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Chapter2
HemorrhoidectomyUsinga BipolarElectrothermalDevice (BED)andVibratory (Harmonic)Energy(VE)
WilliamC.Cirocco,GuyR.Orangio,KurtG.
Davis,andSyedG.Husain
“Havinggottheanustoprotrudeasmuchaspossible, fomentwithhotwater,andthencutofftheextremities ofthehemorrhoids.”
—Hippocrates∼400B.C.
1

INDICATIONS/CONTRAINDICATIONS

SinceHippocratesthequestforapainless,bloodlesshemorrhoidectomy hasbeenanelusivegoalforsurgeons.Fordecades,thescalpel,scissors, orelectrocauteryhasbeenthegoldstandardtoolsutilizedforexcisional hemorrhoidectomy.Effortstodecreasetheamountofintraoperative bleeding,postoperativepainanddisabilityfollowinghemorrhoidectomy haveledtotheintroductionofalternativeenergydevicestodissectand excisehemorrhoidtissue.TheLigaSure(computer-guidedbipolar electrothermydevice[BED])andtheHarmonicScalpel(vibratoryenergy [VE])aretwoalternativeenergysourcesthathaveimprovedhemostasis andreducedpostoperativepainanddisability.
Thecomputer-guidedBEDcombinesthepressureappliedbythejaws oftheforcepswiththeenergytailoredtotissueimpedancesuppliedbya platformgenerator.Anautomaticadvancedfeedbacksystem
incorporatesintelligentsensorsthatrecognizetissuechanges200 times/secondandconsequentlyadjusttheoutputcurrentandvoltage basedonthepowersettingtomaintainaconstanteffectacrossthe differenttissuedensitiesandresistance.Averyhigh-frequencycurrent provideshemostasisbydenaturingcollagenandelastinfromthevessel wallandthesurroundingconnectivetissue.Becauseofthehigh­frequencycurrentandactivefeedbackcontroloverthepoweroutput,it hasthepotentialtoensurecompletecoagulationandsealthe hemorrhoidaltissuebetweentheforcepsoftheinstrumentwithminimal collateralthermalspreadandtissuechartotheadjacenttissue,resulting indecreasedpostoperativepainwithafasterrecoveryandreturnto normaldailyactivities.BEDmaintainsanappropriatebalanceofenergy andpressuretoinducethemeltingofcollagenandelastinresultingin tissueseal,includingbloodvesselsupto7mmindiameter.Thesealof denaturedproteinhasstrengthcomparablewiththatofsuture.Thehead ofthedevicehasbeenengineeredwith“heatsink”capacitytoensurea coolsurface(<45°C).Histologicstudiesandinsituthermalimaging confirmnegligibleevidenceofthermaldamagewithlateralspread calculatedat1–2mm.Afterthecompletionofcoagulationissignaledby thefeedbacksensor,thetissueisincisedalongthemiddleofthelineof coagulum.Thedifferenceandimprovementoverconventionalbipolar systemsisthatBEDuseslow-voltageandhighcurrentresultinginthe cold-cuttingoftissueswiththetemperatureoftheforcepsnever exceeding50–80°C.
p.7
p.8
TheVEconsistsofcuttingshearsthatvibrateat55,500Hz,at amplitudesof60–100μm;resultsindisruptionofhydrogenbondsthat causedenaturingofintracellularproteins.Thismechanismresultsin shearingofthecoaptedtissueandcreationofa“sticky”hemostatic coagulumthatassistsinhemostasis.TheVEhastwomodalitiesofcutting tissue:
Pressureresultsfromcompression(coaptation)ofthe“vibratory”blade ontoa“static”pressurepadontheoppositebladeoftheshears.The combinationoffocusedpressureandVEoptimizesdivisionofthe coaptedtissue.Thecombinationoftheseenergymodalitiesallowsthe tissuetobedividedatalowertemperaturethanelectrocautery,thus minimizinglateralthermalinjury.Thedecreasinglateralthermalinjury mayresultinlesspostoperativepainafterhemorrhoidectomy.
ThesetwoenergysourcesBEDandVE,combinefocusedpressurewith energysourcesthatenhancehemostasisanddecreaselateraltissueinjury therebydecreasingbleedingandpostoperativepainthusdiminishing
postoperativedisability.Utilizingthesetypesofenergysourceswillresult inminimalintraoperativebleeding,allowingforaclearoperativefield andimprovedvisualizationforcomplexhemorrhoiddisease.Sincethe firsteditionofthistextbook,theseinstrumentsaremoreergonomic, enhancingusercomfortandfunctionality,minimizinguserfatigue(Fig.
2-1).
FIGURE2-1Photoofanergonomicenergyinstrument.
Theindicationsforperformingansurgicalhemorrhoidectomyarethe samefortheutilizationoftheBEDandVEastheenergysources: complexhemorrhoidsthathavefailedmedicalmanagementandGrades IIIandIVhemorrhoiddisease.Thechoiceofsurgicalapproachisbased onthesurgeon’sexperienceandjudgment.Theremaybeadvantagesfor utilizingalternativeenergysourcesbecauseoftheirremarkable hemostaticpropertiesonpatientswhomthesurgeonanticipatesmore intraoperativehemorrhage:large,circumferentialhemorrhoids, underlyingcirrhosis/certaincoagulationdisorders,andpatientson anticoagulationtherapy.
Relativecontraindicationsofsurgicalhemorrhoidectomyinclude patientswhoareimmunocompromisedandthosewithpoorlycontrolled bleedingdiathesis.PatientswithHIV–AIDSorpatientswithactive Crohn’sdiseaseandthosewithadvancedmalignancymaybeconsidered aftertheirunderlyingdiseaseareundermedicalcontrol.Thesurgeon shouldagainhisorherexperience,judgmentandahighdegreeof “selectivity”whenconsideringthispopulationofpatientsforelective surgicalhemorrhoidectomy.
Apriorhistoryofanorectalsurgeryisarelativecontraindicationasthe
resultantscarringfromsuchproceduresmaypotentiallyincreasetherisk ofinjurytotheunderlyinganalsphincterresultingin,fecalincontinence, andanalstenosis.
Absolutecontraindicationstoenergy-basedhemorrhoidectomyinclude failedstapledhemorrhoidopexyorpatientsreceivingultra-lowanterior resectionsforrectalcancer,becauseofresidualstaplesnearthe hemorrhoidswillinterferewiththeuseoftheseenergysources.
1
WorksbyHippocrates,TranslatedbyFrancisAdamsin:TheInternetClassicsArchivebyDanielC.
Stevenson,WebAtomics.
PREOPERATIVEPLANNING
Thepreoperativeplanningisnodifferentfromanyotherlowriskanal rectalprocedure.Acompletehistoryandphysicalexaminationshouldbe performedbytheoperatingproviderpriortoproceedingtotheoperating room.Anylaboratoryorradiographicdataobtainedshouldbefor medicalnecessityratherthanroutinepractice.Young,healthypatients maynotrequiresignificantpreoperativework-up.Patientsofadvanced ageorwithseverecomorbidconditionsmayneedpreoperativetesting, optimization,andclearanceforsurgery.Patientswhohaveindications indicatedforcolonoscopyshouldhaveitperformedpriortothedateof thehemorrhoidectomy,toruleoutanyotherpathologyinthecolorectal pathology.Perioperativemanagementofthepatient’shomemedications isindividuallytailoredbasedonunderlyingmedicalcomorbiditieswith medicationstakenwithasipofwateronthedayofsurgery.Noninsulin­dependentdiabeticsareinstructedtoholdoralhypoglycemicmedications onthedayoftheoperation,andinsulin-dependentdiabeticsshouldbe administeredhalftheusualdoseofinsulin.Nonsteroidalanti­inflammatorydrugsandantiplateletagentsareavoided,ifpossible, duringthe2weeksprecedingtheoperation.Anticoagulants,suchas warfarinareheld5–7days,moreorless,tocorrectcoagulopathiesprior tothesurgerywithorwithoutinjectableLovenoxorheparinasabridge. Thesedecisionsaremadeincollaborationwiththepatient’sphysician andmedicalspecialists.Antibioticprophylaxisisgenerallynotindicated. Preoperativeandintravenousfluidsarekepttoaminimum(<250ml)to facilitatepostoperativevoidingandavoidurinaryretention.
Priortotheprocedure,thesurgeonshouldhaveanindepthdiscussion withthepatientastodietaryandfluidintake,theinclusionofbulking agentsandtheuseofstoolsoftenersandlaxatives.Utilizationofwarm bathspostoperativelyandperianalcleansingpostdefecationisimportant tominimizepostoperativediscomfortandanxiety.Theuseofnarcotic analgesicsshouldbelimitedbecauseofthesecondarysideeffectof constipationandtheincreasedincidenceofurinaryretentioninmenover 50yearsold.Informedconsentforhemorrhoidectomyshouldincludethe risksoffecalincontinence,postoperativehemorrhage,persistentpain anddiscomfort,prolongedhealing,fissureorfistulaformation,and recurrenceirrespectiveofthemethodutilizedforsurgical hemorrhoidectomy.Itisimportanttomanagethepatient’sexpectations priortotheprocedureandtoassessthepatient’sdesireswiththe procedure.Symptomatichemorrhoiddiseaseiswellmanagedbysurgical excision,buttheachievementofawrinkle-freeperianalareafreeofskin tagsisnearlyimpossibletoachieve,andpatientsshouldbeadequately
counseledregardingthis.Afullmechanicalbowelprepisunnecessary priortotheprocedure,butitmaybeadvantageoustohavethepatient performanenemashortlybeforetheoperationtoremoveanysolidfeces fromtheanalcanalthatcanimpedevisualization.Prophylactic intravenousantibioticsarealsonotindicatedbecausetheincidenceof infectiouscomplicationsisuncommoninpostanorectalsurgery.Inthe preoperativeholdingarea,intravenousfluidsmustbekepttoaminimum (totalfluids<250ml)tofacilitatepostoperativevoidingandavoid urinaryretention.
Theexcisionalhemorrhoidectomyismostcommonlyperformedinthe outpatientsettinginanAmbulatorySurgicalCenter.

SURGERY

Positioning
Thepatientpositionisdeterminedbytheoperatingsurgeon’spreference, lithotomyorprone-jackknifeposition,underanappropriateanesthetic: spinal,general,ormonitoredanthesthesiacarewithlocalanestheticare themostcommonutilized(Figs.2-2and2-3).
FIGURE2-2GradeIVhemorrhoidsmodified-lithotomy
position.
FIGURE2-3GradeIVhemorrhoidsprone-jackknife
position.

TECHNIQUE

Theperianalareais(andshavedaspersurgeonschoice)anddrapedina standardmannertocreatea“sterile”operativefield.Alocalanestheticis injectedusuallywithanepinephrinecomponenttoimprovehemostasis duringthedissectionaswellaspainreliefinthepostoperativeperiod. Recentlytheutilizationofbupivacaineextended-releaseliposome injectionatthetimeofthesurgeryhasshownaprolongedpostsurgical analgesia.
ThesurgicaltechniqueforhemorrhoidectomyutilizingeithertheBED orVEenergysourcesisthesame,particularlywiththerecent developmentsofthemoreergonomicinstrumentsandtheeliminationof thefootpedals.Thecurrentinstrumentsarecontrolledbethesurgeon’s handand“failsafe”beepingsoundstoguidethesurgeonwhenthe deliveryofenergyiscompletedtothetissue.
Afterinsertionofananalretractorinspectionconfirmsthestandard rightanterior,rightposterior,andleftlateralconfigurationofthe advancedstagehemorrhoiddiseaseandanyotherabnormalanal pathology.Theexternalcomponentofthehemorrhoidtissueisgrasped andgentlyliftedawayfromtheunderlyingsubcutaneousfibersofthe externalsphinctertowardtheanalcanal(Fig.2-4).Somesurgeonsutilize injectionoflocalanesthesiawithepinephrineatthistimetolifttheskin awayfromtheexternal/internalsphincterfibersduringthiscritical dissection.TheBEDorVEisthenappliedtotheelevatedperianalskin andthetissueabovetheinternalsphinctercarryingthedissectionalong theanalcanaltothedentateline(Fig.2-5).TheadvantageoftheBEDor VEisthattheyeachhavecurvedtippedjawsthatcanfollowthecontour oftheanalcanalwhilecontinuingthedissectiontothevascularpedicle, whileliftingthehemorrhoidofftheinternalsphincterthuspreventing injurytotheinternalsphincter(Fig.2-6).Isolationofthevascular pedicle,whichisproximaltothedentateline,isperformedwiththe curvatureoftheinstrumenttowardtheanalcanal.However,when amputationofthevascularpedicleisnecessary,theinstrumentcurvature isthen“flipped”,sothatitstillbendstowardthelumenofthebowelbut awayfromthemoreproximalrectum(Fig.2-7).Atthispoint,theentire hemorrhoidtissueisremovedfromtheoperativefield.Atthispoint, thereissomecontroversyaboutclosingthemucosaldefectwhichis probablynotnecessary,butmanysurgeonsdoneedthatadditional “peaceofmind.”Ifthepedicleissutureligated,thesurgeonmust considerthatthissuturecancontributetodevelopmentofischemiaand necrosisoftheareaandmaycontributetopostoperativefever,ulceration, andhemorrhage.Caremustbetakennottopenetratethesphincter
mechanismbecausethismaycausepostoperativepainandspasm.
FIGURE2-4Theexternalhemorrhoidisgraspedwitha
hemostatandplacedongentiletractionto“tentup”the externalcomponent.
FIGURE2-5Theenergysourcestraddlestheanalskin
closetotheedgeofeachhemorrhoidcomplex.
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