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314
S.D. Holubar and D.E. Rivadeneira
Fig. 20.1 Grade 3 hemorrhoids with attenuated RV septum (Courtesy
of Richard Billingham, MD)
Table 20.1 Internal hemorrhoidal disease grading (classifi cation)
Grade Physical/anoscopic fi ndings
I No prolapse
II Prolapse with spontaneous reduction
III Prolapse requiring manual reduction
IV Irreducible
fi stula formation or sphincter disruption and the development of gross fecal incontinence. Most often a history of prolapse, along with the physical fi ndings (Table 20.1 ) and the
daily impact on the patient’s quality of life, will guide the
appropriate therapy.
Furthermore, you must always have a high index of suspicion for other competing etiologies of recurrent rectal bleeding such as other anorectal pathology, colorectal cancer,
infl ammatory bowel disease, COPD, or portal hypertension,
mostly based on history, other symptoms, and family history
(Fig. 20.2 ). Just because you see hemorrhoids on examina-
tion does not mean they are the underlying cause for your
patient’s symptoms.
Dietary and Bowel Habits
Key Concept: Every patient can benefi t from supplemental
fi ber and education on proper bowel habits.
Focused history should quantify and qualify the patient’s
typical dietary and bowel habits. Almost all patients will initially state their diet is high in fi ber. Yet, you should specifi cally determine whether or not a high-fi ber diet (12 servings
per day) or supplement is used and the frequency of stooling
and the quality of stool using a standardize instrument
(Bristol stool chart, Table
allows assessment of the size and shape (nuggets vs. large) as
20.2 ; see also Fig. 13.1) [ 4 ]. This
Fig. 20.2 Atypical anal fi ssure in a patient with concomitant hemorrhoids (Courtesy of Philip Y. Pearson, MD)
Table 20.2 Bristol stool form scale [
Type Description
1 Nutlike nuggets, hard to pass
2 Tubular and lumpy, hard to pass
3 Tubular with cracks on surface
4 Tubular, soft, and smooth
5 Soft blobs with clear cut edges
6 Mushy, fl uffy, ragged edge stool
7 Completely watery stool
4 ]
well as quality (soft vs. hard vs. watery diarrhea). It is also
something you can characterize and follow over time to see
their response to therapy. Hemorrhoid disease patients will
often report habits, which include straining in order to affect
a bowel movement, and often they will spend an inordinate
amount of time on the commode. Reading on the commode
while stooling is to be avoided. Likewise patients with diar-
rheal stools can have rectal bleeding that may be related to
the frequency of wiping or competing etiology. It is important to exclude those causes. Another tool we fi nd useful for
assessing patients with constipation is the Rome-III criteria
20 Hemorrhoidal Disease: Postoperative Complications
315
Table 20.3 Rome-III criteria for functional constipation *
1
Must include two or more of the following:
– Straining during at least 25 % of defecations
– Lumpy or hard stools in at least 25 % of defecations
– Sensation of incomplete evacuation for at least 25 % of
defecations
– Sensation of anorectal obstruction/blockage for at least
25 % of defecations
– Manual maneuvers to facilitate at least 25 % of defecations
(e.g., digital evacuation, support of the pelvic fl oor)
– Fewer than three defecations per week
2 Loose stools are rarely present without the use of laxatives
3 Insuffi cient criteria for irritable bowel syndrome
* Criteria fulfi lled for the last 3 months with symptom onset at least
6 months prior to diagnosis
for functional constipation (Table 20.3 ) [ 5 ]. This is a helpful
adjunct to classify the constipation, the usual root of the
hemorrhoidal disease, as functional (slow transit or related to
pelvic fl oor dysfunction) as opposed to irritable bowel syndrome type C.
Fecal continence (or lack thereof) also has a major impact
on the development of and treatment recommendations for
patients with symptoms attributable to hemorrhoidal disease.
If intervention is required, an elderly female with frequent
incontinence to gas, liquid, and occasionally solids may be
better served by serial rubber band ligation, or hemorrhoidectomy, as opposed to hemorrhoidopexy, as cases of worsening continence after passage of the transanal stapling device
has been observed.
Colonoscopy
Key Concept: Colonoscopy is not for diagnosing hemorrhoids
but should be performed in at-risk patients, concerning fi ndings, and those without resolution of their symptoms.
The role of colonoscopy has a defi nite place in the targeted evaluation and follow-up of rectal bleeding initially
ascribed to hemorrhoids [ 6 , 7 ]. Consider the case of an
adopted 30-year-old man with a 2-year history of rectal
bleeding. Most physicians would initially attempt a trial of
fi ber management and anoscopic rubber band ligation if you
suspected internal hemorrhoids as the source. However,
given the lack of family history, it is still crucially important
that he have defi ned follow-up for the bleeding, as many
colorectal surgeons have seen young patients with rectal
bleeding, ascribed to as hemorrhoidal by the other providers,
who then present much later with a locally advanced colorectal cancer after the bleeding never really resolves.
This is not to say that colonoscopy for rectal bleeding is
the fi rst diagnostic test, only that it must nonetheless be
Table 20.4 Side effects of common antiplatelet and anticoagulants
Medication Selected side effects
Aspirin Bronchospasm, allergy, PUD
Clopidogrel Cytopenia (rare); TTP, PUD, angina,
hypertension, headache
Prasugrel Hypertension, TTP, cough, rash, nausea,
headache
Dipyridamole Cardiac ischemia/angina; nausea, vomiting,
headache; least risk of bleeding
Glycoprotein IIb/IIIa
antagonists
Coumadin Several medication interactions
All can cause bleeding
PUD peptic ulcer disease, TTP thrombotic thrombocytopenic purpura
Thrombocytopenia; highest risk of bleeding
reserved for appropriate circumstances. Clearly all colorectal surgeons bear a shared responsibility for assessing adherence to national standard of care guidelines and at a minimum
inquiring if their patients are up-to-date with screening
colonoscopy [ 8 ].
Antiplatelet Agents and Anticoagulants
Key Concept: A number of both OTC and prescription medications can not only increase the risk of bleeding but also
need to be addressed prior to intervention.
Hemorrhoidal disease is commonly seen in patients older
than 50 years of age, the typical age of onset of symptomatic
coronary artery disease and/or peripheral vascular disease.
Given the side array of antiplatelet agents and anticoagulants
(Table 20.4 ), colorectal surgeons must review their patient’s
medication lists and be familiar with these medications. As
newer, more effective agents are added to the market, surgeons must also continuously be aware of the potential of
bleeding events when operating on patients actively taking
them, as well as the risk of thromboembolic events if they are
held. A widely held tenet in medicine is that thromboembolic disease is more diffi cult to treat and more lethal than
bleeding, which can generally be managed nonoperatively
with transfusions in all but the most extreme circumstances.
One widely used medication is clopidogrel (Plavix TM),
a potent antiplatelet agent that currently is without known
antidote other than time and platelet transfusion. This medication, in conjunction with aspirin, is routinely given for
1 year after percutaneous vascular stenting in order to reduce
thromboembolic events prior to endothelialization. It is recommended that the decision to hold this medication be made
by the colorectal surgeon in conjunction with their cardiology colleagues, and studies suggest that for most patients
after 5 days of cessation of therapy, surgery can be undertaken without increased risks [ 9 ].
316
S.D. Holubar and D.E. Rivadeneira
“Every pain in the bottom is not a hemorrhoid” – How to deal with patients and referring providers when this is not hemorrhoids and they are convinced it is
Key Concept: You should take this opportunity to educate
your referring physicians and patients, not chide them.
This is one of the most frustrating and most commonly
encountered scenarios. As stated, as much as 50 % of symptoms such as rectal pain, bleeding, and prolapse are inappropriately attributed to hemorrhoids by the primary care
physician, endoscopist, or the patient themselves. Therefore,
part of the scope of practice is not to educate just the patients
but the referring providers as well. It is also a bit of a balancing act between providing proper education and avoiding
accusations or arguments. One thing we have found successful, even prior to an in-offi ce enema administration or anorectal examination, is counseling patients that they should
have an open mind as to what we will fi nd. We often tell
them about the 50 % statistic and ask them to keep in mind
this may be the fi rst time they are seeing a subspecialist.
They should be aware that anorectal problems are commonly mistaken for each other, and they may be diagnosed
with some competing etiology such as fi ssures, fi stulas,
infections, poor hygiene, or in a minority malignancy.
Furthermore, we let them know that they may have hemorrhoids, but the symptoms are coming from something else.
Most commonly, a simple question even without exam as to
the quality of the pain (sharp as opposed to dull) gives a clue
that one is dealing with a fi ssure as opposed to hemorrhoids
(or infrequently both). Often patients have suffered for so
long with “hemorrhoids” that they are quite relieved to not
only fi nally have the proper diagnosis but also leave with
what hopefully is an effective treatment plan. If they truly
are convinced it to be a hemorrhoidal problem, you should
consider a referral to another colorectal surgeon for a second
opinion.
Similar to patient misperceptions, the fl exible endoscopic
appearance of anorectal pathology can be quite different than
on anoscopic exam, and primary care providers (and even
gastroenterology) who do not perform a high volume of
anoscopy may be obviously trying to help but limited in their
depth and breadth of anorectal experience. You must be careful not to offend the referring providers and ideally point out
how common misperceptions of anorectal pathology occur
in the copy of the note or letter that is sent back to the referring physician. Family Medicine and/or Gastroenterology
Grand Rounds along with other educational venues are an
ideal way to increase local provider awareness of common
anorectal pathology. Certainly arming our colleagues with
knowledge of optimal lifestyle modifi cation is a crucial fi rst
step.
Table 20.5 Lifestyle modifi cations for patients with hemorrhoidal
disease
Lifestyle modifi cation
Diet High-fi ber booklet
Soluble fi ber
supplement (bulking
agent)
Fluids 2 l fl uid intake by mouth per day
Straining Avoid straining on the commode
Commode Avoid reading on the commode or spending
Perianal hygiene Avoid excessive cleansing; use a peri-
Nothing per rectum Avoid suppositories, digital dis-impaction,
Kegel exercises Age appropriate for borderline continence
Pelvic fl oor retraining If concomitant pelvic fl oor dysfunction
One heaping tablespoon in 8 oz of water
once or twice daily with the goal of
producing soft, bulky stool on a daily basis
(ideally). Can reduce amount of water to
4 oz if loose stool
excessive time on the commode
bottle, sports bottle, sitz bath, detachable
showerhead, or bidet. Apply zinc oxide or
other diaper ointment before each bowel
movement to protect perianal skin
or any other transanal instrumentation or
intervention
or incontinence
Lifestyle Modifi cation
Key Concept: Fiber does really work, if your patients take
adequate amounts on a regular basis.
In the United States, governmental and medical society
recommendations suggest that Americans should ingest at
least 25 g of dietary fi ber (12 servings of fruits and/or vegetables per day). Many patients fi nd the goal of 25 g of dietary
fi ber per day a diffi cult goal to obtain. Yet, it is also the basis
for recommendations, based on level 1 data, for the use of
supplemental soluble fi ber to allow a soft, bulky stool, which
minimizes hemorrhoidal tissue trauma. In a meta-analysis of
seven randomized trials, Alonso-Coello et al. showed that
fi ber results in an approximate 50 % decrease in symptoms
[ 10 ]. Most, if not all, patients should try lifestyle modifi ca-
tion before any more invasive intervention. Table 20.5 lists
examples of lifestyle modifi cation.
Surgical Decision-Making: How to Decide on What Surgery to Do (Open, Closed, Energy, PPH, THD)
Key Concept: A number of surgical options exist for hemorrhoidectomy. Understand the risks and benefi ts with each
one, and use them as appropriate in indicated patients.
In 1992, Bleday et al. reviewed the University of Minnesota
experience with hemorrhoidal disease [
21,000 patients, 45 % were offered conservative therapy,
45 % rubber band ligation, and 9.3 % underwent operation.
11 ]. Of an initial
20 Hemorrhoidal Disease: Postoperative Complications
317
Table 20.6 Surgeon- and patient-related factors that infl uence the
choice of operative intervention for hemorrhoidal disease refractory to
conservative treatment
Surgeon-related Patient-related
Prior education and training Age, gender, medications
Operative experience Bowel and sphincter function
Local resources Patient travel resources
Product availability Patient work and family preferences
Confi dence of diagnosis of
isolated hemorrhoidal disease
(i.e., concurrent pelvic fl oor
dysfunction, fecal
incontinence, IBD)
Magnitude of hemorrhoidal
disease burden (i.e., how big
are they?)
Red fl ag comorbidities: portal
hypertension, Crohn, pregnancy, hx
pelvic radiotherapy/radiation
proctitis, immunosuppression/
immunocompromised, bleeding
diatheses, poor functional status,
limited life expectancy, others
Magnitude of the hemorrhoidal
disease on the patient’s daily quality
of life (i.e., how bad is it?)
Certainly this experience suggests only 10 % of patients
require more than lifestyle modifi cation and/or rubber band
ligation. If the surgeon and patient decide that more than conservative measures are warranted, many factors may infl uence the choice of intervention (Table 20.6 ). Clearly one size
does not fi t all, and treatment needs to be tailored and individualized for each patient based on the estimation of benefi t
and risk of the various surgical options and surgeon comfort
and experience with chosen technique being crucial.
In general, grade II hemorrhoidal disease is treated with
lifestyle modifi cation and then banding, while the gold standard operation for grade III hemorrhoidal disease is the
closed modifi cation of the classic open Milligan-Morgan
excisional hemorrhoidectomy (i.e., closed Ferguson excisional hemorrhoidectomy), due to its lowest recurrence rate.
However, patients must be willing to sacrifi ce a signifi cant
amount of days off work (average of 2 weeks), and pain and
discomfort may take 6 weeks or longer to subside with an
excision. A common modifi cation of this operation is the use
of a Harmonic Scalpel® (Ethicon, Cincinnati, OH) or
LigaSure™ device (Covidien, Mansfi eld, MA), even for
grade IV disease [ 12 , 13 ]. In general these adjuncts, despite
their increased costs, decrease operative time and may result
in less pain, fewer complications (less bleeding and urinary
retention), and better patient satisfaction [ 12 – 16 ]. Initial
concerns that the LigaSure may result in anal stenosis are
likely due to lack of experience with the technique [ 17 – 19 ]
and in experienced hands lead to equivalent outcomes as
conventional hemorrhoidectomy. Although a meta-analysis
of nine randomized trials from 2007 suggested that although
use of the LigaSure hemorrhoidectomy reduced operative
time and blood loss, it may not decrease pain or result in
faster time to return to work [
20 ]. Subsequently the Cochrane
Collaboration meta-analysis from 2009 of 12 randomized
studies on this topic suggested that given apparent equivalent
outcomes with decreased pain and earlier return to work
(4.8 days earlier), LigaSure hemorrhoidectomy appears
superior to conventional excisional hemorrhoidectomy [
21 ].
Compared with excisional hemorrhoidectomy, stapled
hemorrhoidopexy is a relatively new, minimally invasive, technologically driven procedure. Despite it being a young procedure (approximately 10 years old), extensive level I data exists
with which to guide optimal patient selection and educate
expected outcomes [ 22 , 23 ]. Due to its increased recurrence
rate, the procedure for prolapse and hemorrhoids (PPH) should
be used selectively as an alternative to conventional or bipolar
excisional hemorrhoidectomy in patients with circumferential
grade III hemorrhoidal disease without an especially large
external component. Well-over a dozen randomized trials exist
which usually show, similar to laparoscopic (minimally invasive surgery), that the PPH has a shorter operative time, less
postoperative pain, and faster return to work compared to excisional hemorrhoidectomy [
22 ]. In essence the device is a cir-
cular end-to-end anastomotic (EEA) stapler up-sized for the
anorectal canal and specifi cally designed and intended for
endoluminal supra-hemorrhoidal tissue mucosal resection (not
full- thickness resection!). Thus, it results in pexying the prolapsing hemorrhoids higher in the anorectal canal (“face-lift
for the anus” similar conceptually to serial rubber band ligation done all at once). The resultant mucosal resection should
have very few if any muscle fi bers in it and ideally should be
symmetric and not be eccentric or “waisted .” Median operative times should be around 30 min for those over the learning
curve. Despite short operative times and less postoperative
pain, widespread adoption has been limited over surgeon concern regarding (a) the different, potentially more serious complications and (b) lack of long-term data. The most recent
meta-analysis on the topic showed that the PPH procedure has
a higher recurrence rate, with need for more re- interventions,
compared with excisional hemorrhoidectomy [
24 ]. Thus, it
would appear patients and surgeons must weigh the short-term
gains vs. the long-term potential for recurrence.
A number of randomized trials have compared LigaSure
hemorrhoidectomy to stapled hemorrhoidopexy [
25 , 26 ].
Arsiani recently randomized 98 patients and found that the
stapled procedure had non-statistically signifi cantly higher
complication rate (24 % vs. 14 %) and recurrence rate (11 %
vs. 2 %). These results are nearly identical to those of Sakr
et al. who randomized 68 patients and found complications
in 24 % vs. 6 % and residual prolapse in 12 % vs. 3 %.
Transanal Hemorrhoidal Dearterialization (THD)
Key Concept: THD appears to be effective for grade II and
III hemorrhoids but has (at present) a niche role in the treatment of hemorrhoids.
The newest minimally invasive, alternative treatment
option for hemorrhoidal disease for patients who defer or
318
S.D. Holubar and D.E. Rivadeneira
have contraindication to excisional hemorrhoidectomy is
transanal hemorrhoidal dearterialization (THD) also known
as Doppler-guided hemorrhoidal artery ligation (HAL ) .
Giordano et al. performed a systematic review of the procedure which reviewed 17 studies and almost 2,000 patients
[ 27 ]. Although its place in the hemorrhoidal disease treat-
ment algorithm remains uncertain, it appears to be an effi cacious, minimally invasive option for grade II and grade III
disease. As an outpatient procedure, operative times were
typically less than 1 h, with most patients returning to work
within a few days and only 18 % of patients experiencing
pain. Acute hemorrhage was rare—seen in only three
patients. Despite these excellent short-term outcomes, at
1-year symptom recurrence was relatively common—11 %
for prolapse, 10 % for bleeding, and 9 % for painful defecation. Subsequently in a review of 170 patients, Ratto et al.
reported bleeding in 1.2 %, confi rmed residual prolapse in
10 %, and recurrent disease requiring operative intervention
in 4 % [
28 ]. In this at 1 year, bleeding and prolapse were
controlled in 94 and 90 %, respectively. Clearly results are
superior in grade II or II disease compared to grade IV disease, in which this therapy is likely a suboptimal choice [ 27 ,
28 ]. Given the paucity of high-quality data, this procedure
will not be discussed in the remainder of this chapter.
Hemorrhoidal Crisis: What Do You Decide to Do at the Time?
Key Concept: When presented with this situation, it is not the
time to be overly aggressive surgically. Stick to your basic
principles of preserving anoderm, relieve the infl ammation
and clot, and do not damage the underlying sphincter.
Hemorrhoidal crisis , defi ned as acutely incarcerated or
strangulated internal hemorrhoids with a component of secondary external thrombosis, requires expedient expert care
(Figs. 20.3 and 20.4 ). These patients usually have a past his-
tory of constipation and prolapse and present with severe
anorectal pain as well as urinary retention. In the past,
patients were treated conservatively with analgesics, ice
packs, and sitz baths given the major impendent to surgical
clot burden as well as the marked edema. However, true risk
to patients, especially if diabetic, exists with nonoperative
approach given necrotic tissue.
In order to expedite resolution of suffering, colorectal surgeons facile with excisional hemorrhoidectomy can and
should intervene selectively in single or multiple quadrants
as the distorted anatomy and comfort of the surgeon allows
excising necrotic tissue, expressing thrombosis, and reducing prolapse. Optimal intervention includes either closed or,
in the presence of signifi cant necrotic tissue, open excisional
hemorrhoidectomy (Fig.
avoid stapled hemorrhoidopexy in these circumstances for
20.5 ). In general, the authors would
Figs. 20.3 and 20.4 Hemorrhoidal crisis (Courtesy of Richard
Billingham, MD and Philip Y. Pearson, MD)
fear of the large 33-mm stapler or large dilator causing inadvertent sphincter damage. In addition, a large part of the
symptoms from this situation is from the external component—something that the stapled pexy does not address.
In 1982, C. Wang from Taiwan reported on his experience
with urgent closed hemorrhoidectomy in 56 patients [
29 ].
The reported technique specifi cally used packing to push the
mucosal fl aps against the anorectal wall and to reduce hemorrhage, and he reported excellent outcomes. More recently
20 Hemorrhoidal Disease: Postoperative Complications
319
After elective hemorrhoidectomy, in addition to taking
fi ber and increased fl uids, it is important for patients to preemptively treat and avoid narcotic-induced constipation. We
recommend fi ber twice daily, stool softener three times daily,
and if no bowel movement within 48 h, then 60 cc of milk of
magnesia every 12 h until a movement is achieved. An alternative regimen would be fi ber in the morning and MiraLax
(17 g in a tall glass of water) in the evening.
Pain Control with Narcotics, NSAIDS
Key Concept: Non-narcotics aid in reducing not only the
pain but also decreasing the need and side effects from
narcotics.
Optimal analgesia is achieved using a combination of
nonnarcotics and narcotics including, for example, maximum dose Tylenol (recently reduced from 4 to 3 g per 24 h
by the FDA due to concerns over hepatic toxicity) 750 mg by
mouth every 6 h, alternating every 3 h with 600 mg of ibuprofen with food every 6 h. Opioid-naïve patients are then
typically prescribed oxycodone 5–10 mg every hour as
needed for breakthrough pain, with titration as needed. The
amount of postoperative opioids may be reduced by the
intraoperative use of ketorolac, as well as other newer
adjuncts as described below [ 31 ].
Fig. 20.5 Wounds following excision for hemorrhoidal crisis. This
patient is the same as Fig.
Pearson, MD)
20.2 for comparison (Courtesy of Philip Y.
a randomized trial of a potentially less morbid alternative of
incising the mucosa overlying the clots (similar to as for
external hemorrhoids) with rubber band ligation was shown
to be safe and effective [ 30 ].
In our experience, the choice of what to offer the patient
depends highly on the surgeon assessment of the degree of
anatomic distortion and presence or absence of gangrenous
changes—the latter a clear indication for excision. Also, if a
less invasive approach is undertaken, without adequate
assessment of gangrene or suboptimal results, a contingency
plan for expeditious treatment must be in place if the patient
decompensates (i.e . , rural or unreliable patients may need to
be admitted for observation).
Postoperative Regimen
Bowel Management and Avoiding Constipation
Key Concept: Ensure your patient is on a proper bowel regimen postoperatively or obstipation (or extreme pain with
hard bowel movements days later) will ensue.
Sitz Baths: Do They Work?
Key Concept: Despite lack of evidence, sitz baths are widely
used and have little downside.
Used since ancient times, little level I data exist for the
effect of warm sitz (from the German word “sit”) baths on
hemorrhoidal pain, but several studies have documented that
warm water sitz baths do indeed result in a decrease in anorectal canal pressure for both fi ssure and hemorrhoid patients
32 , 33 ].
[
Patients are counseled that soaking the buttocks and anus
in warm water for 15 min four times a day is generally recommended and is thought to (1) aid in keeping the area
clean, (2) increase perfusion to aid healing (3) reduce anorectal canal resting pressure, and (4) be soothing for most but
not all patients. In our experience, sitz baths are effective for
the stated reasons, and patients should be counseled that they
are an important component of their optimal postoperative
outcome and one which they need to take responsibility for.
Preoperative Counseling and Postoperative Instructions
Key Concept: Managing patients’ expectations ahead of time
and having preprinted instructions for the postoperative
320
S.D. Holubar and D.E. Rivadeneira
Table 20.7 Post-hemorrhoidal banding patient instructions
Self-care after banding
Discomfort in rectum Sitz baths, Tylenol, ibuprofen
Constipation prevention 1st-line fi ber, 2nd-line milk of magnesia
Bleeding Minor bleeding expected
Infection Rare; if delayed urinary retention or
fever >101.3 °F (38.5 °C), then consider
proceeding to the emergency department
Passing the band Expect to not necessarily see the band(s)
pass in the stool
Recurrent symptoms Return to clinic no sooner than 6 weeks
for consideration of additional banding
period that addresses many of the commonly encountered
scenarios and questions go a long way in making this easier
on your patient (and you).
Banding
As part of the informed consent process, patients should be
counseled re: the likelihood of needing additional banding
every 4–6 weeks until the problem is cured or the patient and
the surgeon decide to try a different therapy. In addition, we
cover the possibility of vasovagal reaction (relatively common) that they may experience some additional bleeding
after the band falls off in 5–7 days, discomfort with the feeling that something is stuck in their rectum for approximately
24 h, feel the urge to defecate, and that rarely the rubber band
application of the rubber band may result in perianal sepsis
and risk of colostomy or death. Patients are counseled if they
have fever or urinary retention to proceed to the emergency
room for evaluation. Table 20.7 shows a sample of banding
patient instructions.
Stapled Hemorrhoidopexy
Patients should be counseled that the fi rst part of the operation is an exam under anesthesia, and sometimes those
fi ndings will steer us away from the stapled procedure;
you and patient should, ahead of time, discuss the possibility that the EUA may change the operative plan, and the
surgeon may recommend just banding at the time of EUA
or excisional hemorrhoidectomy. Although stapled hemorrhoidopexy results in less discomfort relative to excisional procedure, patients may still experience signifi cant
discomfort that may last as long as 2 weeks (or permanently in the setting of complications) and should be given
appropriate analgesics (i.e ., narcotics) and bowel regi-
men. Also, most of the complications of stapled hemorrhoidopexy (see below) should be discussed with the
patient, including chronic or permanent alterations in
bowel habits and permanent pain and need for additional
surgery. In general the recommendations from Table 20.7
apply, with the exception that patients may see staples as
opposed to bands.
Excisional Hemorrhoidectomy
This procedure is notoriously painful, and patient should
expect pain and discomfort for the better part of 6 weeks.
Patients need to be committed to doing sitz baths and preventing constipation that can be anticipated due to the narcotics
and also fear of painful defecation (fi ber twice daily, Colace
100 mg orally three times daily at a minimum, increased fl uid
>2 l per day). If the patient does not have a bowel movement
within 48 h of surgery despite the above regimen, then we
recommend starting 60 cc of milk of magnesia every 12 h
until a bowel movement is achieved. Use of ice packs (frozen
peas which mold to the area as they soften) may also be used
to treat discomfort and swelling. Patients also need to understand that after approximately 24–48 h, the wounds are likely
to open up and signifi cant swelling may occur. It is also a
good idea to let your patient know they may have open
wounds for weeks that will eventually heal in but may be left
with small tags that can always be removed in the offi ce.
Complications of Hemorrhoidectomy: What Are They, How Often Do They Occur, and How to Approach and Manage Them?
Key Concept: Hemorrhoidectomy typically goes very well,
but it is not a benign operation. You need to be aware of not
only how to avoid complications but also how to manage
them.
Other than surgical texts which provide exhaustive
reviews of complications [ 34 , 35 ], some of the best available,
real-world data on hemorrhoidectomy complications comes
from the University of Minnesota experience in over 21,000
patients [ 11 ]. Overall a small percentage developed a com-
plication of excisional hemorrhoidectomy. A similar, small
but interesting study (largely due to the fact that they reported
what the complications were attributable to) is a review of
over 700 Russian patients that found complications occurred
in 23.3 %—likely higher than many surgeons would estimate
[ 36 ]. They found that one-quarter of these were attributable
to occult concomitant anorectal pathology at the time of the
hemorrhoidectomy, one-third attributable to the excision
itself, and 36 % attributable to systemic disease. A summary
of complications is shown in Table 20.8 .
Urinary Retention
One of the more common occurrences after excisional hemorrhoidectomy, urinary retention can be a nuisance for
patient but can also predispose to urinary tract infection secondary to repeated catheterization. The University of
Minnesota study [ 11 ] reported that 20 % of patients
developed either urinary retention or infection. Retention is
20 Hemorrhoidal Disease: Postoperative Complications
Table 20.8 Complications of excisional hemorrhoidectomy [ 36 ]
Frequency Possible preventive measures Management
Pain 100 % Preemptive analgesia, avoid excessive anoderm
(skin) excision. Preoperative expectation
management
Skin tags Common Preoperative expectation management Consider excision only if associated with exceptionally
Urinary
retention
Incontinence 2–12 % Avoid incising sphincter muscle. Patient selection
Recurrent
hemorrhoids
Hemorrhage 2–6 % Completion anoscopy, packing, hold aspirin,
Stricture/severe
anal stenosis
Infection/
chronic open
wounds
Whitehead deformity
Wet anus and
pruritus ani
Chronic pain ? Avoid excising posterior midline Defi ne and treat underlying source of pain
2–36 % Limit intraoperative fl uids, mandatory voiding, and
bladder scans prior to discharge
(avoid excision in patients with preexisting
incontinence)
<10 % Optimal patient selection and technique,
preoperative expectation management
NSAIDs, antiplatelet agents preoperatively
<6 %
<6 %
? Do not excessively exteriorize the advanced
? Do not excessively exteriorize the advanced
Avoid excessive excision without adequate mucosal
bridges between quadrants
Avoid excessive excision without adequate skin
bridges between quadrants. Preoperative smoking
cessation/nutritional optimization
mucosa beyond the dentate line
mucosa beyond the dentate line. Avoid incising
sphincter muscle. Patient selection (avoid excision
in patients with preexisting incontinence)
Tylenol, NSAIDs, narcotics, bowel regimen
poor hygiene and/or quality of life and not stenotic
Intermittent clean catheterization, Foley catheterization,
outpatient follow-up
Seepage and soiling usually resolves by 8 weeks. Pads,
bulking agents, antimotility agents. Kegel exercises,
pelvic fl oor retraining
Banding, redo excision
Exam under anesthesia, suture ligation
Anal self-dilation, dermal advancement fl aps/anoplasty
Wound hygiene, bulking agents, nutritional optimization
Dermal advancement fl aps/anoplasty
Dietary changes, bulking agents, antimotility agents. If
ectropion, then anoplasty with excess mucosal excision
and anchoring of cut mucosal edge +/− dermal
advancement fl ap
321
certainly multifactorial and related to excess IV fl uids, rectal
pain and spasm, and narcotics. (See preventative strategies at
the end of this chapter and in Table 20.8 .) Typically patients
will require placement of a Foley catheter with a leg bag for
3–7 days, followed by successful resolution following a “fi ll
and pull” in the clinic setting.
Hemorrhage
Early acute postoperative hemorrhage after excisional hemorrhoidectomy, defi ned as within the fi rst 24 h, is a technical
error from inadequate suture ligation of the apex of the hemorrhoidal pedicle. Delayed hemorrhage is typically reported
at 2.4–6 % [ 11 , 34 ] and may represent disruption of the ped-
icle suture by erosion or destruction by sepsis and is likely
unavoidable in most cases. Although the vast majority of
cases are self-limiting, moderate to severe stenosis will often
require a repeat examination under anesthesia and suture
ligation.
Whitehead Deformity
Mucosal ectropion (Fig. 20.6 ) is a complication most com-
monly seen after Whitehead operation, also known as circumferential hemorrhoidectomy. Currently, in the early
twenty-fi rst century, given the success and durability of
3-quadrant open or closed excisional hemorrhoidectomy,
Fig. 20.6 Mucosal ectropion following circumferential hemorrhoidectomy (Courtesy of W. Brian Sweeney, MD)
relatively few colorectal surgeons have been trained in the
procedure or perform it commonly. Nonetheless, it can still
result from excessive hemorrhoidectomy and/or improper
technique of suturing the mucosa not approximately to, but
distally to, the dentate line and or anal verge or suturing
excessive/prolapsing mucosa. Such improper technique can
also lead to anal stricture. When confronted with this situation, resection of the excess mucosa and bilateral fl aps are
often successful (Fig. 20.7 ).
322
S.D. Holubar and D.E. Rivadeneira
Fig. 20.7 Completed bilateral house fl aps for mucosal ectropion
(Courtesy of W. Brian Sweeney, MD)
Fecal Incontinence
Frank fecal incontinence after hemorrhoidectomy is rare;
however, continence alteration may be relatively common
(2–12 %) and likely due to preexisting incontinence in older
or female patients with altered pelvic fl oor. This may be
partly attributable to anal retracting/exuberant exam under
anesthesia or rarely can be seen in the case of massively
chronically prolapsing hemorrhoids where the chronic clot
has fi brosed and obliterated the normal anatomic planes suffi ciently to allow the surgeon to damage the external sphincter inadvertently (Fig. 20.8 ). Incontinence to fl atus is likely
more common given the proximity of the hemorrhoidal bundle to the internal sphincter, especially those already at risk.
This is also the main reason not to perform concomitant
sphincterotomy. We prefer to approach these patients with
bulking agents, bowel-slowing medications (i.e., Imodium),
and, more than anything, allowing suffi cient time to determine the ultimate function, as most will improve.
Anal Stricture
Anal stricture, estimated to occur in 0–6 % of patients after
hemorrhoidectomy, represents the trading of one surgical
disease for another (Fig. 20.9 ) [ 37 ]. Patients with very large
essentially circumferential hemorrhoidectomy, in whom a
three-quadrant or circumferential excision is undertaken and
the wounds are closed under tension, are prone to develop
this complication. It can certainly also develop in lesser cases
in patient known to be predisposed to excess scar formation.
The underlying pathophysiology is lack of elastic tissue
encircling the sphincter complex, with removal of the anoderm, preventing iris-like dilation during defecation.
Treatment is anoplasty with healthy elastic perianal skin is
Fig. 20.8 Chronic grade three hemorrhoids. Note the chronic hypertrophic skin changes and mucosa with stigmata of recent bleeding
Fig. 20.9 Anal stenosis following hemorrhoidectomy. Note the small
maximal diameter with eversion of the anal canal (Courtesy of W. Brian
Sweeney, MD)
brought into the anal canal (Fig. 20.10 ). Severe, circumfer-
ential anal canal stenosis is rare and typically managed either
by chronic self-dilation with Young’s dilators [ 34 ] or dermal
advancement fl aps such as house, V-to-Y, or diamond fl aps.
Chronic Open Wounds
In a review of 1,184 hemorrhoidectomies, Pattan-arun found
that at 2 weeks, although wound dehiscence was found in
2 %, irrespective if the case was done urgently for hemorrhoidal crisis or electively, by the fourth postoperative week
all had healed without stricture [ 38 ]. We have not always had
this success rate at 4 weeks, and typically tell our patients
their wounds may be open for 6–8 weeks prior to fi nal closure. A small percentage of patients will continue to have
20 Hemorrhoidal Disease: Postoperative Complications
323
Fig. 20.10 House fl ap anoplasty for anal stenosis (Courtesy of W.
Brian Sweeney, MD)
found good results with avoiding soaps and other methods in
attempt to “clean” the area. Also, Calmoseptine® ointment
(Calmoseptine Inc), using non-deodorant baby wipes, cotton
balls at the anal verge for moisture wicking, and avoidance
of scratching all are part of a regimen to relieve symptoms.
Chronic Pain
Chronic pain is rare. While it has been described more commonly following PPH, it may also be seen after hemorrhoidectomy. We refer you to the excellent chapter in this text by Drs.
Bastawrous and Billingham on the approach to this condition.
Skin Tags (They Want It Flat!)
Excision of the external component of hemorrhoids is a standard part of excisional three-quadrant hemorrhoidectomy.
However, patients must be counseled regarding the possibility
of residual skin tags. While the patient or surgeon quest for
“the perfect anus” is plausible, it may result in anal stenosis or
anal fi ssuring—thus, trading one problem for another, potentially more troublesome, and more diffi cult to treat, problem.
However, removal of small external tags following a hemorrhoidectomy is often easily accomplished in the clinic.
Fig. 20.11 Chronic open wounds following 3-quadrant hemorrhoidectomy (Courtesy of Richard Billingham, MD)
open wounds (Fig. 20.11 ). We have found anecdotally that
10 % metronidazole ointment applied bid has worked well in
this situation. You should always consider the possibility of
underlying Crohn’s disease in these patients. Occasionally,
in the absence of healing, you may need to perform a
dermal fl ap.
Wet Anus and Pruritus Ani
This complication can result either from lack of approximation of the anal cushions resulting in mucus seepage, pH
alterations, and chronic perianal itching or from mucosal
ectropion. Depending on the source, this often resolves with
complete healing of the wounds. Ectropion (as above) may
require revisional surgery. While the causes of pruritus ani
are extensive (and beyond the scope of this chapter), we have
Recurrent Hemorrhoids
Management of recurrent disease may be strongly infl uenced
by prior excisional hemorrhoidectomy. Reassessment of all
the baseline characteristics is mandatory, including lifestyle
modifi cation and weight reduction and reevaluating the need
for colonoscopy, as is obtaining the initial consultation and
operative reports. Consideration of other previously recognized factors, which may be infl uencing the symptoms of
bleeding, as simple as noncompliance, or as complex as
unrecognized bleeding diatheses or original misdiagnosis is
crucial prior to recommending optimal treatment.
Depending on the size of the problem, the recurrence may
now be amenable to banding or in select cases a directed
hemorrhoidectomy ensuring you leave enough anoderm to
avoid stricture.
Banding Complications
Key Concept: While several of the complications seen with
excisional hemorrhoidectomy can also occur with banding,
unique complications do occur with this procedure that you
need to be familiar with and counsel your patients
accordingly.