, allow the patients a few minutes to rest. Beware of a
vasovagal response. Patients who get nauseated or have excessive sweating during the procedure are at risk for a syncopal
episode.

Operations
Injecting local anesthetic with epinephrine decreases bleeding. Always remember to aspirate first so that epinephrine is not
injected into a blood vessel. When injecting the mucosa, elevate it off the internal sphincter with the injection to help ensure the
sphincter is not clamped during an excisional hemorrhoidectomy.
During a stapled hemorrhoidopexy, evert the anal canal with 4 silk sutures prior to placing the dilator. It brings the dentate line
closer to the anal verge, decreasing the possibility of incorporating anoderm into the staple line. If a large amount of redundant
mucosa is present, place a small sponge into the anal canal before inserting the anoscope, as it will allow better visualization of
the operative field.

During HAL procedures, make sure the hemorrhoidopexy is not too close to the dentate line; leaving at least a 1-centimeter
margin will help decrease postoperative discomfort.

Office-based procedures
Sclerotherapy, rubber band ligation and infrared coagulation have similar morbidities. Potential complications include pain,
urinary retention, bleeding, and local sepsis. Complications are generally due to poor placement of injections, rubber bands, and
the coagulator.
Bleeding, which is usually limited, may also occur as the mucosa sloughs off and an ulcer forms. This may especially be true in
patients continuing antiplatelet medications after treatment. Perianal sepsis after rubber band ligation has been reported. This
dreaded complication is exceedingly rare in patients that are not immunocompromised.

Acute postoperative complications

Pain
Pain is an important factor in a patients decision whether or not to undergo hemorrhoidectomy. However, postoperative pain is
very dependent on the individual patient. Therefore, it is natural for surgeons to want to use a procedure that produces as little
pain as possible.[3] Newer techniques like PPH and HAL have been shown to cause significantly less pain when compared with
the conventional techniques.
Urinary retention
Urinary retention can occur in up to 15% of patients posthemorrhoidectomy.[3] Many factors are thought to contribute to urinary
retention following hemorrhoidectomy, with pain being a major contributor. Perioperative restriction of fluid intake has been
shown to reduce the need for catheterization. In general, most patients have no further issues after 1 catheterization. Men with
enlarged prostates may require an indwelling Foley catheter for up to 72 hours.
Bleeding
Bleeding is often minor and can be stopped with external pressure. If the location of the bleeding is uncertain, or if the patient
becomes hemodynamically unstable with undetected bleeding, he or she should be examined in the operating room
under general anesthesia. After the rectum is irrigated with sterile saline, the bleeding site should be ligated under direct vision.

Chronic complications
Poor wound healing
An anal fissure or ulceration, although rare, may develop if one of the hemorrhoidectomy sites fails to heal properly. If it
develops, supplemental fiber, nitroglycerin ointment, and diltiazem creams may be used to aid healing. [3] Stools should be kept
soft. Healing generally occurs without further intervention.
Abscess or fistula
Anorectal sepsis formation is rarely reported following hemorrhoid procedures. In these cases, the wound should be examined
under anesthesia and reopened to promote continued drainage.
Incontinence
Frank incontinence is rare, although some patients experience leakage and soiling from the anus that usually resolves by 6
weeks to 2 months.[3] There are not enough data to meaningfully comment on the incidence after stapled hemorrhoidopexy or
HAL.
Anal stenosis

This complication is uncommon and can be prevented in most cases by leaving significant mucosal bridges between excision
sites. Using a closed technique with a retractor in place ensures adequate room in the anal canal.
If any narrowing of the anal canal is observed during the first postoperative visit, encourage the patient to use an anal dilator
along with diet modification. Anoplasty may be considered if the anus cannot be easily dilated and medical treatment has failed. [3]

Postoperative Care after Hemorrhoidectomy, Hemorrhoidectomy

Complications
Print

Postoperative Care after Hemorrhoidectomy

After surgery, the patient is taken to the postanesthesia care unit (PACU). Patients are closely monitored by the
nursing staff and remain there until they are stable. The amount of time spent in the PACU depends on the
patient's progress and the type of anesthesia received. General anesthesia must wear off and the patient must
be awake and coherent before they leave the PACU.
Outpatients are transferred to another room to finish their recovery, and inpatients are taken to their hospital
room. The intravenous line remains in until clear liquids are taken and tolerated. This can be almost immediately
following surgery, especially if local anesthesia was used. Sometimes general anesthesia induces nausea, which
may delay taking oral fluids. Once clear liquids are tolerated, the diet progresses to solid foods.
Spinal anesthesia usually wears off within a few hours. During the first hour following surgery, patients lie flat on
their back to decrease the risk for an anesthesia-induced headache, which can be painful and prolonged. Before
being discharged, the patient must regain full sensation in the lower part of the body.

Because of swelling and the dressing, some patients have temporary difficulty urinating. If there is urgency, but
the urine will not flow, a catheter is used to empty the bladder. Outpatients may need to stay overnight, if they
are unable to urinate. Patients must be able to urinate on their own before being discharged.
Even though the anesthesia has worn off, most patients remain groggy for the rest of the day. Patients must
arrange for a family member or friend to be with them if they are being discharged the same day as the surgery.
Patients experience pain and discomfort during the immediate postoperative period (i.e., about 10 days). Pain
medication is prescribed and should be taken as directed. Sometimes relief can be achieved with an over-thecounter preparation such as Tylenol. If a pack was inserted into the rectum following surgery, the physician
usually removes it in a day or two.

An ice pack can help reduce swelling. Soaking in a sitz bath (a shallow bath of warm water) several times a day
helps ease the discomfort. Using a doughnut ring (cushion with a hole in the middle) can make sitting upright
more comfortable.

It is important to avoid constipation at this time so, the physician will prescribe stool softeners and a laxative.
Eating a high-fiber diet and drinking plenty of liquids also helps. A small to moderate amount of bleeding,
usually when having a bowel movement, may occur for a week or two following the surgery. This is normal and
should stop when the anus and rectum heal.
Complete recovery takes 6 weeks to 2 months. Most patients return to work within 10 days. Heavy lifting should
be avoided for 2 to 3 weeks.

Hemorrhoidectomy Postoperative Complications

Most patients are satisfied with the results of the surgery and recover without any problems. Complications
associated with hemorrhoidectomy are rare and include:

Anal fistula or fissure

Constipation

Excessive bleeding

Excessive discharge of fluid from the rectum

Fever of 101F or higher

Inability to urinate or have a bowel movement

Severe pain, especially when having a bowel movement

Severe redness and/or swelling in the rectal area

Side effects of anesthesia (e.g., spinal headache)

The surgeon should be notified if any of these symptoms are experienced during the immediate postoperative
period.

Scalpel Handle for Blades No 10 thru 15

The handle comes with a scale and is designed to fit surgical blade
nos. 10 thru 15.

Qty: 2

McGivney Hemorrhoidal Ligator, 7in

McGivney Hemorrhoidal Ligator, Complete w/ Loading Cone 100 O
Rings - 7in Working Length

Qty: 1
McGivney Hemorrhoidal Grasping Forceps,

Brinckerhoff Rectal Speculum, Medium, 4-

7.5in

1/2in x 1in

McGivney Hemorrhoidal Grasping Forceps, Angled Shanks, 7.5in

Qty: 1

Qty: 1
Backhaus Towel Clamps, 5-1/4 in

Qty: 6

Fansler Speculum
Fansler (Ives) Speculum, 7/8in x 3-1/8in

Qty: 1

Metzenbaum Lahey Scissors 5-1/2 in, TC-

Blades

Halstead-Mosquito Forceps, Straight, 5 in

Qty: 4

Qty: 1

Foerster Sponge Forceps, Straight, Smooth,

9-1/2 in
These sponge forceps have serrated jaws.

Qty: 1

Hirschman Anoscope Medium

Hirschman Anoscope, Medium, 3/4in x 2-3/8in

Qty: 1

Allis Tissue Forceps, 4x5 Teeth, 6 in

Qty: 2
10in

Sawyer Rectal Retractor, Small, 2-1/2in x 7/8in,

Qty: 1

Sawyer Rectal Retractor, Large, 3-1/2in x 11/2in

Qty: 1

Dressing Forceps, 5-1/2 in, Serrated Tips

Qty: 1

Tissue Forceps, 1 x 2 Teeth, 5-1/2 in

Qty: 1