hemorrhoidectomy
TRANSCRIPT
OUTLINE• Definition • Indications • Type • Preoperative preparation• Anaesthesia • Position • Procedure • Post op. management • Complication
Definition Haemorrhoidectomy is the surgical excision of a haemorrhoid.Indications;• Symptomatic grade III, grade IV, or mixed internal and external
hemorrhoids• Where there are additional anorectal conditions that require surgery• Strangulated internal hemorrhoids and some thrombosed external
hemorrhoids (weeks after relieve of acute symptoms by conservative methods)• Where patients who cannot tolerate or fail minimally invasive
procedures
Types • Open Haemorrhoidectomy (Milligan-Morgan haemorrhoidectomy)• Closed Haemorrhoidectomy• Stapled Haemorrhoidectomy
Preoperative preparation• Patients should ideally be put on a high fibre diet and stool softeners
for several days prior to the procedure, this is to reduce post operative pain and to reduce the chances of post operative faecal impaction.• Lactulose taken for 4 days prior to Haemorrhoidectomy reduces post
operative pain. • Antibiotic prophylaxis is advisable for all clean-contaminated
operations such as haemorrhoidectomy• Enema on the day of the operation• Prophylactic antibiotic (at induction)
• Anaesthesia; spinal anaesthesia or GA • Position; lithotomy position• Skin prepared; perineum and anal canal.• Surgeon sits facing the perineum.• Procedure; insert Parkes anal speculum to display the haemorrhoid to be
operated upon. Grasp the haemorrhoid at the mucocuteneous junction with a haemostatic forceps and retract towards the surgeon. Incise the skin at the base of the haemorrhoid with a scissors as a V-shape incision with the base of the V towards the haemorrhoid. Extend this incision into the mucosa either side of the haemorrhoid raising it off the muscles of the internal sphincter. The dissection is continued just beyond the dentate line. Transfix and ligate the pedicle of the haemorrhoid with a 2-0 vicryl suture leaving a long length of suture material attached. Excise the haemorrhoid 0.5cm distal to the ligature.
• Repeat the procedure with the other haemorrhoids. Leave a mucocutaneous bridge between each haemorrhoid to reduce any subsequent anal stricture. At the end place a small paraffin soaked pack to reduce bleeding within the anal canal, supported by a T-shaped bandage.
Post operative management;• Adequate analgesia, bulk laxative and antibiotics • Warm sitz bath • DRE at 5th day to exclude anal stenosis
Complications • EARLY • Haemorrhage • Acute urine retention• Constipation with pain resulting in faecal impaction
• LATE • Anal stenosis • Fissure • Skin tag • Recurrence• incontinence