Closed Hemorrhoidectomy JAMES A. FERGUSON, M.D., J. RICHARD HEATON, M.D.

From the Ferguson-Droste-Ferguson Clinic, Grand Rapids, Michigan

HEMORRHOIDECTOMY PROBABLY can be considered a standard surgical procedure. Despite the fact that few surgeons employ identical technics, it is quite unlikely that any feature utilized by a surgeon can be considered new. The procedure herein described is not identical to usual opera- tions for hemorrhoids and possesses some advantages which justify this presentation.

There are certain criteria upon which the need for hemorrhoidectorny should be based, and they are determined by evalua- tion of the patient's symptoms and an ap- praisal of the condition of the rectal out- let. Th e latter problem can be solved only by careful inspection of the anal margins and perianal tissue and by anoscopic and proctosigmoidoscopic examination. Obvi- ously the validity of these requirements depends on the knowledge and experience of the physician and within broad limits they are susceptible to individual interpre- tation. However, they are so well under- stood that, like hemorrhoidectomy, they too can be considered "standard."

Adequate appraisal of the problem in- cludes a complete history of the patient's disability and a thorough anorectal exami- nation, which consists of inspection and palpation of the perianal area, the anal canal, and the rectum and visualization of the distal portion of the sig-moid. Usually the condition of approximately 20 cm. of the bowel can be determined during the course of the examination. If the patient's symptoms bear significant relationship to the condition discovered in the hemor- rhoidal area and if there is no other dis- order, such as cancer, or a general condition which would require another approach to

the problem, hemorrhoidec.tomy should be recommended. A complete investigation which is the best insurance against error, should include a complete physical exami- nation, thorough roentgenologic examina- tion of the colon and appropriate labora- tory tests.

Preparat ion for Opera t ion

A liqui d diet is provided dur ing the 24- hour period prior to operation, two ounces of castor oil are administered 16 hours before operation and cleansing enemas are given 12 hours and two hours prior to operation. Th e per ianum is shaved and the tissues adjacent to the anus are scrubbed with pHisohex after which the patient is draped appropriately.

A modified Sims' position is used and surgical instruments are placed at the foot of the operating table. T h e operative field is well lighted and an assistant exposes the surgical area by retracting the right buttock. T h e hemorrhoids are exposed with the aid of a retractor and the operative field is kept free of blood by continuous suction.

We prefer local anesthesia or local anesthesia combined with pentothal sodium administered intravenously. T h e anesthetic agent of choice is a solution of 0.5 per cent Novocaine and 0.05 per cent Nupercaine. Skillful injection of this solution produces immediate anesthesia which lasts approxi- mately one to one and one half hours. Eighty cc. of the solution is injected and the operat ion-can be started immediately after injection is completed. Unfavorable reactions are rare and are mild when they occur. Despite the fact that we use large quantities of anesthetic solution, complica-

176

CLOSED H E M O R R H O I D E C T O M Y 177

tions such as abscess or para-anal cellulitis practically never occur.

Operation The technic employed while performing

this operat ion is radical but readily adapt- able to most requirements. T h e hemor- rhoidal masses, which usually number three or more, are operated upon in their natural position and are not distorted by eversion. A Ferguson-Hill retractor is used to pro- vide proper exposure and by making a series of elliptical incisions around the areas of m a x i m u m deformity, the tissues to be removed are outl ined (Fig. 1). Dis- section is begun at the external border of the externo-internal hemorrhoid and di- rected inward until the varicosities are re- moved, the .fibers of the external and in- ternal sphincter muscles are exposed, and only a mucosal pedicle remains attached. A Buie-Smith crushing clamp is applied to this pedicle and the hemorrhoidal mass is excised at the superior level of the blades of the clamp. At this point, if the operat ion has been performed properly, it will be observed that the muscle fibers are clearly visible and all varicosities have been re- moved. T h e pedicle is then ligated with 000 chromic catgut and the crushing clamp

Fro. 1. Elliptical incisions are m a d e a r o u n d the areas of m a x i m u m deformity.

S u b c u t a n e o u s d i s s e c t i o n

t l c l e

a c h e d

Fro. 2. T h e c rush ing c lamp has been removed and the pedicle has been ligated. T h e l igature is re ta ined for closure of the wound.

is remOved (Fig. 2). Th is l igature is not cut because it is utilized later when the operat ion is completed by closure of the margins of the wound. Residual varicosities are carefully dissected f rom under the ad- jacent skin margins. Fibers of the inter- muscular septum (termination of the longi- tudinal muscle of the rectum) are divided under the adjacent skin on either side of the incision to provide mobil i ty necessary for subsequent closure of the wound. After dissection is completed, the margins of the wound are drawn upward into the anal canal by one or more locking stitches and are secured to the pedicle by the suture which was retained. Using this same suture, the remainder of the wound is closed with a continuous whip stitch tied loosely at the outer extremity of the wound (Fig. 3). Sphincterotomy may or may not be re- quired. The appearance of the per ianum following complet ion of the procedure in three quadrants is represented in Figure 4o Despite the degree of hemorrhoidal de- formity and skin redundancy, this technic when properly executed can provide an anal canal devoid of hemorrhoidal veins and lined with true skin in it5 external two thirds.

i 78 FERGUSON AND HEATON

No immediate postoperative dressings may be required but sometimes it is well to insert a vaseline wick, or apply an oxycel gauze roll. We have used oxycel gauze more for its action as a splint for the anal canal than for its hemostatic effect. Ap- propriate dressings are then applied ex- ternally and the patient is re turned to his room.

Postoperative Care

A general diet is begun immediately and fluid intake is encouraged. Morphine sulphate is administered hypodermically to control pain. Patients are catheterized when necessary, ba throom privileges are permit ted on the day of operation and full ambulat ion is encouraged on the first post- operative day. Sulfathaladine is adminis- tered orally, one Gm. three times daily, and the wound is observed carefully during the

]riG. 3. The wound is closed with a continuous whip stitch.

\

FIG. 4. Closed operation completed.

period when there is any possibility of hemorrhage. Dressings are removed after an elapse of 24 hours.

While the patient is confined to the hos- pital, he is placed in the l i thotomy position and the wound is inspected and cleansed daily. On the third and sixth postopera- tive day, digital examinat ion of the rectal outlet is performed with the little finger. This is not done for the purpose of dilation, but to determine the condit ion of the wound. Anesthesia is not required for this examination. A small saline enema is ad- ministered when necessary and the patient is discharged on the seventh to the tenth postoperative day. If he lives in the im- mediate vicinity, he is discharged early, but if he resides in another community, his stay in the hospital is prolonged for an ap- propriate period of time.

On discharge from the hospital, the pa- tient is instructed to continue a general diet including adequate water intake and he is permitted to use a small saline enema when necessary. He is instructed to exercise judgment regarding his physical activities. A bland ointment containing boric acid, zinc oxide, or petrolatum is provided for use following each bowel mc-vement. T h e patient is informed of the clinical and the

CLOSED H E M O R R H O I D E C T O M Y 179

x-ray findings, and of the microscopic ex- amination of the tissue removed. We find that providing this information greatly im- proves the patient-physician relationship.

Outpat ient visits at the end of the second and the fifth weeks are generally required before a patient is discharged. Usually pa- tients return to work after an elapse of about three weeks following the operation, but as a matter of policy, four weeks is the maximum amount of time allowed before a patient is certified as able to re turn to work.

Comment Details of the surgical technic herein

described differ from the usual evertive and amputative type of hemorrhoidectomy. T h e basic principles of operation were evolved by Dr. Lynn Ferguson and with some modi- fications, have been followed by us as a standard procedure. Hemorrhoidal varices are removed completely and the anal canal is relined in its outer two thirds with true skin.

T h e degree of postoperative distress is modified by the amount of tissue removed, the degree of tissue trauma, the amount of suture material utilized, and the patient's individual tendency to develop fibrous tis- sue. Postoperative stricture may result from devitalization of intervening bridges of skin, from removal of excessive amounts of tissue with the hemorrhoidal varices and subsequent necrosis.

Dilatation of the anal canal should not be necessary at any time during the post- operative period. We purposely use the term "digital examination" to differentiate evaluation of the condition of the wound from actual dilatation of the rectal outlet. The index finger should not be used unless dilatation is required and when this is necessary, anesthesia should be employed.

In general, only one hypodermic injec- tion of morphine sulfate is necessary after

operation, usually patients are catheterized once and pain is not excessive, but the first bowel movement may be accompanied by marked soreness. Exclusion of milk from the diet may decrease the amount of curd- like stools which accumulate in the rectum. Administration of sulfathaladine or sulfa- suxidine plays a significant role in preven- tion of postoperative impactions because, in addition to their bacteriostatic effect, these drugs have a mild cathartic action. Mineral oil, bulk-producing agents, and other types of laxatives have no effect in reducing the postoperative incidence of impaction.

Long-lasting anesthetic agents have been abandoned because they may have an ad- verse effect on healing and usually fail to accomplish the purpose for which they were intended.

Incisions are closed because they heal more dependably, discomfort is lessened, the danger of postoperative bleeding is re- duced, postoperative hospital visits are re- quired less frequently, and the healed anal canal has a natural and complete pliability which we believe the open method of hem- orrhoidectomy does not provide consist- ently. Closure of the skin incisions is not followed by abscess formation, para-anal cellulitis, or other complications.

Summary A method for the surgical management of

hemorrhoidal disease is presented which emphasizes the importance of preoperative selection and preparation. A form of anesthesia and surgical technic is described which differs somewhat from that generally employed and a plan of postoperative care is advocated which is simple and effective. Th e surgical technic assures complete re- moval of hemorrhoids and provides a skin- lined anal canal which is in keeping with the best principles of plastic surgery and is productive of excellent results.