2. Submucosal hemorrhoidectomy: Parks suggested that the pain after ligation and excision is due to the defect of the anoderm in the anal canal which causes anal spasm and anal fi ssure and due to ligation or packing into the sensitive anal mucosa. And he also suggested that the submucosal hemorrhoidectomy, compared with the excision and ligation method, shows less mucosa removal, shorter hospitalization period, and early return to work. However, many reports later on suggested that there are no signifi cant difference between the submucosal hemorrhoidec­tomy and other procedures. Nevertheless, I am con­vinced that submucosal hemorrhoidectomy causes much less pain than ligation and excision.

surgery. Since pain is usually caused by the spasm of the internal anal sphincter after hemorrhoid surgery, postop­erative pain can be reduced by decreasing the contrac­tion of internal anal sphincter. Decreasing the contraction is also helpful on wound healing through improving cir­culation. Both manual dilatation of the anus and lateral internal sphincterotomy are ways to reduce the resting anal pressure caused by the contraction of internal anal sphincter. In 1810, Copeland argued that manual dilata­tion of the anus was effective, instead on hemorrhoids were caused by excessive tension of the anal sphincter, and in 1968, the procedure was reintroduced by Lord. Hemorrhoidal blood vessels are connected to the portal venous system through the submucosa of the lower rec­tum, and they are easily closed, regurgitated and engorged at the point where they pass through the sub­mucosa by the increased rectal pressure or intra­abdominal pressure, so the hemorrhoidal plexus becomes congested and much larger. Hemorrhoids get more pres­sure by the pectin band of the internal sphincter. So theo­retically, if the pectin band were dilated, the hemorrhoids could also be treated with prevention of the vascular engorgement. Watt et al. have reported that manual dila­tation of the anus relieved postoperative pain. However, Goligher, Mortensen, and Mathai et al. have reported that the procedure was not effective in relieving the pain, but rather has possibility of provoking incontinence of gas or feces. In my experience, combined lateral internal sphincterotomy during a hemorrhoidectomy reduced the postoperative pain. Therefore, rather than performing on all patients, these procedures should be selectively per­formed on patients with a preoperative hypertonic anal sphincter or on patients concerned with anal stricture after the surgery.

(d) Drugs injected into the surgical site at the time of opera-

tion: Injecting analgesics, such as ketorolac, directly into the anal sphincter before completing the surgery can be helpful on reducing the pain. It also enables day surgery or discharge on the day of surgery after local anesthesia. Moreover, ketorolac inhibits the contraction of the inter­nal sphincter by suppressing the generation of prosta­glandin and relieves postoperative pain with anti-infl ammatory reaction. It also has the effect of reducing urinary retention. A long-acting local anes­thetic, such as bupivacaine or ropivacaine, can also be injected into the skin around the anus.

Hot sitz bath has a cleansing effect by removing the secretion of the wound, relaxes the sphincter to reduce anal pressure, and increases blood circulation helping wound healing and pain relief after a surgery. The author recommends only bidet after a defecation. I believe that since hot sitz bath makes edema and engorgement of anus, it worsens anal wound in spite of pain relieving effect.

Bleeding after hemorrhoid surgery is one of the most per­plexing complications for both the patient and surgeon. Colorectal surgeons should make rapid decision and manage the bleeding because it usually worsens and becomes mas­sive, triggering shock, which can create a serious situation to the patient. Regardless of the explanation given to the patients about possible postoperative bleeding in advance, surgeon may lose a good relationship with the patient and even get involved in a medical litigation.

0.9 % by Kang, thus averaging about 1 %. The different fre­quency rate of late bleeding is probably not only because of the various surgical methods but also the standard of defi ning bleeding. For example, in some reports, minimal bleeding is also regarded as late bleeding, and in others, only massive bleeding is regarded as late bleeding. Chicuba et al. of Japan reported that bleeding from the submucosal hemorrhoidec­tomy is less frequent than that from the ligation and excision, and the author also agrees with this report.

If the patient complains of diarrhea after the surgery, bulk­forming fi ber without magnesium oxide will be recom­mended. These medicines will be prescribed for 3–4 weeks after the surgery. In case of chronic constipation, however, the prescription continues even after 3–4 weeks, depending on the patient’s request, and the dose will be reduced gradually.

A skin tag is a prominence of the skin around the anus, which can be defi ned as “a stretched anoderm caused by the swol­len skin that is close to the hemorrhoidectomy wound.”

1. Traditional food rather than Western-styled fatty food!

Traditional food uses many ingredients containing fi ber (e.g., seaweed, root vegetables, bean products).

2. Boiled vegetables rather than raw ones!

You cannot take in as much plant fi ber as you might think through raw vegetables. Blanched or boiled vegetables, on the other hand,

decrease in volume so that they can be eaten in larger quantities.

3. Regular meals, three times a day!

The recommended daily intake of plant fi ber is 20 g. Having regular meals with three times a day is the basic principle.

4. Modify your staple foods to suit your taste!

The mechanism of skin tag development has not yet been cleared, but skin tag is thought to be caused by the following factors:

Christensen, who fi rst invented the house fl ap, made an incision on stricture site of anal canal and applied the house fl ap without removing the scar tissue. The disadvantage of this procedure is that the scar tissue remains. My preference is to remove the scar tissue and replace it with normal house fl ap tissue. After excising scar tissue (Fig . 10.5 ), make the incision to be a house shape, pentagon shape. The width of A’-B’ (fl ap area) should be wider than that of A-B (removed area) because the fl ap usually shrinks after dissection. I pre­fer it to be 1.5 times wider. Furthermore, a broad fl ap allows enough anal dilation postoperatively. It is desirable that the length of D-B’ is longer than that of B-F. A slightly round shape of C-E-D is also desirable. It is a kind of the island fl ap. A pentagon-shaped fl ap is made and advanced, lining the entire length of the anal canal, and sutured into place. I prefer to use 3-0 chromic catgut for the suture material.

Under the aggravating hospital management condition nowadays, the treatments need to be effi cient. Especially for the hemorrhoids, since more than 70 % of the hospitals are under the management of DRG system, the effi cient man­agement is becoming inevitable. The critical pathway is demanded to minimize the manpower and consumption of medicine and supplies, but to maintain high-quality treatment.