Overview of Hemorrhoidectomy
Hemorrhoids are a quite common condition, though we don’t know exactly how prevalent they are because many people who have them show no symptoms and usually don’t seek medical help. The estimated number of people who have to undergo surgery to deal with their hemorrhoids is about 10%. The condition tends to affect Americans, particularly individuals between 45 and 65 years old, and it is estimated that about 4.4% of them show symptoms.
Hemorrhoids are found inside the anus and consist of swollen veins that help control bowel movements. They are similar to varicose veins you might see on someone’s legs. However, despite this, the causes of hemorrhoids are not completely understood.
There are different types of hemorrhoids and they can be categorized based on their location and severity. Hemorrhoids located inside the anus are referred to as internal, while those found near the opening of the anus are called external. The severity of internal hemorrhoids is graded from I to IV based on the size and how far they stick out from the anus.
Common symptoms of internal hemorrhoids include painless bleeding that results in bright red streaks in the stool, itching in the anus, discomfort, or lumps of tissue that look like small grapes hanging down from the anus. On the other hand, external hemorrhoids usually do not cause any symptoms, unless a blood clot forms in the vein, a condition known as thrombosis, making them very painful.
To identify and determine the correct treatment for hemorrhoids, medical professionals will ask about symptoms, their duration and intensity. Their treatment can range from changes in diet, medication, or even surgery, depending on their location and severity. Increasing fiber intake is the first recommendation usually given to treat mild hemorrhoids, consuming 20 to 25 grams of it daily to soften the stool which eases its passage and reduces pressure on the affected veins.
For internal hemorrhoids of grade 1 and 2 not responding to medical treatments, procedures like rubber band ligation and infrared coagulation are usually recommended. Rubber band ligation involves placing rubber bands around the hemorrhoid to cut-off its blood supply which causes it to shrink and fall off, whereas infrared coagulation involves using infrared light to create scar tissue which cuts off the blood supply to the hemorrhoid. These procedures may need to be repeated in a few weeks if the symptoms do not improve. Surgery has been found to be the most effective treatment for severe or recurring hemorrhoids. There are different types of surgeries like the Ferguson hemorrhoidectomy (closed surgery) which is common in the USA and the Milligan-Morgan hemorrhoidectomy (open surgery) which is more common in the UK and Europe.
Anatomy and Physiology of Hemorrhoidectomy
Hemorrhoids are cushion-like structures made of blood vessels located in the anal canal. They are not diseases themselves, but a normal part of your body. When viewed under a microscope, they look like small, blood-filled pockets because, like veins, they don’t have muscle tissues. They are similar to the network of veins and arteries in our body, which is why when you have a hemorrhoid that’s bleeding, the blood is bright red and has the same pH level as the blood in our arteries.
The anal canal, where hemorrhoids are located, is typically 4 cm long in adults. Halfway down this passage is a landmark called the dentate line. Hemorrhoids found above this line are known as internal hemorrhoids. You don’t feel pain from these because the area is served by the same nerves that sense pain in our internal organs. These hemorrhoids are covered by a type of cell called columnar epithelium. We divide them into grades based on how much they protrude (or stick out).
Grade 1 hemorrhoids show noticeable blood vessels, but they don’t stick out. Grade 2 hemorrhoids protrude during a Valsalva maneuver (which is when you try to exhale without letting air escape, like when you’re lifting something heavy), but go back in on their own. Grade 3 hemorrhoids also protrude during a Valsalva maneuver, but they don’t go back in without help. Grade 4 hemorrhoids always stick out and can’t be pushed back in.
On the other hand, external hemorrhoids are located below the dentate line. Because they are connected to a type of nerve called the somatic nerve, they are sensitive to touch, stretch, and temperature changes.
Why do People Need Hemorrhoidectomy
A hemorrhoidectomy, an operation to remove hemorrhoids, is usually suggested for larger and more severe hemorrhoids. This operation is commonly performed when:
– Non-surgical treatments failed to relieve symptoms
– The hemorrhoids are severe and unlikely to get better with less invasive treatments
– The hemorrhoids include a protruding external part
– Internal hemorrhoids that have become trapped and need quick treatment
– Patients with blood clotting disorders needing treatment for hemorrhoid-related bleeding
Individuals suffering from symptoms caused by external hemorrhoids or a combination of internal and external hemorrhoids that are protruding should highly consider a hemorrhoidectomy. The recommendation comes from reliable evidence, which includes:
– This operation is recommended for patients who do not respond well to or cannot tolerate in-office procedures, such as tying off the hemorrhoids with a rubber band (rubber-band ligation), injecting chemicals to shrink the hemorrhoids (sclerotherapy), and using infrared light to harden and shrink hemorrhoids (infrared coagulation).
– As previously mentioned, a hemorrhoidectomy is also recommended for patients with large (grade III or IV) hemorrhoids or significant accompanying skin flaps; surgical hemorrhoidectomy remains a very effective approach.
– An analysis of 18 studies comparing a hemorrhoidectomy with in-office treatments showed that a hemorrhoidectomy was the most effective treatment for individuals with large hemorrhoids.
When a Person Should Avoid Hemorrhoidectomy
There are a few situations where certain procedures may not be suitable:
If a patient has other serious health issues that make general anesthesia unsafe, they might not be able to undergo this kind of procedure. General anesthesia is a type of medicine used during surgery to help the patient sleep and not feel pain.
If a person already has trouble controlling bowel movements, a condition known as baseline fecal incontinence, the procedure might not be suitable.
Another condition, known as a rectocele, (which is a bulging of the rectum into the vagina), also makes the procedure less suitable.
People with inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis may not be great candidates for the procedure, either. These diseases cause long-lasting inflammation and sores in the digestive tract.
Patients with portal hypertension and rectal varices – higher blood pressure and enlarged veins in the rectum – might not be suitable for the procedure because of the increased risks involved.
Finally, if a patient has a bleeding disorder that isn’t under control, the procedure might be too risky.
Equipment used for Hemorrhoidectomy
The key tool used for a surgical procedure to remove hemorrhoids, known as an excisional hemorrhoidectomy, is a scalpel. This can be used alone or along with scissors to separate the tissue. In addition, there are other high-tech tools such as Ligasure and Harmonic scalpels that are often used these days.
Ligasure is a device that uses electric current (bipolar cautery) to cut tissue and stop bleeding (coagulation) from blood vessels. The Harmonic scalpel works in a similar way but it uses a vibrating blade to generate heat that cuts tissue and stops bleeding. Though these energy devices have potential benefits, they haven’t been shown to provide significant clinical advantages to justify their cost.
A tool known as monopolar electrocautery is sometimes used, which stops bleeding more effectively than a scalpel. This removes the hemorrhoid completely without needing to secure the area with stitches (suture ligation). However, there’s a downside as the heat it generates can potentially harm the surrounding tissues.
A Hill Ferguson retractor is inserted into the anal canal in order to see the full length of the hemorrhoid tissue.
Several other tools might be used, these include:
- DeBakey forceps: These are a kind of tweezer used for handling delicate tissues
- Mayo scissors: These are a type of surgical scissors normally used for cutting tissue
- Large Kelly clamp: This is a tool used to hold or secure things in place
- Absorbable sutures: These are special stitches that the body naturally break down over time
Who is needed to perform Hemorrhoidectomy?
A hemorrhoidectomy, which is a procedure to remove hemorrhoids, involves several medical professionals. First, there’s an operating surgeon who is in charge of performing the actual surgical procedure. Their primary role is to safely remove the hemorrhoids.
Then there’s the first assistant, who helps the surgeon during the operation. They provide additional hands and eyes to make sure that everything goes smoothly.
A scrub technician is also involved in the process. Scrub technicians are responsible for handling the tools and other surgical instruments during the procedure, making certain everything is clean, organized, and ready for the surgeon to use.
Lastly, an anesthesia team is responsible for making sure you are comfortable and pain-free during the surgery. They are the people who give the medicine that makes you fall asleep and not feel the procedure. They monitor your well being while you’re asleep until you are awake in the recovery room.
All together, these medical professionals work as a team to make sure the hemorrhoid removal is done successfully and safely, so you can recover quickly.
Preparing for Hemorrhoidectomy
Preparing the bowel for this procedure is not always necessary, but in some cases, a special cleansing method called an enema might be used to clear the last part of the large intestine, known as the distal rectum. This is not something everyone will need. Also, giving antibiotics beforehand to prevent infection is not typically needed for this procedure.
The type of anesthetic, which is medicine to numb you or make you sleep during the operation, will be chosen based on what’s best for you. It’s important to know that one type called spinal anesthesia may increase the chances of having trouble emptying your bladder afterwards. Your doctor will discuss this and other potential risks with you before the procedure.
The position you’ll be placed in during the procedure might vary, but one common position is called the ‘prone jack-knife’. In this position, you will lie face down with your buttocks taped apart. This might be preferred over another position called the ‘lithotomy’ position. Again, this can vary depending on what’s the most appropriate for you.
How is Hemorrhoidectomy performed
Hemorrhoidectomy, or surgery to remove hemorrhoids, comes in two forms: open hemorrhoidectomy (Milligan-Morgan technique) or closed hemorrhoidectomy (Ferguson technique). The Milligan-Morgan technique is mostly used in the UK and Europe, while the Ferguson method is common in the US.
During a Ferguson hemorrhoidectomy, a special tool called the Hill Ferguson retractor is used to take a look at the three hemorrhoidal columns in the anal canal. The surgery can be done on just one column, but if necessary, all three can be removed during the operation. The doctors usually handle the biggest problematic columns first.
To begin the operation, the medical professionals use a tool called DeBakey forceps to press on the base of the larger column and make sure the skin around the anus (anoderm) is not strained. They then make an elliptical (oval-like) incision around the hemorrhoid column with a scalpel.
The hemorrhoid column is carefully separated from the internal anal sphincter using Mayo scissors up to a certain point. The hemorrhoid column is then handled with a large Kelly tool, and an element called 3-0 Vicryl is sutured, meaning it is stitch closed. This process is repeated on top of the anal canal to lower the risk of the hemorrhoid resurfacing. The stitch is then used to close the rectal lining, anoderm, and skin near the region.
In addition to these popular methods, a procedure called stapled hemorrhoidopexy can be used. In this procedure, instead of removing the hemorrhoid columns, they are lifted and attached above the opening of the anus. However, studies have shown that this method can have a high rate of recurrence and sometimes can lead to struggles with controlling gas release.
Patients having hemorrhoidectomies are generally advised to use multiple pain management strategies, such as over-the-counter pain reliever medications, which can help promote a quicker recovery. This method helps to limit the use of strong, potentially addictive pain medications, known as narcotics.
Possible Complications of Hemorrhoidectomy
After a surgery to remove hemorrhoids, you might experience certain issues, known as complications:
* Expect to feel pain and a sensation of fullness in your bottom during the first week after the surgery. To help manage the pain, the doctors will ensure you get appropriate pain medication. Also, using stool softeners can ease this period.
* Early problems that may happen right after the surgery include bleeding and difficulty in passing urine.
* Certain severe but rare complications, like infections throughout the body (sepsis), buildup of pus (abscess), and heavy bleeding, would require immediate medical attention.
* Some issues might appear later. These could include narrowing of the anal canal (anal stenosis), extra skin around the anal area (skin tags), hemorrhoids appearing again, bleeding that occurs later, and difficulty controlling bowel movements (fecal incontinence).
* Although complications after a hemorrhoid surgery are not common, bleeding after the procedure is the one that happens most often. It is reported in about 1% to 2% of the cases.
In some cases, around 1% to 15%, patients may have difficulty in passing urine after the surgery and it could lead to delayed release from the hospital. This problem seems to occur more when the patient has been given spinal anesthesia or when the hemorrhoidal artery has been tied off during surgery. To reduce this risk, doctors try to minimize the amount of fluids given through your veins during surgery, and they also carefully control the anesthesia.
What Else Should I Know About Hemorrhoidectomy?
Hemorrhoidal columns are a normal part of our anatomy located in the anus and rectum. However, when they cause symptoms, they might need treatment. The first step of treatment involves managing your diet, and you might need to increase your fiber intake to see improvement. Surgery to remove the hemorrhoids (hemorrhoidectomy) is the next step if the changes in diet don’t help, or if the hemorrhoids have become significantly protruded (prolapsed). Luckily, removal surgery has excellent success rates and low chances of the hemorrhoids coming back. Additionally, the methods of performing the surgery, whether “open” or “closed,” do not notably impact the level of post-surgery pain, the need for pain relief, or the risk of complications.
Some research has shown that the closed approach to hemorrhoidectomy may lead to less pain after surgery, faster healing, and less bleeding after surgery. The same type of surgery can be performed using different devices. According to a review of multiple studies including more than 1300 patients, using an ultrasonic device for the procedure may help patients return to work sooner and experience less pain and fewer complications after the surgery.
Research is still ongoing to find the best approach for these surgeries, especially considering the cost of using different types of surgical devices. Hemorrhoidectomy is known to cause some discomfort post-surgery, so researchers are exploring ways to ease this pain. For example, the use of a certain ointment (2% Diltiazem) has shown to reduce the need for strong painkillers and slightly decrease the levels of pain patients experience after traditional hemorrhoidectomy.
Other treatments, such as surgical sphincterotomy (a procedure that involves making a small cut in the muscle around the anus), have shown to be effective in reducing postoperative pain and the need for analgesics (painkillers) following a hemorrhoidectomy. Also, the use of medication like botulinum toxin A and liposomal bupivacaine (LB), a form of local anesthetic drug, have been found useful in managing the pain and reducing the need for strong painkillers.
In conclusion, for treating hemorrhoids, lifestyle changes are the first step. If those don’t work or if the condition worsens, removal surgery is the next option. Researchers are continuously finding ways to make these surgical procedures less painful and more effective.
