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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_894_Библиотеки_им_академика_М_И_Перельмана.pdf
288
Fig. 17.4 Banding an
internal hemorrhoid. The
internal hemorrhoid is
teased into the barrel of
the ligating gun with (a),
a suction (McGown)
ligator, or (b), a
McGivney ligator. (c)
The apex of the banded
hemorrhoid is well
above the dentate line in
order to minimize pain
D. E. Beck
a
b
A suction ligator (McGown, Pembroke Pines,
Florida) draws the hemorrhoid bundle into the
ligator barrel and closing the handle places the
band around the hemorrhoidal tissue. With a
Barron or McGivney ligator (Electro-Surgical
Instrument Co, Rochester, NY), an atraumatic
clamp (Fig.17.4) is used to retract mucosa and
redundant hemorrhoidal tissue at the apex of the
bundle into the applicator and a small rubber
band is placed. This tight band causes ischemia
of the enclosed tissue. After it necroses, the tissue
sloughs, forming a small ulcer. Excess tissue is
eliminated and as healing occurs, the remaining
lining becomes xed in the anal canal. Rubber
band ligation works best for Grade 2–3 internal
hemorrhoids.
Several points require additional elaboration.
First, it is crucial that the bands be placed on
tissue entirely covered by anal mucosa. If bands
are placed too distal and include any somatically
enervated skin, the patient will develop excruciating pain. The pain is usually so severe that the
c
patient will demand removal of the band. To prevent this from occurring, it is recommended that
bands be placed at the apex of the hemorrhoid
bundle or just cranial to it. As an additional check,
the proposed site of banding is tested by placing
a clamp on the mucosa. If the patient feels the
pain, the procedure should be abandoned. It is
important that the clamp is not pulled after being
applied. As the anal and rectal mucosa is sensitive
to stretch, traction on the mucosa will produce
inappropriate pain.
A second consideration, when using a Barron
type ligator, is to resist too forceful retraction of
the hemorrhoidal tissue. If pulled too hard, the
hemorrhoidal tissue may be torn, resulting in
hemorrhage that is sometimes difcult to control.
This type of bander also requires two hands and
an assistant to stabilize the anoscope during the
procedure. The McGown ligator can be used with
one hand, but it is more difcult to control the
amount of tissue drawn into the bander.
Finallysome providers preload two bands on the
17 Hemorrhoidal Disease
289
applicator to ensure tissue constriction and
guard against slippage and breakage [5]. Other
providers have advocated injecting the pedicle of
tissue contained within the band with saline or
xylocaine. This injection causes the pedicle to
swell, which reduces the chance of the bands
slipping off prematurely.
Controversy exists about the appropriate number of hemorrhoidal bundles that can be banded
at one session [24]. The author prefers to treat
one or two bundles at a time. Banding this number eliminates symptoms in most patients, does
not produce too large an amount of banded tissue
in the anal canal or cause excessive discomfort,
and probably leads to efcient care [25, 26].
Before leaving the ofce, patients are
instructed both verbally and in writing that after
banding they may experience a feeling of incomplete evacuation. The sensation of fullness is
from the bunched tissue in the anal canal. If the
urge to defecate or urinate is noted, patients are
instructed to sit and try to pass the stool. If no
stool is produced, they should refrain from prolonged straining. At 5–7days after treatment the
bands and necrotic tissue will slough which may
be associated with a small amount of bleeding. If
the symptoms have not resolved at reexamination
2–6 weeks later, additional bands are placed.
Normal activities can otherwise be resumed
immediately after banding.
Complications are infrequent with rubber
band ligation (<2%) [17]. They vary from
transient problems such as a vasovagal response
on placement of the bands, to anal pain, or
rarely pelvic sepsis. The vasovagal response to
banding includes diaphoresis, bradycardia,
nausea and mild hypotension. Reassuring the
patient, elevating their feet, and applying a cold
compress to the patient’s forehead are frequently
all that is necessary. Symptoms should resolve
in 10–15 min. Despite the rarity of pelvic
sepsis, the devastating sequelae make it
worthwhile to explain the heralding symptoms
as part of the ofce discharge instructions.
Accordingly, patients must know that if the
pain increases instead of decreases, urinary
retention or fever develop, they should immediately contact their physician.
Pain occurs due to incorporation of somatically enervated tissue into the band. This occurs
when the band is placed too close to the dentate
line or the internal sphincter muscle is included
into the band (i.e. too much tissue included within
the band). In this case, the pain is acute in onset at
the time of banding. Mild pain can be managed
with analgesics such as propoxyphene napsylate
and acetaminophen or injection of a local anesthetic (e.g. 0.5% xylocaine hydrochloride or
0.25% bupivacaine hydrochloride). More intense
pain is best managed by removal of the band by
hooked scissors or a hooked cutting probe
(Fig.17.5). Most patients will require injection of
local anesthetic in order to remove the band. Pain
and swelling that develop several hours after
banding may be due to edema and thrombosis distal to the banded area, which can usually be managed by conservative measures. Increasing rather
than decreasing pain may require emergency evaluation by the surgeon.
Not infrequently, younger patients with
high anal tone may experience mild to severe
anismus. Also, fear of pain may cause patients
to delay defecation as long as possible, leading
to harder stools that are more difcult to pass.
For these reasons patients should be carefully
counseled as to what to expect after banding.
Fecal impaction is best avoided by limiting
narcotic use, adding stool softeners and
maintaining adequate hydration.
Secondary thrombosis of external hemorrhoids may occur in 2–11% of patients [27]. As
with spontaneous thrombosis, mild symptoms
can be treated with topical preparations and Sitz
baths. More severe complaints may require excision. Urinary retention is not common with rubber band ligation. When it does occur, onset is
shortly after banding and will often resolve spon-
Fig. 17.5 Hooked probe for use in cutting misplaced
rubber bands
290
D. E. Beck
taneously, or may require one time catheterization. The development of difcult urination or
urinary retention days after the procedure may
herald pelvic sepsis as described below.
Delayed hemorrhage may also occur, usually
7–10 days postprocedure as the banded tissue
sloughs. Patients should be cautioned that they
might notice a small amount of bleeding which
usually requires no treatment. Major bleeding is
fortunately very rare, 0.5% out of 600 patients
reviewed by Rothberg and others [27, 28].
Signicant bleeding demands immediate attention and may require suture ligation in the operating room. To minimize the risk of hemorrhage
after banding, some providers ask their patients
to refrain from any aspirin products before and
after banding. However, little prospective data
are available on the risks associated with aspirin
use and post-banding hemorrhage. The experience with other anticoagulants such as warfarin is
even less. With the increasing use and need for
anticoagulants, individual decisions must be
made on the risks of stopping the anticoagulant
and potential thrombosis compared to the risk of
bleeding while remaining on the medication. The
author currently bands patients on anticoagulation and has not seen signicant post banding
bleeding.
The most serious complication is post-banding
sepsis, which is believed related to necrosis from
the banded tissue, allowing adjacent soft tissue to
become infected [2]. First reported in 1980, it is
associated with fever, perineal or pelvic pain or
both, and difculty urinating [29, 30].
Development of these symptoms after banding
mandates urgent evaluation. A pelvic CT scan
will often demonstrate changes compatible with
pelvic sepsis. Some patients may require an
anesthetic to adequately evaluate the perineum.
Large doses of broad-spectrum antibiotics to
include Clostridial coverage are indicated for
empirical treatment to reduce the risk of
potentially fatal sepsis. Operative debridement
and removal of the bands is reasonable, and in
cases of overwhelming infections a diverting
colostomy may also be required [17]. This
problem is discussed in greater detail in Chap. 10.
The results with rubber band ligation have
been excellent with patient satisfaction of
80–91% in large series, but probably only
60–70% of patients have been completely cured
of symptoms by one treatment session [31–33]. If
two banding sessions do not ameliorate the symptoms, an alternative form of therapy (hemorrhoidectomy) should be contemplated.
Infrared Photocoagulation
A newer technique, rst described by Neiger
[34], is photocoagulation. Infrared radiation,
generated by a tungsten-halogen lamp, is focused
onto the hemorrhoidal tissue from a gold-plated
reector housing through a solid quartz glass
light guide (Redeld Corporation, Montvale, NJ)
using technology similar to laser devices [2]. The
infrared coagulator (IRC) (Fig. 17.6) light
penetrates tissue to the submucosal level and is
converted to heat, leading to inammation,
destruction, and eventual scarring of the treated
area [35]. The tip of the instrument is applied to
the base of the hemorrhoid and a 1–1.5s pulse of
energy is delivered. This produces an immediate
area of coagulation of 3–4mm2 in diameter. This
area ulcerates and eventually scars over the
subsequent 2 weeks. Three or four applications
are applied to the base of each treated hemorrhoid
(Fig. 17.7). Most authors have recommended
treating only one or two bundles per visit.
Additional treatment if necessary can be
performed every 3–4weeks. However, clinicians
need to be aware that Medicare has placed a
90-day global on reimbursement for IRC.
Fig. 17.6 Infrared photocoagulator
17 Hemorrhoidal Disease
Fig. 17.7 The infrared
photocoagulator creates
a small thermal injury.
Thus several
applications are required
for each hemorrhoidal
column (From Beck
DE.Hemorrhoids. In
Beck DE. (ed)
Handbook of Colorectal
Surgery. 3rd ed. JP
Medical, London, 2013.
With permission)
291
Sites of
Coagulation
Complications with this technique have been
infrequent. Pain can occur if the energy is
inappropriately delivered to the anoderm rather
than the base of the hemorrhoid (Fig. 17.5).
Excessive application can also lead to bleeding.
Most authors report the incidence of bleeding is
considerably less with photocoagulation
compared with banding [5]. In one study of 51
patients, three developed anal ssures after
treatment, and no other complications were
noted after a median follow-up of 8 months
[36]. As mentioned, ulcer formation is an
expected result of both rubber band ligation as
well as IRC. The resultant scarring creates
xation. However, large ulcers may rarely be
associated with ssure formation and persistent
complaints.
The IRC works best on patients with small
bleeding hemorrhoids (rst or second degree).
The number of bundles treated is similar to that
described for banding. An advantage of this
technique is that the maximum discomfort occurs
at the time of IRC treatment and not at a later
time as seen with incorrectly placed bands.
Disadvantages of this technique are the cost of
the instrument is signicantly higher than a
bander and this method is less effective in
eliminating bulky hemorrhoids [17].
Sclerotherapy
Sclerotherapy, one of the oldest forms of therapy,
aims to cause scaring, thereby xation, and
eventual shrinking of hemorrhoidal tissue.
Sclerotherapy works by obliterating the vascularity
of the hemorrhoids, xing them to the adjacent
anorectal muscularis propria and preventing
prolapse. In 1869, John Morgan described
injection of iron persulphate into external
hemorrhoids [37]. Since then, various substances
have been used [38]. Quinine and urea (5%
solution), phenol (5% in almond oil), and sodium
tetradecyl sulfate (1–3% solution) are the agents
currently in use. Most practitioners inject three to
ve milliliters of the sclerosing solution into the
submucosa of each hemorrhoidal bundle, 1cm or
more above the dentate line using a 25-gauge
spinal needle or a specialized hemorrhoid (Gabriel)
needle. The proper site of injection is just proximal
to the hemorrhoidal plexus and the injection
should be sufciently deep to not blanch the
mucosa, but not too deep as to injure the underlying
muscle. Pain occurs if the needle is too deep
causing spasm of the sphincter muscle or too distal
in the anal canal with sclerosant irritating the
sensitive somatic nerves distal to the dentate line
[2]. Contraindications to sclerotherapy include
inammatory bowel disease, portal hypertension,
292
D. E. Beck
immunocompromised states, anorectal infection,
and prolapsed thrombosed hemorrhoids [2].
Complications of sclerotherapy are related to
incorrect placement or excess injection of sclerosing agent [17]. The most frequent problem is
supercial sloughing of the hemorrhoidal
mucosa, which generally heals without treatment. Excessive sloughing may lead to scarring
and stricture. Sclerotherapy may also precipitate
thrombosis of an adjacent hemorrhoidal complex. If the thrombosis is severe, it may require
excision. Most patients, however, can be managed with Sitz baths, a high ber diet, and local
measures. Due to the potential for scarring and
stricture, repetitive use of sclerotherapy is not
recommended. More unusual complications of
sclerotherapy are abscess or oleoma, a granulomatous reaction to an oil-based sclerosant [30].
Results of sclerotherapy have been sparsely
reported and difcult to compare to other forms of
treatment [2]. Alexander-Williams and Crapp [39]
compared injection to freezing and rubber band
ligation and found it “satisfactory” over shortterm follow-up in Grade 1 (rst degree)
hemorrhoids. Denckner and associates [40]
compared sclerotherapy to a variety of other
treatments and found it to be satisfactory in only
21% of patients. Although the results produced by
this method are similar to IRC, sclerotherapy is
being used with less frequency. Similar to IRC,
sclerotherapy works best for Grade 1 or 2
hemorrhoids [6].
Cryotherapy
Cryotherapy is discussed for completeness, but it
is infrequently used. Through a cryoprobe
inserted into the anus, cold (liquid nitrogen) is
delivered to freeze a hemorrhoidal bundle. One
disadvantage is the inability to control the amount
of destruction that occurs. A prolonged, necrotic
tissue slough results, causing increased pain and
an unpleasant anal discharge [28].
Cryotherapy is based on rapid freezing and
thawing of tissue, which theoretically causes
analgesia and tissue destruction. The “ice ball” that
forms around the cryoprobe approximates the
extent of tissue destruction. Although initial reports
were optimistic [41, 42], subsequent experience
demonstrated signicant problems [2, 17]. After
therapy, patients experienced signicant pain and a
profuse foul discharge from the treatment sites.
Healing frequently took 6 weeks or more [43].
Smith and colleagues [44] randomly treated 26
hemorrhoid patients with cryotherapy on one side
of the anus and a closed hemorrhoidectomy on the
other side. Pain was more prolonged and a foulsmelling discharge persisted on the cryotherapy
side, and six of the seven patients who required
additional treatment needed it at the cryosurgical
site [44]. The expensive cumbersome equipment
and signicant side effects have led to almost total
abandonment of this technique.
Electrocautery
Bipolar and direct current devices are currently
available for electrocautery. Bipolar diathermy
uses a bipolar radio frequency (RF) electric current to generate a coagulum of tissue at the end of
a cautery-tipped applicator (Circon ACMI,
Stamford, CT). Patient grounding is not necessary and a 2-s pulse is applied to the base of each
hemorrhoid. Yang and colleagues treated 25
patients with bipolar electrocautery (BPEC) in a
prospective controlled trial [45]. Ulcerations
developed in six patients (24%) and caused minor
rectal pain and self-limited fever. One patient
experienced prolonged pain lasting greater than
1day after therapy and two patients (8%) developed uncontrolled bleeding. In another study of
51 patients, ssures were seen in 2 patients (4%)
[36]. This technique has not been widely accepted
because of the expense of the equipment and lack
of results superior to results with other methods.
Direct current therapy uses a special probe
(Ultroid, Microvasive, Watertown, MA) to deliver
an electrical current (of up to 16mA) to the internal hemorrhoid. The technique entails delivering
the current for up to 10min to each hemorrhoid.
In the randomized study of 25 patients by Yang
etal. [45], 5 patients (20%) had to have the procedure terminated due to pain, 4 patients (16%)
had prolonged pain after the procedure, and 1
patient (4%) had uncontrolled bleeding. The
equipment for both methods is expensive, and
neither method offers any advantage over the
methods previously described [17].
Dilatation
In 1968, Lord described his technique of
dilatation for the treatment of symptomatic
17 Hemorrhoidal Disease
293
hemorrhoids [46, 47]. The treatment is based on
the premise that increased anal pressure contributes to hemorrhoid symptoms [13]. The procedure entails careful but rm dilatation of the anal
canal. Two lubricated ngers of the surgeon’s
hand are inserted into the anorectum and the anus
is pulled laterally, then two ngers of the other
hand are inserted and counter traction is applied.
With increasing dilatation and traction additional
ngers are inserted until the lower rectum can
accommodate up to eight of the operator’s ngers. The amount of dilation varies: the purpose
is to dilate and “iron out” the anorectum until no
“constrictors” remain. Lord cautions that it is
safer to do too little than too much. Patients were
also instructed to use a dilating cone after the
procedure. The necessity of this postoperative
dilation has been questioned [13]. Although used
extensively in Europe with excellent results,
some patients complain of incontinence after
the procedure. An unacceptably high rate of
incontinence occurred in 40% of patients during
the rst month after dilatation in one study [48].
Fortunately most episodes were minor and
resolved with additional follow-up. This treatment option has not gained wide acceptance in
North America [13]. A new a variation on dilatation uses a hydrostatic balloon dilator, which
allows the operator to control the pressure and
volume in a more graduated and reproducible
fashion.
Internal Anal Sphincterotomy
This treatment has been recommended for hemorrhoids for precisely the same theories to which
Lord subscribed. Sphincterotomy seems an
inherently more controlled technique to lower
anal pressure [49]. The technique may be done
under local anesthesia, but in 25% of cases, some
degree of minor transient incontinence may occur
[50]. However, sphincterotomy does not address
associated tags or external hemorrhoids.
A controlled study by Arabi and colleagues
[50] showed no improvement in results when an
internal anal sphoncterotomy was compared to
rubber band ligation in early hemorrhoids, and
Shouten and van Vroonhoven [51] demonstrated
only a 75% success rate with sphincterotomy
alone. Leong and colleagues found no
improvement when internal sphincterptomy
was combined with other procedures such as
hemorrhoidectomy [52]. Although sphincterotomy may be reasonable in the surgical treatment
of hemorrhoids with concomitant anal ssure,
neither the author nor editors recommend its use
as the sole treatment for isolated hemorrhoidal
disease [2]. In addition, most surgeons would be
very hesitant to perform sphincterotomy in
patients with lax sphincters or in elderly patients
for hemorrhoidal symptoms.
Stapled Rectopexy or Procedure
forProlapse and Hemorrhoids (PPH)
Stapled rectopexy, also referred to as Procedure for
Prolapse and Hemorrhoids (PPH), involves transanal, circular stapling of redundant anorectal
mucosa with a modied circular stapling instrument (Proximate PPH 03, Ethicon Endosurgery,
Cincinnati, OH or HEM 3348, Covidien,
Minneapolis, MN). There is continued debate
about the mechanisms by which this procedure
relieves symptoms. As hemorrhoids are thought to
be redundant brovascular cushions, most treatments reduce blood ow and remove redundant tissue. Stapled rectopexy is thought to work by similar
mechanisms. Redundant mucosa is drawn into the
instruction and excised within the “stapled doughnut.” Additionally, mucosal and submucosal blood
ow is interrupted by the circular staple line. No
incisions are made in the somatically innervated,
highly sensitive anoderm, which signicantly
reduces postoperative pain. The procedure involves
techniques that are different from more common
surgical procedures. Proper technique with meticulous attention to detail is required to get a successful result and avoid the serious complications that
have been reported.
Patients are prepared as for a standard hemorrhoidectomy with partial or complete mechanical
bowel preparation. General, spinal, and local
anesthesia have all been described. Patients may
be positioned in prone, lithotomy, or Sim’s position depending upon the surgeon’s preference.
After thorough examination of the anal canal
and perianal tissues, a specially designed anoscope
in inserted and a pursestring suture is placed. The
pursestring should be 2–4 cm proximal to the
dentate line and include only mucosa and
submucosa. Suture “bites” should be close together
as large gaps will allow redundant mucosa to evade
294
D. E. Beck
the stapler resulting in persistent hemorrhoids.
Most surgeons place eight bites of the pursestring
suture. The circular stapling instrument is then
introduced (usually a 33 mm), fully opened, into
the anal canal, and the suture tightened between the
anvil and shaft of the instrument. Ends of the suture
are drawn through slots of the stapler drawing
distal redundant mucosal proximally into the jaws
of the stapler. After tightening the stapler, a nger is
anovaginal septum has not been included within
the stapler. The stapler is then red and removed
(Fig. 17.8). Following this, the staple line is
inspected for gaps and particularly for bleeding
points, which can then be cauterized or oversewn.
Some authors routinely place three gure of eight
sutures at the location of the primary hemorrhoidal
bundles to minimize the chances of postoperative
bleeding.
placed transvaginally in females to assure that the
abc
def
Fig. 17.8 Stapled rectoplasty (procedure for prolapse
and hemorrhoids [PPH]). (a) Retracting anoscope and
dilator inserted. (b) Monolament pursestring suture
(eight bites) placed using operating anoscope approximately 3–4 cm above anal verge. (c) Stapler inserted
through pursestring. Pursestring suture tied and ends of
suture manipulated through stapler. (d) Retracting on
suture pulls anorectal mucosa into stapler. (e) Stapler
closed and red. (f) Completed procedure
17 Hemorrhoidal Disease
295
A meta-analysis of randomized trials between
2000 and 2013 comparing Milligan-Morgan to
PPH, identied 1343 patients. The PPH had shorter
operative time, duration of hospitalization, and
return to normal activity. PPH had better patient satisfaction, but higher rate of prolapsed and need for
subsequent surgery [53]. A multicenter prospective
controlled trial with long-term follow-up compared
stapled rectopexy to a modied Ferguson technique
[54]. The authors demonstrated that stapled rectopexy offered less postoperative pain, less requirement for analgesics, and less pain at rst bowel
movement, while providing similar control of
symptoms and need for additional hemorrhoid
treatment at 1-year follow-up from surgery.
In summary, stapled rectopexy is a technique
available to patients otherwise requiring surgical
hemorrhoidectomy. In published studies, stapled
rectopexy it is associated with signicantly less pain
and similar complication rates when compared to
conventional treatment. Considering the technique,
however, the potential for disastrous complications
may be higher (rectovaginal or rectourethral stula
due to including too much tissue within the pursestring). Bleeding also remains a problem and cases
of perforation and leaks have been reported. It is
also important to note that stapled rectopexy has not
been compared to ofce treatments for grade I and
II hemorrhoids and should not replace thesetechniques for minimally symptomatic hemorrhoid disease. The proven decreased pain of PPH as
compared to excisional hemorrhoidectomy may
justify its use despite a potentially increased incidence and spectrum of serious complications and
recurrence. If the PPH approach is desired, meticulous surgical technique is mandatory.
Transanal Hemorrhoidal Dearterialization (THD)
A newer addition to surgical armamentarium
is Doppler-guided arterial ligation with
hemorrhoidopexy (Fig.17.9) [56]. The technique
has evolved and currently uses a Doppler-guided
ligation of hemorrhoidal arterial inow with a
suture rectopexy. There are currently two
commercial products available in the US [57].
Transanal hemorrhoidal dearterialization (THD,
American Ankeny IA) and hemorrhoidal artery
ligation and recto anal repair (HAL/RAR, A.M.I,
Inc., Natck, MA). These non excisional techniques
rely on detection and ligation of the branches of the
superior hemorrhoidal artery in the mucosa that
lacks sensation, well above the dentate line. The
associated suture rectopexy reduces the redundant
prolapsing mucosa and internal hemorrhoids.
The procedure is performed in the operating
room and requires anesthesia similar to a traditional hemorrhoidectomy. A specially designed
anoscope with a removable Doppler ultrasound
probe and a slot for suture placement is used.
After insertion, the anoscope is rotated until one
of the arterial branches is located. Through the
anoscope slot the vessel is suture ligated (2–3cm
above the dentate line). Loss of the Doppler signal conrms accurate placement of the ligating
suture. After ligating the vessel, the suture is used
to oversew the internal hemorrhoid with a running technique from proximal to distal direction.
The suture is completed proximal to the dentate
line to minimize pain. Usually four to six arteries
are ligated and depending on the patient’s anatomy and two to four hemorrhoids and xated.
Step 1 Step 2 Step 3
Fig. 17.9 Transanal hemorrhoidal dearterialization (THD) device
296
D. E. Beck
The operation has a short operating time and
purports to accomplish the same goals as a stapled
hemorrhoidopexy [56]. It is an operative procedure
which includes anesthesia risks, operating room
expense, and surgical risks of bleeding, infection,
urinary retention, hematoma, and postoperative
pain. The specialized anoscope and Doppler probe
are disposable and add cost to the procedure which
is somewhat less than a stapled hemorrhoidopexy.
A variety of publications have documented safety,
reduced pain and short recovery with the technique
[58]. It appears effective for grades 2 and 3 hemor-
rhoids, but long-term results and cost-benet analysis need additional study.
External Hemorrhoids
Acute Thrombosis
The management of thrombosed external hemorrhoids depends on when in the course of the
disease the patient presents [5]. The natural
course of this condition starts with thrombosis of
an external hemorrhoid. This event is often associated with effort or straining (moving or lifting
furniture, heavy exercise, etc.). The tissue around
these clots swells causing moderate to severe
pain. If not treated, in 2–4weeks, the clot in the
thrombosed vessels will either spontaneously
drain through the thinned overlying skin or be
gradually resorbed and the discomfort will gradually diminish. After resolution, redundant anal
skin will remain which is usually asymptomatic
and requires no treatment. If a tag causes irritation or difculty in cleansing the anal area, a conservative excision under local anesthesia can be
performed in the ofce.
If symptoms have stabilized or are improving,
nonoperative care including stool bulking agents
and pain medication are indicated. The patient
should be reassured that the symptoms will resolve
in 1–2weeks. If the patient presents early, the procedure of choice is excision (Fig. 17.10). The
remaining wound may be left open or closed.
The goal with excision is to remove the clots and
leave a cosmetically pleasing wound. The proce-
ab
Fig. 17.10 Thrombosed external hemorrhoid. (a) Site of
incision. (b) Running stitch for wound closure (From
Beck DE.Hemorrhoids. In Beck DE. (ed) Handbook of
Colorectal Surgery. 3rd ed. JP Medical, London, 2013.
With permission)
ab
cd
17 Hemorrhoidal Disease
297
dure can be performed with local anesthesia.
Incision and drainage has no role as it removes
only a portion of the clot, may not adequately
relieve symptoms, and leaves excess skin when
healing occurs.
Operative Hemorrhoidectomy
For symptomatic combined external and internal
hemorrhoids, a hemorrhoidectomy is indicated
[59, 60]. Several different operative techniques
have been described [13]. Each of these procedures can be performed with general, spinal or
local anesthesia. The choice must be individualized for each patient, but the national trend is
toward local anesthesia. With a general anesthetic, the author prefers the Sims’ (left lateral
decubitus) (Fig. 2.1) position, although the editor
(SDW) prefers the prone jack-knife position.
With all other anesthetics, the prone jackknife
position is used (Fig. 2.1). The anus is prepared
with a povidone-iodine solution. If a local anesthetic (1% xylocaine with 1:100,000 epinephrine) is not being used, the anal submucosa is
inltrated with plain 1:100,000 epinephrine solution. The perineum is re-prepped and draped. An
examination conrms the preoperative ndings
and determines the number of hemorrhoidal bundles to be excised.
The preferred procedure of both the author
and editors is a modied closed Ferguson
technique [13, 61]. A medium or large Hill-
Ferguson or Fansler retractor placed in the anus
exposes a hemorrhoidal bundle. A double
elliptical incision is made in the mucosa
(Fig.17.11). For a pleasing cosmetic result, the
incision should be at least three times as long as
Fig. 17.11 Excisional
hemorrhoidectomy. (a)
Double elliptical
incision made in mucosa
and anoderm around
hemorrhoid bundle with
a scalpel. (b) The
hemorrhoid dissection is
carefully continued
cephalad by dissecting
the sphincter away from
the hemorrhoid. (c)
After dissection of the
hemorrhoid to its
pedicle, it is either
clamped, secured, or
excised. The pedicle is
suture ligated. (d) The
wound is closed with a
running stitch. Excessive
traction on the suture is
avoided to prevent
forming dog ears or
displacing the anoderm
caudally