Haemorrhoids

Haemorrhoids

Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.
 

Description of procedure

Haemorrhoids are enlarged vascular cushions around the anus and can be internal (proximal to the dentate line) and external. Internal haemorrhoids can be further subdivided into grades 1 – 4. Traditionally, treatment of haemorrhoids has fallen into two categories: non-surgical techniques such as rubber band ligation, sclerotherapy, infrared coagulation, and cryotherapy; and surgical procedures such as Haemorrhoidectomy and stapled haemorrhoideopexy.

Non-Surgical Treatments

Non-surgical treatments should be advocated in the first instance for 1st and 2nd degree haemorrhoids with surgical procedures reserved for3rd and 4th degree haemorrhoids:

  • 3rd and 4th degree haemorrhoids.
  • Those that have failed to respond to non-surgical measures.
  • Significant external component.
  • Extensive thrombosis (may be managed conservatively).
  • Associated fissure-in-ano.

Surgical Procedures

For surgical procedures, the procedure is generally performed under general anaesthesia.

Haemorrhoidectomy: A proctoscope is inserted to adequately visualise the ano-rectal mucosa. The haemorrhoids are identified and excised either using cautery/scalpel or alternatively with a staple gun. Haemostasis is ensured and a local anaesthetic may be injected to minimise postoperative pain. A haemostatic pack may be inserted in the rectum to aid haemostasis and this will pass within a day or two.

Stapled Haemorrhoideopexy: A circular anal dilator is inserted and the prolapsed mucous membrane falls within the device. A purse-string suture anoscope is then inserted and rotated allowing a purse-string suture to be stitched into the anal circumference. A circular stapler is then introduced and traction applied to the purse-string. This pulls the prolapsed mucous membrane into the stapler and the device is fired excising a circumferential layer of mucosa. Meticulous haemostasis is then achieved.

Operative techniques

Patients should also be advised about conservative measures such as dietary modification, topical ointments, and retraining toilet habit (i.e. the avoidance of straining).

Additional procedures that may become necessary
  • None.
Benefits
  • Therapeutic: Reduce the symptoms associated with haemorrhoids and prevent complications associated with large haemorrhoids (e.g. thrombosis/ulceration).
Alternative procedures/conservative measures
  • Conservative: Dietary modification, topical ointments, and retraining toilet habit (i.e. the avoidance of straining).
Serious/frequently occurring risks

Bleeding, infection, post-procedural pain, recurrence.

Haemorrhoidectomy

  • Early: Urinary retention (20.1%), bleeding (secondary [7 – 10 days post-procedure]) or (reactionary 2.4% - 6%), subcutaneous abscess (0.5%).
  • Late: Anal fissure (1.2% - 6%), anal stenosis (1%), incontinence (0.4%), fistula (0.5%).

Stapled Haemorrhoideopexy

  • Postoperative bleeding (1.5 – 9%), urinary retention (<5%), external haemorrhoidal thrombosis (1.2 – 4.7%), pelvic sepsis, rectovaginal fistula, rectal perforation, anal stenosis.

These are all well-recognised complications of stapled haemorrhoideopexy and should be included in the consent process. Temporary faecal incontinence and faecal urgency have been reported, although these resolved in all cases by 3 months.

Blood transfusion necessary
  • Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions.
Type of anaesthesia/sedation
  • General Anaesthesia.
  • Local.
  • Regional.
Follow-up or need for further procedure
  • Routine outpatient review is required.
  • Patients must be discharged on laxatives and analgesia and given appropriate advice regarding diet and toilet habits.

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