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20
ab
Fig. 3.8 ( a , b ) Primary closure after excisional hemorrhoidectomy
P. Sivalingam et al.
fi rst. Generally, the best defi ned, least complex
hemorrhoid and that seems to be main offender
should be tackled fi rst. Tissue distortion should be
avoided all the time. The larger the hemorrhoids
are, the longer the incision. It should be with a ratio
of 3:1 (length to breadth). The technique of excision is similar to that of open technique. After
excision of long triangular segment of hemorrhoidal tissue to the level of the anorectal ring, suffi cient undermining of the wound edges is
accomplished to facilitate the removal of accessory
hemorrhoidal tissue and tension-free closure of the
wound. Starting from the pedicle, a running suture
with 2/0 Vicryl is used for wound closure (Fig. 3.8a,
b ). No internal anal dressing is necessary. The
advantages of closed hemorrhoidectomy are less
postoperative discomfort, minimal inpatient stay,
practically no outpatient care, and no need for subsequent dilatation. Occasionally, the surgery is
done by making a linear incision in the region of
the hemorrhoidal mass, undermining fl aps carefully, followed by excision of hemorrhoidal tissue
without removing anoderm or skin. The wound
can then be closed with sutures thereby reducing
the risk of postoperative stenosis. A prospective
randomized trail comparing open with closed
hemorrhoidectomy in patients with grade III or IV
hemorrhoids demonstrated less postoperative pain
in close hemorrhoidectomy group (You et al.
2005 ). Though another study by HO et al. ( 1997 )
concluded that closed hemorrhoidectomy was
associated with faster healing, there was no difference in postoperative pain and complication.
3.6.4.3 White Head (Submucosal) Hemorrhoidectomy
The procedure is repeated for other hemorrhoidal mass. The operation is technically diffi cult, bloody with high rate of postoperative
stricture, loss of normal sensation, and development of ectropion. The ectropion is so common
that it is called as “white head deformity.” Some
surgeons, however, claimed good results after
modifying the technique (Whitehead 1882 ;
Wolff and Culp 1988 ).
The submucosal hemorrhoidectomy of Sir
Allen Park ( 1956 ) gave good results in his hands.
According to him, because no anoderm or skin
was removed, the wound heals fast with less
induration, scaring, and stenosis.
3.6.4.4 Laser Hemorrhoidectomy
Both carbon dioxide (CO 2 ) and NeodymiumYttrium- Aluminum-Garnet (Nd: YAG) laser have
been used for surgical management of hemorrhoids. Either instrument can be used to excise or
evaporate the tissue. When used as a cutting
instrument, the technique is exactly the same as
that for a blade. The duration of wound healing
after laser technique is almost equal to any other
technique, but there is higher risk of stenosis
(Wang et al. 1991 ).
3.6.4.5 LigaSure Hemorrhoidectomy
LigaSure (LigaSure TM, Valleylab, Covidien) is
a bipolar electrothermal device which is used to
excise the hemorrhoidal tissue with the intention
3 Hemorrhoids
21
to reduce bleeding with minimal thermal damage
of adjacent tissues.
3.6.4.6 Hemorrhoidectomy by Ultrasonic Scalpel (HUS)
Harmonic scalpel relies on ultrasonic waves producing simultaneously cutting and coagulation
effect with minimal lateral thermal damage to the
adjacent soft tissue and minimal bleeding. That is
why this method is also known as bloodless ultrasonic scalpel hemorrhoidectomy (BUSH). This
method is making scientifi cally proven positive
waves in the method of management of grade III
and IV hemorrhoids all over the world (Bulus
et al. 2014 ). Ideally, HUS is indicated in one to
two columns of grade II and grade IV hemorrhoids. Though it can be used for all three- column
hemorrhoidectomy, a stapled hemorrhoidopexy
is more preferable in such circumferential disease in my view (Chung et al. 2005 ; Tsunoda
et al. 2011 ).
3.6.4.6.1 Mechanism
US blade vibrates longitudinally at a speed of
55.5 Hz per second, which is equivalent to
55,500 cycles per second, transferring mechanical energy to tissue. An electrical signal causes
the peizoelectric ceramics in the hand piece of
the US blade to expand and contract, converting
electrical energy to mechanical motion which is
transmitted to the blade extender. As the ultrasonic wave leaves the blade extender, its motion
is amplifi ed as it travels to the blade tip where
maximum motion occurs. The blade tip moves
longitudinally in a distance range of 50–100 μm.
3.6.4.6.2 Coaptive Coagulation
The coagulation effect occurs through the transfer of mechanical energy to the tissue which
causes internal cellular friction thus breaking
down the hydrogen bonds. It leads to protein
denaturation thereby forming a sticky coagulum
that seals small vessels of size <3 mm. This
occurs at a temperature under 100 °C therefore
minimizing smoke and charring (Tsunoda et al.
2011 ). Comparatively, electrocautery causes
water vaporization and desiccation at a temperature between 100–150 °C, while the laser causes
tissue burning and charred scab formation at a
temperature of 150–400 °C.
As grip force is applied to the tissue; in combination with the blade motion, the tissue gets
separated. Energy is transferred to the tissue
through the active blades under applied force
which minimizes lateral thermal spread.
3.6.4.6.3 Cavitation Effect
As the active blade of the US blade vibrates over
the static passive blade with the tissue included in
between, there is a cavity created with a lowpressure zone that causes tissue dissection.
Vapors from the tissue fl uid expand and spread in
adjacent tissue thus causing separation of tissue
layers and planes. This visualization of vascular
and tissue planes enhances the precision and
quality of dissection.
The US blade has several different surfaces
for cutting and coagulation (Fig.
3.9 ).
The comparative advantages of US blade:
• Compared to other electrosurgical devices,
US blade offers better control and precision
for cutting and coagulation.
• The lateral thermal damage with US blade is
1–3 mm which is the least as compared to
bipolar (2–6 mm), laser (4–8 mm), or monop-
olar (4–12 mm) electrocautery (Abo-hashem
et al. 2010 ; Bulus et al. 2014 ).
• There is less smoke and charring.
• No stray energy (jumping current sparks to
adjacent tissue).
• There is no neuromuscular stimulation as it is
heat energy and not electrical energy.
• No electricity passing through patient’s body,
as in monopolar electrocautery, therefore
reducing potential risk of burns especially at
the exit cautery grounding plate area thus
making it safe to be used in patients fi tted
with other electrosurgical devices like pace-
makers, etc.
3.6.4.6.4 Technique
The procedure can be done under spinal or local
anesthesia with IV sedation. Mark the area to be
dissected with US tip/nose spot coagulation dots
taking care to involve less anoderm but complete
22
55,500 cycles per second
P. Sivalingam et al.
Clamping surface
Shown in slow motion for illustration purposes
Flat Back
Fig. 3.9 Ultrasonic scalpel blade surfaces (With Permission from Ethicon, Mumbai, India)
pedicle. Saline/lignocaine + adrenaline infi ltration is done in the subcutaneous and submucosal
area. This achieves better hemostasis and also
causes separation of tissue planes between submucosa, where the vessels lie, and the internal
anal sphincter (IAS).
A charred plastic-like rolled up coagulum is
formed by the use of electric or ultrasonic devices
on skin surface. In my view, the skin incision is
better taken by a cold knife or scissors. This minimum one to two drops of bleeding is worth the loss
than an augmented wound edge which may affect
the wound healing due to increased wound edema
and slough which is a potential reason for secondary wound infection and other potential complications. As it is, this minimal bleeding is reduced by
the infi ltration and can be easily controlled by light
pressure for some time with a gauze piece held by
an assistant over the wound. Being in the correct
plane of dissection, which a surgeon will master
eventually after operating a few cases, is the key to
bloodless fi eld of dissection.
The active blade is always placed under vision.
The corrugator cutis ani muscles are cut by the
US along the line of the marked incision thus
exposing the plane between the submucosa and
the IAS. The IAS is refl ected laterally away from
the wound, and hemorrhoidal tissue is clamped
loosely and cut by low-power US setting bit by
Concave Surface
bit. The pedicle of the hemorrhoid is fi rst scored
coagulated at base by the US blade, and fi nal cutting of the pedicle is done by applying the US
slightly distal to this scored line in order to avoid
bleeding during fi nal stage of pedicle dissection.
A word of caution though there is a tendency to
fi nish the pedicle cut quickly as by now, the surgeon is happy and confi dent due to the relatively
bloodless and quick surgery done so far. In this
haste, a small tug on the left over pedicle may
snap away before getting coagulated completely
by the US blade. This results in signifi cant bleeding. In the haste to control this bleeding, the surgeon may use electrocautery desperately just to
fi nd increased bleeding as the vessels would have
retracted below the mucosa. A deep suture may
then be required with an absorbable suture material in order to fi nally achieve hemostasis.
Therefore, it is safe for the surgeon to be patient
enough to allow the US blade to completely
coagulate and cut the tissue on its own.
Small oozing, if present, can be coagulated
using the tip of the US blade or its fl at back surface. It is the individual surgeon’s choice to either
leave the wound open as in Milligan Morgan
method or to close it with an absorbable suture as
in Ferguson’s method (Sohn et al.
Goligher, in his textbook, has mentioned that histologically the wounds are the same after 1 week
Cutting Edge or Knife Down
Blunt Nose
2008 ).
3 Hemorrhoids
23
in open or closed methods (Armstrong et al.
2001 ; Tsunoda et al. 2011 ).
To sum up, US blade is safe, effective, causes
least lateral thermal damage, achieves good
hemostasis, coagulates and cuts simultaneously,
and causes less postoperative pain and other
complications ranging from infection to incontinence and anal stenosis with greater patient satisfaction (Sohn et al. 2008 ; Ivanou et al. 2007 ;
Kwok et al. 2005 ; Chung et al. 2002 and Khan
et al. 2001 ).
3.6.4.7 Stapled Hemorrhoidectomy or
Procedure for Prolapsed
Hemorrhoids (PPH)
In the context of hemorrhoids, the concept of
localized pile masses to be removed by surgery
underwent a paradigm shift when Antonio Longo
came on the scene in the 1990s.
In 1993, after having performed 500 hemorrhoidectomies and being unsatisfi ed with the
results, he looked for a “new surgical solution.” A
conventional circular stapler was used to perform
the prolapsectomy between 1993 and 1996.
In 1995, during the 24th International Congress
of Latin Mediterranean, Longo for the fi rst time
presented his hypothesis that hemorrhoidal tissue
is normal to the anal canal. The basic pathology of
the hemorrhoidal disease is the prolapse above the
hemorrhoidal tissue. It is not necessary to remove
the hemorrhoids. He proposed the correction of
prolapse by carrying out a resection of the prolapsed suprahemorrhoidal rectal mucosa using stapler. The original hypothesis was that by
repositioning the hemorrhoids in the anal canal, it
would be possible not only to cure the symptoms
but also to restore the anatomy and physiological
function of the anus while avoiding the typical
hemorrhoidectomy sequelae.
The paradigm shift was from the concept of
hemorrhoidectomy in whatever form and the
preservation of hemorrhoids while correcting the
prolapse.
The PPH instrument was devised, and he presented his concept and the technique of reduction
of mucosa and hemorrhoidal prolapse with a circular suturing device at the 6th World Congress
of Endoscopic Surgery in Rome, Italy, in 1998
Fig. 3.10 Stapler haemorrhoidopexy equipment: 33-mm
hemorrhoidal circular stapler, circular anal dilator, pursestring suture anoscope, and suture threader
(Longo 1998 ). He made the dramatic announce-
ment that the anal cushions are necessary for normalization of anal canal lining and should never
be removed. The whole pathology of piles is due
to prolapse of mucosa and the submucosal anal
cushions. The surgical procedure performed
should be replacement of the cushions in their
normal place and not excision.
“ If your pants are sliding down, you don’t cut
away the pants but pull them up. ”
The original procedure devised by Longo was
called “procedure for prolapse and hemorrhoids.”
The instrument devised to carry it out was labeled
PPH01 (Fig. 3.10 ). It became popularly known as
“stapled hemorrhoidectomy.” Longo himself
called the procedure “stapled anopexy.”
Around the same time, Allegra et al. and
others including Pernice presented their experiences with hemorrhoidectomy using a circular
stapler with disastrous results. Longo went to
great pains explaining the difference in the underlying concept of stapled hemorrhoidectomy and
stapled anopexy: two opposite concepts and procedures (Longo
2002 ).
Indications for stapled hemorrhoidectomy
include reducible grade III and grade IV hemorrhoids, circumferential hemorrhoids, and patients
in whom other forms of treatment have failed. It
is contraindicated in presence of perianal sepsis,
anal stenosis, and full-thickness rectal prolapse.
Earlier experience with the new technique of
stapled anopexy by surgeons who still thought of
it as stapled hemorrhoidectomy resulted in a long
24
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P. Sivalingam et al.
cd
e
Fig. 3.11 Steps of stapled anopexy: ( a ) fi xation of anoscope, ( b ) purse-string suture, ( c ) insertion of stapler, ( d ) tight-
ening purse-string, ( e ) fi ring stapler, and ( f ) inspecting suture line
list of complications that were due to the nonappreciation of the underlying change in the etiology. The principle highlights of the procedure
(Fig. 3.11a–f ) are that:
f
now modifi ed to PPH03. This consists of a
circular stapler (HCS33), a suture threader
(STI00), a circular anal dilator (CAD33), and
a purse- string suture anoscope (PSA33).
(b) After anal dilatation by dilator, purse-string
(a) Procedure for piles and prolapse of hemor-
rhoid set initially used was called PPH01,
suture using nonabsorbable monofi lament
material, approximately 4 cm cephalad to the
3 Hemorrhoids
25
dentate line, is placed into the mucosa and
submucosa of the lower rectum avoiding the
muscular layer and vagina in females.
(c) The suture is placed suffi ciently high so that
when stapler is fi red, it does not incorporate
the dentate line, anoderm, and the underlying
internal anal sphincter.
(d) The suture is tied around the opened anvil,
which has been passed, and the stapler closed
while a gentle traction has been applied to
the suture brought out through the side windows in the stapler.
(e) A donut of complete circular mucosa and
submucosa is removed and should measure
approximately 2 cm in its width.
The removal of a circular strip of mucosa and
submucosa above the hemorrhoidal tissue results
in disruption of the blood supply by superior
hemorrhoidal arteries and pulling up and fl attening of the hemorrhoidal tissue which reduces the
prolapse. The reported literature on stapled anopexy confi rmed the benefi ts of the procedure as
reduced pain, shorter length of stay, early return
to work, no distortion of the anal opening, and
good long-term results in grade III piles.
Most of the reports mentioned that some
venous engorgement of the anal mucosa remains
in the postoperative period, and the additional
procedures of removal of skin tags may be
necessary.
Problems of the purse-string suture giving
incomplete donut have been reported and various
methods devised to overcome it. Hoffman from
California described in modifi cation of putting a
washer with spikes to impale the mucosa instead
of a purse-string suture (Hoffman
2005 ).
3.6.4.7.1 Complications of Stapled
Anopexy
All surgical procedures carry an inherent risk of
operative and postoperative complications. The
main complications noted for these procedures
include postoperative bleeding (Fig. 3.12 ), sep-
sis, anastomotic dehiscence and stricture, injuries to lower rectum and the sphincter complex,
rectovaginal fi stula in females, urgency, and
tenesmus.
Fig. 3.12 Bleeding after stapled anopexy
These complications occur in centers where
the understanding of the pathophysiology is not
appreciated and the procedure is carried out
without being formally trained to do so. Antonio
Longo mentioned that postoperative pain supposedly due to muscular inclusion in the staple
line is possible in well-done operations and
may be due to the neural injuries or inclusion of
the anoderm in the donut. These cases are far
and few. The majority of the results are satisfactory both for the patient and the surgeon
(Kaider–Person et al.
2007 ). In a systematic
review of 25 randomized, controlled trials comparing stapled with conventional hemorrhoidectomy, Tjandara and Chan (Tjandra and Chan
2007 ) concluded that stapled anopexy is safe
with many short-term benefi ts (lesser operative
time, early return of bowel function, less pain,
shorter hospital stay, faster wound healing,
early return to work and higher patient satisfaction). Long-term results were similar to conventional hemorrhoidectomy. The fi ndings of
this study were replicated in a large meta-analysis of 29 randomized clinical trials (Shao et al.
2008 ). Increased cost of instruments is bal-
anced by shorter operative time, shorter hospital stay, and early return to work.
To conclude, stapled hemorrhoidopexy is
safe and effective treatment for large symptomatic piles with fewer early and late postoperative complications compared to closed
hemorrhoidectomy.
26
P. Sivalingam et al.
3.6.4.8 Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL)
Distribution patterns of the superior rectal artery
widely vary (bipartition in 82 %, trifurcation in
12 %) just at the entering points of its branches
into the rectal muscle layer. Thus, the position of
the rectal arteries is not predictable as all these
branches are end arteries. So their ligation will be
effective in controlling the bleeding and also the
prolapse. Aigner et al. 2004 reported in their
study that the superior rectal artery had three
times the caliber compared to healthy volunteers,
and blood fl ow was also nearly three times higher
in patients of symptomatic hemorrhoids. Their
study provides strong evidence that the arterial
blood supply is of relevance in the development
of hemorrhoidal cushions. Vascular dilatation
and increased blood fl ow suggest that there might
exist an increased arterial infl ow rather than a
venous stasis or outfl ow problem in the development of hemorrhoids. Thus, evidence-based
detection of these branches by Doppler and their
ligation become justifi ed. Arterial supply
becomes relatively higher and arterial ligation
appears as a logical recent development.
Normally, only three arterial branches have been
described, but when detected through Doppler
probe, the number may vary from 12 to 15 (Rama
Kant 2010 ). The superior rectal artery may not
course in exactly defi ned positions of the rectal
mucosa (3’, 7’, 11’). The middle rectal artery
may be missing on both sides in 20.6 % of
patients (Aigner et al.
2004 ).
The concept of DGHAL was given by
Kazumasa Morinaga in 1995 and was approved
by the FDA in the same year. This is the latest
most innovative technology being carried out in
the world and emerging as minimal invasive procedure of choice in hemorrhoids all over world
(Dal Monte et al. 2007 ; Sohn et al. 2001 ; Ratto
et al. 2010 ; Giordano et al. 2009 ). The hemor-
rhoidal artery ligation operation (HALO) is a
new technique designed to eradicate piles without the need for cutting. As such, it is relatively
pain-free, and most patients are back to work
after 24–48 h with only a minimum of discomfort. The basis of the operation is to restore the
hemorrhoids back to their anatomical position
Fig. 3.13 Doppler-guided hemorrhoidal artery ligation –
equipment
and occlude the blood supply to the vascular
cushions forming the hemorrhoids resulting in
their shrinking.
3.6.4.8.1 Procedure
DGHAL is done under local, regional, or general
anesthesia in lithotomy or left lateral position
after nothing per orally for last 6 h and an enema
in the morning. A short course of antibiotic for
both aerobic and anaerobic may be advised. For
grades I or II hemorrhoids, only ligation will be
required which can be done even under 2 %
Xylocaine jelly and 5 % Xylocaine ointment
application, and the patient can be discharged the
same day. In grade III and IV hemorrhoids, anesthesia is required and patient should stay overnight and discharged the next morning. In these
patients, HAL is supplemented by rectoanal
repair (RAR) to take care of prolapsing mucosa.
This technique uses a specially adapted proctoscope with an inbuilt Doppler probe which is
used to detect feeding hemorrhoidal artery which
is subsequently ligated, viz, Doppler machine
with display graph and inbuilt printer and HAL
proctoscope (Figs. 3.13 and 3.14 ). A miniature
Doppler ultrasound device, inserted after lubrication in the anal canal and rectum, locates branches
of arteries supplying the hemorrhoids 2–3 cm
above the dentate line by arterial sound of
Doppler and also the graphs at its screen. This
also provides information of the depth of the
artery and facilitates the ligation. Usually, we
start at 12 o’clock position fi rst clockwise and
then anti-clockwise and ligate all signifi cant
3 Hemorrhoids
Fig. 3.14 HAL proctoscope
with Doppler sensor ( white ),
sheath, and cable
27
Fig. 3.15 Procedure of DGHAL
arterial branches (Fig. 3.15 ). As soon as blood
vessels are tied off, the Doppler sound of artery
disappears and the hemorrhoid shrinks immediately and further over the subsequent days and
weeks. Usually, about four to nine branches are
ligated with 2/0 Vicryl on 5/8th circle needle with
taper end. Prolapsing and grade III and IV hemorrhoids also need RAR. This is done by another
equipment called RAR equipment (Fig.
3.16 ).
Scope is inserted in the rectum and focused on
the site of prolapsing hemorrhoid and then fi rst
suture is taken deeper to fi x deeper tissue and
then sutures are continued below stopping just
above dentate line. The last suture is taken after
removal of the RAR scope. The suture once tightened will pull the hemorrhoid mass up and ensure
its fi xation, leading to mucopexy (Fig. 3.17a, b ).
Thus, almost a normal looking anal opening is
left at the end of procedure (Fig.
3.18a, b ). A
small pack with 2 % jelly is left to be removed
3 h later. Patient is catheterized as after saddle
anesthesia he will not be allowed to sit and may
develop retention of urine. The catheter is
removed the next morning. Because the stitches
are placed in the lower rectum where there are
virtually no sensory nerves, the procedure is
pain-free. Most patients are back to work within
24–48 h with only minimum of discomfort.
Postoperatively, only dietetic restrictions,
stool softener, short course of antibiotics, and
local Xylocaine 2 % jelly application are advised.
No sitz bath is recommended.
3.6.4.8.2 Postoperative Complications
In a systematic review of 17 studies with a total
of 1996 patients, a subset of six studies with a
28
P. Sivalingam et al.
Fig. 3.16 RAR procedure, tightening the suture pulls all prolapsing piles up
ab
Fig. 3.17 ( a, b ) Diagrammatic representation of RAR
follow-up of 1 year or more (850 patients treated
by the procedure) bleeding, pain on defecation,
and prolapse was reported in 10 %, 9 %, and
11 % of patients, respectively. A subset of nine
studies with a follow-up of less than 1 year (855
patients treated by the procedure) bleeding and
prolapse was reported in 6 % and 8 % of patients,
respectively. The proportion of patients with preoperative bleeding, pain, and prolapse ranged
from 45 % to 100 %, 12 % to 83 %, and 12 % to
100 %, respectively (Infantino et al. 2010 ;
Morinaga et al.
1995 ). Reports show low
3 Hemorrhoids
ab
Fig. 3.18 ( a , b ) Results after DGHAL and RAR
29
complication rates and lower postoperative pain.
Bleeding, urinary retention, prolapse, and swelling of external hemorrhoids were included among
complications. However, complications are easily managed by conservative approach.
3.6.4.8.3 Results
DGHAL is associated with recurrence rate of
6–13 %. Hemorrhoids can and do come back in
10–20 % of people following any hemorrhoid
surgery in the fi rst 12 months. This is partly
because patients fail to control their food habits
and modify their lifestyle.
Pain, hospital stay, time to fi rst bowel movement, complete functional recovery, complications, and recurrence were signifi cantly better for
the DGHAL patients as compared to other procedures especially stapler hemorrhoidopexy.
DGHAL is most effective for second- or thirddegree hemorrhoids. It may not improve prolapsing symptoms in advanced and circumferential
hemorrhoids. However short-term outcomes and
1 year recurrence rates of DGHAL did not differ
from those of conventional hemorrhoidectomy
(Bursics et al.
2004 ). Given the fact that there is
the possibility of revascularization and recurrence of symptomatic hemorrhoids, further studies on the long-term outcomes of DGHAL are
still awaited (Faucheron and Gangner 2008 ). In
the follow-up examination 12 months after RAR
procedure, there were 25 % of minor residual
hemorrhoidal prolapse, while only 5 % reported
residual symptoms (painful defecation and itching)
(Rama Kant 2010 ). Scheyer et al. in 2006 reported
little pain and minimal morbidity with about
60 % patient satisfaction in terms of resolution of
symptoms in 308 patients predominantly with
grade II and III hemorrhoids.
To summarize, DGHAL is a safe and effective
minimally invasive method of treating hemorrhoids with no risk of incontinence, has minimal
postoperative pain, and has lower recurrence rate.
Patient satisfaction is high and return to work is
early.
3.7 Postoperative Complications
of Hemorrhoidectomy
3.7.1 Pain
Fear of pain is the most important reason why
patients avoid hemorrhoidectomy. The pain is of
two types, persistent discomfort and painful
spasm. The persistent discomfort is due to the
raw area and lasts for a day or 2.
The spasm pain is caused by the contraction of
sphincter muscles. These spasms are involuntary
and may be aggravated by morphine injection.
Spasm may be precipitated by movements. The
most painful period in almost every case is that
associated with the fi rst bowel movement. Pain is
markedly reduced in stapled hemorrhoidopexy.
The post-hemorrhoidectomy pain is managed
with analgesics and nonsteroidal antiinfl ammatory agents, sitz bath, and laxative.