Surgery for Hemorrhoids

Surgical Classification of Hemorrhoids


Hemorrhoids (piles) arise from congestion of internal and/or external venous plexuses around the anal canal. They are classified, depending on severity, into four degrees. First degree hemorrhoids bleed but do not prolapse outside of the anal canal; second degree prolapse outside of the anal canal, usually upon defecation, but retract spontaneously.
Third degree hemorrhoids require manual placement back inside of the anal canal after prolapsing, and fourth degree hemorrhoids consist of prolapsed tissue that cannot be manually replaced and is usually strangulated or thrombosed.

Symptoms associated with hemorrhoids include pain, bleeding, puritus ani (itching) and mucus discharge. In IV degree prolapse, the area where the rectal mucous membrane meets the anal skin (the dentate line) is positioned almost outside the anal canal, and the rectal mucous membrane permanently occupies the muscular anal canal.

For more detailed about information, about the concepts of hemorrhoidal anatomy as applied to rectal surgery, view our video on Overview: Anatomy of Prolapse and Hemorrhoids > get Real Player , an alternative approach to the surgical treatment of hemorrhoids. In order to explain the rational of the surgical procedure for prolapse and hemorrhoids it is helpful to take a moment to review some concepts of anatomy.

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Traditional Surgery

In many cases hemorrhoidal disease can be treated by dietary modifications, topical medications and soaking in warm water, which temporarily reduce symptoms of pain and swelling. Additionally, painless non-surgical methods of treatment are available to most of our patients as a viable alternative to a permanent hemorrhoid cure.

In a certain percentage of cases, however, surgical procedures are necessary to provide satisfactory, long-term relief. In cases involving a greater degree of prolapse, a variety of operative techniques are employed to address the problem.

Milligan-Morgan Technique
Developed in the United Kingdom by Drs. Milligan and Morgan, in 1937. The three major hemorrhoidal vessels are excised. In order to avoid stenosis, three pear-shaped incisions are left open, separated by bridges of skin and mucosa. This technique is the most popular method, and is considered the gold standard by which most other surgical hemorrhoidectomy techniques are compared.

Ferguson Technique
Developed in the United States by Dr. Ferguson, in 1952. This is a modification of the Milligan-Morgan technique (above),
whereby the incisions are totally or partially closed with absorbable running suture.

Furgeson Technique

A retractor is used to expose the hemorrhoidal tissue, which is then removed surgically. The remaining tissue is either sutured or is sealed through the coagulation effects of a surgical device.

Due to the high rate of suture breakage at bowel movement, the Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain, or postoperative morbidity.

Conventional haemorrhoidectomy can be performed as a day-case procedure. But due to poor post-operative care in the community and high level of pain experienced after the procedure, an in-patient stay is often required (average of 3 days).

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Complications of Hemorrhoid Surgery

Early Complications Include:
1) Severe postoperative pain, lasting 2-3 weeks. This is mainly due to incisions of the anus, and ligation of the vascular pedicles.
2) Wound infections are uncommon after hemorrhoid surgery. Abscess occurs in less than 1% of cases. Severe necrotizing infections are rare.
3) Postoperative bleeding.
4) Swelling of the skin bridges.
5) Major short-term incontinence.
6) Difficult urination. Possibly secondary to occult urinary retention, urinary tract infection develops in approximately 5% of patients after anorectal surgery. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study).

Late Complications Include:
1) Anal stenosis.
2) Formation of skin tags.
3) Recurrence.
4) Anal fissure.
5) Minor incontinence.
6) Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and narcotic use. Most surgeons recommend stimulant laxatives, or stool softeners to prevent this problem. Removal of the impaction under anesthesia may be required.

7) Delayed hemorrhage, probably due to sloughing of the vascular pedicle, develops in 1 to 2 percent of patients. It usually
occurs 7 to 16 days postoperatively. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for one or more stitches.

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Knowing What to Ask Your Surgeon

Before choosing the procedure you wish to have performed, there are questions you should ask the surgeon:

1. What types of procedures have they performed?
2. How many of each procedure have they performed?
3. Why are they recommending one particular procedure over another?
4. How long will the procedure take?
5. Will this procedure require a hospital stay and how long
do they anticipate your hospital stay will last?
6. How long do they expect the recovery process to take?
7. How soon will you be able to return to “normal” activity?
8. Will having the procedure mean having to change how I live, work or eat?

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References

1. Endo-Surgery Inc, 2001, Ethicon Endosurgery, Procedure for Prolapse and Hemorrhoids, 2001

2. The University of Birmingham, National Horizon Scanning
Centre, Stapled Haemorrhoidectomy, United Kingdom, 2001

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Video References
1. Video: Overview: Anatomy of Prolapse and Hemorrhoids (3 1/2 minutes), Ethicon
Endo-Surgery Inc. 2001, get > Real Player,

2. Video: View
Actual Hemorrhoid Surgery using the Harmonic Scalpel
(8minutes), Ethicon Endo-Surgery Inc. 2001,

3. Video: Harmonic Scalpel & Laser Hemorrhoidectomy

(5 minutes), Rick Shacket, DO. 2002, get > Real Player

4. Video: Hemorrhoid Surgery Tutorial – The National Library of Medicine
http://www.nlm.nih.gov/medlineplus/tutorials/hemorrhoidsurgery/htm/index.htm

5. Video: General Anesthesia Tutorial – The National Library of Medicine
http://www.nlm.nih.gov/medlineplus/tutorials/generalanesthesia/htm/index.htm