Complications

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FIGURE2-6Thedissectionofthehemorrhoidintheanal

canalmustpreventinjurytotheinternalsphincter.

FIGURE2-7Thehemorrhoidvascularpedicleissealed

withtheenergysourcewiththecurvatureoftheinstrument directedtowardthelumenofthebowel/analcanal.

Themostimportanttenantinhemorrhoidsurgery,nomatterwhich energysourceormethodisutilized,istopreservetheintactanodermand mucosabetweentheexcisedhemorrhoidcolumnstopreventanal stenosis.Ifthedenudedareasaretoowide,overtimethescarcontracts

andcanleadtoseverestrictureandpainfulfissureformation.Some surgeonsrecommendweeklysimpledigitaldilatationforapproximately3 months.Patientcomplianceispoor,becauseoftheaddeddiscomfort duringself-dilatationwithadigitordilators.Thegoalistoreturnthe anustothesameelasticityasprehemorrhoidectomy.

POSTOPERATIVEMANAGEMENT

Patientsaremonitoredinthepostanesthesiacareunit(PACU)untilfully awakewithastableairwaysandnorectalbleeding.Mostpatientsare requiredtovoidpriortodischarge(especiallymen50andover)because oftheincidenceofurinaryretention.Patientsthatdevelopurinary retentionmayrequiresterileurinarystraightcatheterizationpriorto discharge.Somepatientswithmultiplecomorbiditiesmayrequire23 hoursobservation,thiswillbedependentonPACUrecoveryandjoint decisionbetweenthesurgeonandtheanesthesiologist.

PatientinstructionsforhomeincludewarmSitzbathsoaksthreeto fourtimesdailyfor15–20minutesatatime,alongwithpsylliumfiber supplementPOBID.Somesurgeonsrecommend30mlofmineraloil BIDfor5daystoallowfor“smoother”bowelmovements.Patientsshould drinkplentyoffluidsandmaintainhighfiberdiettosoftenthestools.A narcoticanalgesicisusuallyprescribedevery4hourstodecreasethe postoperativepain,howeverpatientshouldbewarnedthatallnarcotics causeconstipationandmayaddtodifficultbowelmovements.

Patientsarewarnedofbleedingthatdoesnotstopafterabowel movement,feverthatdoesnotrespondtoantipyretics,excessivepain (butthisisaverysubjectivecomplaint)andurinaryretention.Usually patientsareseen2–4weekspostoperativelyforfollowupintheoffice.

COMPLICATIONS

Earlypostoperativebleedingoccurswithinthefirst48hoursin1–2%of patientsandismainlysecondarytoinadequatehemostasisduringthe procedure.Thesepatientsusuallyrequireimmediatereturntothe operatingroom.Delayedpostoperativehemorrhageoccurs7–14days postoperativelywiththeseenergysourcesin0.6–2.4%ofpatients,owing topediclenecrosis(infection/ischemia),anduseofnonsteroidalantiinflammatoryagents.Thesepatientswhenreturnedtooperatingandmay nothaveanactivesitenoactivebleedingsiteidentifiedsoshouldbe closelymonitoredforatleast24hourstoensurenorebleeding.

Latepostoperativecomplicationsincludeanalstenosisandfecal incontinence,in0.8–2%ofthesepatients.Thepatientswithlateanal stenosisareusuallymanagedwithanaldilatorsorsurgicalcorrectionif theyfaildilatation.

RESULTS

PostoperativebleedingwithBEDandVEinstrumentshasbeenshownto belessfrequentthanconventionaldiathermyhemorrhoidectomy, althoughnotstatisticallysignificantbetweenthetwogroups. Theoreticallybothenergysourcescreatelessthermalinjurywhichinturn decreasespostoperativepain.Theliteratureisnotconsistentregarding potentialenhancedwoundhealingwithBEDorVEhemorrhoidectomy versusdiathermyhemorrhoidectomy.Inonestudy,comparing30 patientswithBEDhemorrhoidectomyversus31Fergusonprocedures, therewasnostatisticalsignificanceinwoundhealing.Anotherreport suggestedasignificantlyfasterwoundhealingandafasterreturnto normaldailyactivitiesinpatientsfollowingBEDhemorrhoidectomy versusdiathermyhemorrhoidectomy.HemorrhoidectomywithVEmay resultsinlesspostoperativediscomfortandfasterrecoverytonormal activitythanconventionalhemorrhoidectomy.

CONCLUSIONS

Thebenefitsoftheutilizationofthesetwoenergysourcesinperforming excisionalhemorrhoidectomyincludereducedintraoperativebleeding, lesstissueinjury,andpostoperativepainwithafasterreturntoworkand dailyactivities.However,surgeonsmustalwaysutilizemeticulous surgicaltechniquetopreventanalsphincterinjuryandinjurytoadjacent normalmucosainordertolimitlong-termdisabilityinpatientsrequiring excisionalhemorrhoidectomy.

RECOMMENDEDREFERENCESAND READINGS

ArmstrongDN,AmbrozeWL,SchertzerME,OrangioGR.Harmonicscalpelhemorrhoidectomy:

fivehundredcases.DisColonRectum2002;45(3):354–9. ArmstrongDN,FrankumC,AmbrozeW,SchertzerME,OrangioGR.Harmonicscalpel

Hemorrhoidectomy:fivehundredconsecutivecases.DisColonRectum2001;44(4):558–64. ChungCC,HaJP,TaiYP,TsandWW,LiMK.Double-blind,randomizedtrialcomparing

harmonicscalpelhemorrhoidectomy,bipolarscissorshemorrhoidectomy,andscissors

excision:ligationtechnique.DisColonRectum2002;45(6):784–94. ChungYC,WuHJ.ClinicalexperienceofsuturelessclosedhaemorrhoidectomywithLigasure.

DisColonRectum2003;46:87–92. FranklinEJ,SeetharamS,LowneyJ,HorganPG.RandomizedclinicaltrialofLigasurevs

conventionaldiathermyinhaemorrhoidectomy.DisColonRectum2003;46:1380–3. GorfineSR,OnelE,PatouG.IrivokapicZ.Bupivacaineextended-releaseliposomeinjectionfor

prolongedpostsurgicalanalgesiainpatientsundergoinghemorrhoidectomy:amulticenter,

randomizeddouble-blind,placebo-controlledtrial.DisColonRectum2011;54(12):1552–9. JayneDG,BotterillI,AmbroseNS,BrennanTG,GuillouPJ,O’RiordainDS.Randomizedclinical

trialofLigaSureversusconventionaldiathermyforday-casehaemorrhoidectomy.BrJSurg

2002;44:428–32. KhanS,PawlakSE,EggenbergerJC,etal.Surgicaltreatmentofhaemorrhoids:prospective,

randomizedtrialcomparingclosedexcisionalhaemorrhoidectomyandtheHarmonicScalpel

techniqueofexcisionalhaemorrhoidectomy.DisColonRectum2001;44:845–9. MastakovMY,BuettnerPG,HoY-H.Updatedmeta-analysisofrandomizedcontrolledtrials

comparingconventionalexcisionalhaemorrhoidectomywithLigaSureforhaemorrhoids.Tech

Coloproctol2008;12:229–39. MuziMG,MilitoG,NigroC,etal.RandomizedclinicaltrialofLigaSureandconventional

diathermyhemorrhoidectomy.BrJSurg2007;94:937–42. NeinhuijsS,deHinghI.ConventionalversusLigaSurehemorrhoidectomyforpatientswith

symptomatichemorrhoids.CochraneDatabaseSystRev2009;1:CD006761. OzerMT,YgitT,UzarAI,etal.Acomparisonofdifferenthemorrhoidectomyprocedures.Soudi

MedJ2008;29(9):1264–94.

Chapter3

ProcedureforProlapsing Hemorrhoids

JustinKellyandSamAtallah

INDICATIONS

Theprocedureforstapledhemorrhoidectomywasinitiallydescribedby LongoatthesixthWorldCongressforEndoscopicSurgeryinItalyin 1998andsubsequentlyadoptedwithvaryingpenetrancebytheglobal surgicalcommunity.Althoughaplethoraofdescriptiveeponymsexistfor thisoperation,mostsurgeonsagreethatitbetitledastapled

hemorrhoidectomy,stapledhemorrhoidopexy,orprocedurefor prolapsinghemorrhoids(PPH).Withinthislattertitleliesthemain

indicationfortheoperation.Inspiteofhemorrhoidsbeingavery commonentity,theprolapseitselfrepresentsaspectrumthatvariesfrom mucosalprolapsetocompletehemorrhoidalprolapsesandprolapseofan associatedinflammatoryrectalpolypofhemorrhoidorigin.Suchfindings shouldbecarefullydifferentiatedfromrectalmucosaandfull-thickness prolapseoftherectalwall.

Whileassessingthemyriadpatientsinanambulatorysetting,care shouldbetakentoensurecorrectandappropriatediagnosisofpatients presentingwithhemorrhoids.Cautionshouldsubsequentlybetakento appropriatelyselectthosepatientswhoaretobenefitfromintervention. ChoosingwhichofthesepatientsaremostlikelytobenefitfromaPPHas opposedtootherformsofacceptedtreatment(medicaltreatmentwith topicalagents,hemorrhoidalbanding,sclerosantinjectiontherapy, transanalhemorrhoidaldearterialization[THD],orexcisional hemorrhoidectomy)isofparamountimportance.Therapyshouldbe directedbythesymptomsthepatientsexperienceandnotthe macroscopicappearanceofthehemorrhoidsonclinicalexaminationand anoscopy.Asageneralprinciple,patientswhowillbenefitmostfrom PPHaresymptomaticfromgradeIIorgradeIIIprolapsinghemorrhoids

(Figs.3-1and3-2),perGoligher’sclassification.Practicestandards typicallydonotadvocatetheuseofPPHforgradeIorgradeIVinternal hemorrhoids,andtheoperationisnotdesignedforthemanagementof externalhemorrhoids.PPHismostsimilartoTHD,inthatit circumferentiallytargetstheinternalhemorrhoids,andbecauseboth proceduresdonotviolatethedentatelineandtheanoderm,andwhen correctlyperformed,bothresultinminimalpostoperativediscomfort. However,thetechniqueforthetwooperationsisquitedifferent,whereas THDonlyrequiressuturedligationandmucopexy,PPHisanexcisional procedure(Fig.3-3).TheuseofPPHversusTHDisoftenrelatedto deviceavailabilityandsurgeonpreference.Thesetwomodalitiesfillagap inthespectrumofsurgicaloptions—betweenpatientswhowould nominallybenefitfromrubberbandligationandforthosewhom conventionalhemorrhoidectomyisexcessive.

FIGURE3-1Prolapsingcircumferentialhemorrhoidal

disease.

FIGURE3-2Statusoftheanorectumpostprocedure.

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