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

Urinary retention after anorectal surgery can substantially increase the morbidity of hemorrhoidectomy by delaying the discharge of patients after this day-surgery procedure or by requiring emergent reevaluation of the patient later in the day. The need for urinary drainage may also increase the potential for urinary tract infection.

Grade 1/2 complication

• Repair

Urinary retention after hemorrhoidectomy is treated by temporary urinary drainage with a Foley catheter, typically over a 48-hour period. The need for formal urologic evaluation is rare, except in patients with substantial urologic difficulties that were present preoperatively. Conservative measures, including voiding while submerged in a tub of warm water, may avoid the need for catheterization.

• Prevention

Steps taken to avoid acute overdistention of the bladder, including the use of a heparin lock rather than con tinuous intravenous fluid administration and preoperative voiding, have been shown to decrease the incidence of urinary retention after hemorrhoidectomy.^5–7 Adequate administration of local anesthetics (bupivacaine [Marcaine]) may also reduce early postoperative levator spasm, leading to less urinary retention after surgery.

Anoscopy and Operative Planning

Inappropriate Hemorrhoidal Excision

Prior to excision, a full operative plan needs to be established by careful anoscopy. Typically, either two or three hemorrhoidal complexes are excised. Even most “circumferential” hemorrhoids can be grouped for excision into the common hemorrhoidal quadrants: left lateral, right posterior, and right anterior.

• Consequences

Failure to fully plan the excisions at the start of the operation will lead either to inadequate excision and persistent symptoms or to overaggressive resection and subsequent anal stenosis.

Grade 1/2/3 complication

• Repair

If an inadequate resection is initially made, additional resection can be done at the end of the case. Anal stenosis and its treatment are discussed later.

• Prevention

Careful preexcision planning is mandatory to obtain an adequate and appropriate hemorrhoid resection.

Ligation of the Pedicle

Hemorrhage

• Consequences

Failure to adequately ligate the plexus can result in significant postoperative bleeding from the pedicle, which can require reoperation to control. The rate of this complication should be less than 1%,⁸ but it represents one of the most serious complications of hemorrhoidectomy.

Grade 2/3 complication

• Repair

Pedicle bleeding recognized at the time of initial surgery can be simply religated. Identification and resuturing of the pedicle may be facilitated by leaving the pedicle suture long and in place while the excision and incisional closure are completed. Once the excisions are all completed and the incisions closed, the pedicles can all be examined carefully for persistent bleeding. Significant hemorrhage in the early postoperative period requires reexploration and ligation.

• Prevention

Deeply ligating the pedicle well within the rectal vault, including the mucosa and submucosa and encircling the entire hemorrhoidal plexus, will minimize the incidence of postoperative bleeding (Fig. 28-1).

Figure 28-1 Ligation of the hemorrhoidal pedicle, including the mucosa, submucosa, and hemorrhoidal plexus.

Anal Stenosis

Placing the pedicle sutures too low, within the narrow anal canal rather than the capacious distal rectum, may lead to an increase in the likelihood of postoperative anal stenosis (Fig. 28-2). The consequences and repair of this complication are discussed later.

Figure 28-2 The pedicle suture secured well within the rectal vault, high above the dentate line.

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).

Figure 28-3 The sphincter complex underlying the hemorrhoidal plexus.

• Consequence

Inadequate visualization of the underlying sphincter complex can lead to sphincter injury and weakening. The incidence of this complication should be extremely low, less than 0.5%.⁹

Grade 2/3 complication

• Repair

Although quite unusual, future sphincteroplasty to repair sphincter injury after surgical hemorrhoidectomy may be indicated.⁹

• Prevention

Careful identification and preservation of the sphincter beneath the hemorrhoid should essentially eliminate the chance of significant sphincter injury during hemorrhoidectomy.

Anal Stenosis

Anal stenosis remains one of the most serious complications of hemorrhoidectomy. Poor planning or execution of a number of steps during the hemorrhoidectomy—including poor exposure, inadequate anesthesia, low ligation of the pedicles, and excessive excision—may contribute to this complication.

• Consequence

The excision of excessive anal canal mucosa during the hemorrhoid excision is the most common factor leading to anal stenosis. This serious complication of hemorrhoidectomy occurs with a frequency of 2% to 4%.¹⁰ It is potentially a source of symptomatic distal gastrointestinal obstruction, which may carry substantial morbidity and, in its more severe forms, may require surgical correction.

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