Chapter 28 Hemorrhoidectomy
INTRODUCTION
Although many nonresective procedures have been described for the treatment of hemorrhoidal disease over the years, surgical hemorrhoidectomy continues to maintain an important role in the therapy of hemorrhoids and may be one of the most common anorectal operations performed by the general surgeon. Because surgical hemorrhoidectomy has been done for many decades, ample evidence indicates that this procedure can be done safely, with a low complication rate and with a high degree of effectiveness in the reduction of hemorrhoidal symptoms.1 Despite this efficacy, surgical hemorrhoidectomy has well-described, specific complications, and their existence and the steps in their prevention should be well understood by the surgeon embarking upon these cases.
In addition, the substantial postoperative pain associated with surgical hemorrhoidectomy is well recognized.2 In an attempt to reduce this morbidity, a new technique, stapled hemorrhoidectomy (also referred to as procedure for prolapse and hemorrhoids [PPH]), has been introduced. This chapter describes both the traditional closed Ferguson excisional hemorrhoidectomy3 and the stapled hemorrhoidectomy, with emphasis on the operative steps and the avoidance of the specific technical complications associated with each.
Traditional Hemorrhoidectomy
OPERATIVE PROCEDURE
Anesthetic Considerations
Urinary Retention
Urinary retention, due to overdistention of the bladder during surgery or postoperative levator spasm from incisional pain, is one of the most common complications of anorectal surgery, including hemorrhoidectomy. Large series have reported this complication as frequently as 25% to 35%.4
• Consequence
• Repair
• Prevention
Anoscopy and Operative Planning
Ligation of the Pedicle
Hemorrhage
• Consequences
• Repair
Excision of the Hemorrhoidal Pedicle
Sphincter Injury
Once ligated in the distal rectum, the hemorrhoidal plexus and its overlying epithelium are sharply excised starting peripherally on the perianal skin. A plane is developed between the hemorrhoid and the underlying sphincter complex, which should be easily identified (Fig. 28-3).
• Consequence
Anal Stenosis
• Consequence
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