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27
2 Hemorrhoids
Complications of Hemorrhoidectomy
Pain
Hemorrhoidectomy is recognized to be painful, but the degree of pain varies from
patient to patient. Closed hemorrhoidectomy is thought to be less painful than open
hemorrhoidectomy. A variety of maneuvers have been employed to reduce postop-
erative pain. Commencing laxatives prior to operation seems appropriate to prevent
postoperative constipation. There was a vogue for combining hemorrhoidectomy
with sphincter dilatation and even sphincterotomy to limit painful spasm of the
internal sphincter. This approach should be avoided as it is likely to increase the risk
of incontinence. Newer approaches include the use of GTN ointment, diltiazem
ointment, and injection of botulinum toxin as well as using antibiotics such as met-
ronidazole. It should not be forgotten that adequate analgesia without inducing con-
stipation may be a simpler approach and often is all that is required.
Bleeding
Primary bleeding arises from the vascular pedicle or the cut edges of the mucosa.
Simple pressure may be all that is required to stop the bleeding. In the lower rectum,
this can be applied by infl ating a Foley catheter balloon in the rectum with 30–50 cc
of water and applying gentle traction to the catheter for an hour or two. Brisker
bleeding requires further examination under anesthetic and suture ligation. The
prone jackknife position is helpful as blood in the rectum runs away from the opera-
tive site. Secondary hemorrhage usually arises as a consequence of infection in the
hemorrhoidectomy wound and occurs between the seventh and fourteenth days
postsurgery. Bleeding is often brisk and will require admission to hospital, fl uid
resuscitation, and examination under anesthetic. Antibiotics should be prescribed
and continued for a few days after the hemorrhage ceases.
Case Scenario 2
A 65-year-old lady presents with symptomatic third-degree hemorrhoids. She
is keen to have the problem resolved and agrees to undergo hemorrhoidec-
tomy. Her past medical history is unremarkable, and she is not on any medica-
tion. This is her fi rst anal operation, but she has had three children born
vaginally. The operation is performed by Milligan-Morgan technique, with
three large hemorrhoids removed. She stays in hospital overnight but is well
enough to go home the next day. One week later, she is readmitted with
increasing anal pain and persistent incontinence of loose stool. There is some
bleeding.
What are the possible explanations for her symptoms?
How would you assess the situation?
How would you manage her symptoms?
28
J.G. Williams
Urinary Retention
Retention of urine is more common in male patients than female patients and is
thought to arise as a result of refl ex spasm of the urinary sphincter in response to
pain. Patients with preexisting symptoms of urinary outfl ow obstruction are more
prone to retention, as are patients who receive a caudal anesthetic to supplement
pain relief. Fluid restriction in the perioperative period is thought to reduce the risk
of retention.
Infection
Infection following hemorrhoidectomy is unusual, despite high bacterial contami-
nation of the operative fi eld. Submucous abscess with subsequent fi stula formation
can occur after closed hemorrhoidectomy. Rare cases of fulminant infection after
hemorrhoidectomy usually involve patients who are immunosuppressed. However,
as the consequence of infection can be catastrophic, a high index of suspicion should
be maintained in any patient who is unwell and experiencing increasing pain fol-
lowing hemorrhoidectomy.
Anal Fissure
An anal fi ssure can develop in one of the wounds following hemorrhoidectomy and
usually arises from delayed healing of the wound as a consequence of increased
tone in the internal sphincter. Topical sphincter relaxing agents should be used in the
fi rst instance, but sphincterotomy may be required. Anorectal physiology studies
can guide treatment.
Anal Stenosis
Development of anal stenosis refl ects excessive removal of anoderm with cicatriza-
tion of the anal canal during healing. Simple dilatation may be all that is required to
correct the problem, but advancement fl ap anoplasty is sometimes required to cor-
rect the stenosis.
Incontinence
Anal leakage and soiling is common in the early postoperative period but is thought
to resolve as the wounds heal. However, two recent studies have reported late leak-
age rates of the order of 30% after open and closed hemorrhoidectomy. Postoperative
anal leakage may have a number of causes. Anorectal physiology studies have
shown changes in mucosal sensitivity and anal sphincter pressures following sur-
gery. Furthermore, removal of hemorrhoidal tissue will affect the symmetry and
closure of the anal canal. More worryingly, a recent paper reported endoanal ultra-
sound evidence of damage to the internal and external sphincter of 12 symptomatic
patients following hemorrhoidectomy.
29
2 Hemorrhoids
2.7.4 Newer Surgical Treatments for Hemorrhoids
2.7.4.1 PPH (Procedure for Prolapse and Hemorrhoids)
The procedure of stapled hemorrhoidectomy was described by Longo in 1998
[
13 ] and has been adopted with great surgical enthusiasm. A variety of terms have
been used to describe the procedure, but most surgeons now agree that the term
PPH or stapled hemorrhoidopexy most accurately describes the operation. While
conventional surgical hemorrhoidectomy involves excision of hemorrhoidal tis-
sue, anoderm, and perianal skin, stapled hemorrhoidopexy simply excises a ring
of rectal mucosa above the hemorrhoids, which returns the prolapsed distal
mucosa and hemorrhoidal plexus to its normal position. At the same time, there is
disruption of the distal branches of the superior rectal arteries feeding the hemor-
rhoidal plexus. Removal of rectal, rather than anal tissue, means that the proce-
dure is much less painful than traditional hemorrhoidectomy. It is postulated that
it achieves a more physiological result by replacing the displaced hemorrhoidal
tissue in its anatomical position, as opposed to excising it, recognizing the impor-
tance of the hemorrhoidal cushions in contributing to fecal continence.
The operation is performed with a modifi ed circular stapling instrument ( PPH-
03 – Ethicon Endo Surgery, 50–100 Holmers Farm Way, High Wycombe.
Buckinghamshire. HP12 4DP UK ), although other manufacturers are introducing
similar instruments. The procedure is performed under a general anesthetic. The
key maneuver is insertion of the mucosal purse-string suture. This should be
placed at least 2 cm caudad of the dentate line, making sure that each bite of
suture includes only mucosa and not rectal muscle and that the needle is inserted
immediately adjacent to the last exit site, such that the suture is completely buried
in the submucosal plane. Care should be taken that each bite of suture is the same
distance from the dentate line and that “spiraling” of the suture is avoided. Once
the suture is placed, the gun is inserted and opened such that the anvil lies above
the level of the purse-string suture. The suture is then tied around the shaft of the
instrument, which is then closed tight, and after a slight pause and further tighten-
ing, the gun is fi red. Once the gun is opened and removed, the staple line is
inspected, any bleeding point is under run with an absorbable suture.
Contraindications to the procedure are listed in Box 2.3 . The major advantages of
the procedure are that it is usually a quick operation to perform and that it is
Box 2.3: Contraindications to PPH
Concomitant anal sepsis
Gangrene or thrombosed hemorrhoid
Anal stenosis
Full thickness rectal prolapse
Pre-existing sphincter injury
30
J.G. Williams
associated with less pain, both in severity and duration, than conventional hemor-
rhoidectomy. However, some patients do fi nd the procedure painful, and this is
especially so if the purse string is placed too low and sensitive anoderm is included
in the staple line.
Mixed early reports suggested PPH may have long-term detrimental results on
anorectal function, relating to chronic pain and functional problems [
14 ] . While
many complications have been reported, including rectovaginal fi stula, pelvic sep-
sis, perineal sepsis, bacteremia, iatrogenic rectal diverticula, to name a few, the
reality is that these complications are rare in a unit that performs stapled hemor-
rhoidectomy regularly; the commonly encountered side effect of tenesmus and fecal
urgency is usually short lived.
Comparison with conventional Milligan-Morgan hemorrhoidectomy in random-
ized controlled trials reveals signifi cant reduction in analgesic requirements and an
earlier return to full activities for the stapled hemorrhoidectomy patients [ 15, 16 ] .
Recent meta-analysis of all controlled trials comparing PPH with conventional
hemorrhoidectomy shows that PPH is less painful than conventional hemorrhoidec-
tomy, is quicker to perform, requires a shorter hospital stay, and patients recover
quicker [ 17 ] . However, PPH has a higher rate of recurrent prolapse and need for
further surgery. Furthermore, when cost analysis is performed, the lower hospital
costs are offset by the cost of the disposable instrument, and there is little difference
in overall cost of the operations [ 18 ] .
It is likely that PPH will remain a viable option for the treatment of hemorrhoids.
Patients should be aware of the increased likelihood of requiring further treatment
as well as the benefi ts of the procedure. The operation is more suited to patients with
signifi cant mucosal prolapse and large internal hemorrhoids which have not
responded to outpatient treatment. Patients with large external hemorrhoids are
probably better treated by conventional hemorrhoidectomy.
2.7.4.2 Transanal Hemorrhoidal Dearterialization
Transanal hemorrhoidal dearterialization (THD), also known as Doppler-guided
hemorrhoidal artery ligation (DGHAL), is a new approach to the treatment of hem-
orrhoids. It is a nonexcisional surgical technique that aims to interrupt arterial fl ow
to the hemorrhoidal plexus by means of Doppler-guided localization of the feeding
vessels and per anal ligation of the terminal branches of the superior rectal artery.
The procedure is performed under GA using a specifi cally designed proctoscope
incorporating a Doppler transducer. At the distal end of the Doppler transducer,
there is a small window that allows the accurate placement of the sutures by local-
ization of all the terminal branches of the hemorrhoidal arteries, which are then
sequentially sutured, transfi xed, and ligated with an absorbable suture. The sutures
are placed in a “fi gure of 8” about 4 cm above the dentate line. Once a 360° dearteri-
alization is completed, the rectal mucosa is plicated in three or four quadrants deal-
ing with the largest prolapsing components. The plication commences as far in as
the proctoscope allows, normally 4 or 5 cm proximal to the dentate line. A continuous
suture is then inserted toward the dentate line taking the mucosa and submucosa.
31
2 Hemorrhoids
The suture is stopped at about 5 mm from the dentate line taking care not to catch
the anal mucosa to avoid postoperative pain.
THD aims to correct the physiology of the hemorrhoidal plexus by restoring normal
anatomy rather than excising disrupted tissue. This may be achieved through a reduc-
tion of the arterial infl ow (dearterialization) and an elimination of the mucosal prolapse
(mucosopexy). Indeed, since it has been suggested that mucosal sliding may impair
venous drainage, mucosopexy might improve the venous drainage from the hemor-
rhoidal plexus, thus reducing recurrences. Furthermore, repositioning the hemorrhoidal
cushions rather than excising them maintains their physiological role in the continence
mechanism. Finally, the fact that this technique is carried out above the sensitive ano-
derm minimizes postoperative pain with potentially quicker recovery times. It has not
been established which is the most important step in the procedure. Should this be
mucosal plication, then this can be achieved without the considerable expense of the
disposable instruments required to identify and perform the arterial ligation.
The main selling point (a term used specifi cally as there is a large commercial
element to this technique because of the disposable instrument used) for this tech-
nique is the minimal pain the patient experiences after the procedure. A number of
series have been published with good initial results and failure rates of the order of
5–25% [
19– 23 ] . However, little data comparing TDH/DGHAL against conventional
hemorrhoidectomy is available. Randomized trials confi rm that hemorrhoid artery
ligation is less painful and equally effective, but the number of patients included
were small and follow-up short [ 24, 25 ] .
2.8 Thrombosed Hemorrhoids
Acutely thrombosed hemorrhoids are an unusual but fairly dramatic complication
of hemorrhoids. Often, there is a precipitating event, such as parturition, cerebro-
vascular event, or myocardial infarction, which has a bearing on the treatment
options available. A history from the patient will establish whether the thrombosis
occurred on a background of long-standing hemorrhoidal problems or arose de novo .
The options for management lie between conservative treatment (nonconstipating
analgesics, laxatives, topical ointments, and ice packs) and urgent surgical excision.
Older textbooks warn against acute surgery because of a risk of portal pyemia. This
risk is exaggerated, and patients can be operated on safely in the acute phase, which
is the author’s preferred approach. The natural history of the condition is for gradual
resolution, and it is surprising how normal the anus looks some months after an
episode of acute thrombosis. If surgery is undertaken, a large volume of local anes-
thetic and adrenalin solution should be infi ltrated into the thrombosed hemorrhoids
and massaged for a few minutes. This will reduce sphincter spasm and edema in the
tissues and make it simpler to defi ne the tissue to be excised and much easier to
preserve adequate bridges of anoderm between each hemorrhoid. It is more impor-
tant to maintain adequate skin bridges than remove all thrombosed tissue. The
author’s approach is to discuss these issues with the patient and to perform hemor-
rhoidectomy if the patient wishes.
32
J.G. Williams
2.9 Perianal Hematoma
Perianal hematoma is a discrete thrombosis confi ned to the subcutaneous external
hemorrhoidal venous plexus at the anal margin. The swelling and pain is usually
of rapid onset. The patient describes an acutely tender, fi rm lump at the anal mar-
gin. Pain builds to a crescendo over a matter of hours and is fairly constant for a
few days before the pain gradually eases. The lump takes longer to resolve as the
clot is absorbed and may leave a small skin tag as a souvenir. Sometimes, the clot
discharges spontaneously, and the patient may describe the alarming symptom of
passing dark blood and clots. Treatment depends on the point at which the patient
seeks help. If in the phase of resolution, then surgery should be avoided. In the
acute phase, options lie between incision of the hematoma or excision, both
options performed under local anesthetic in the emergency admissions unit or
clinic. The author’s preference is to excise the hematoma. Local anesthetic is infi l-
trated around the hematoma, and an elliptical incision is made at the base with a
small scalpel or scissors. The hematoma is easily stripped off the underlying
sphincter by sharp dissection, taking care not to extend the incision into the anal
canal. The resulting defect is left open. Incision of the hematoma is even simpler
to perform, but there is a risk of leaving pockets of hematoma in part of the venous
plexus.
2.10 Conclusions
Symptomatic hemorrhoids are common. Many patients will be happy to be reas-
sured that there is not a more serious cause for their symptoms and will not
require any specifi c treatment. Outpatient treatments, while likely to improve
symptoms in upward of three-fourths of patients, are associated with high rates
of recurrent symptoms. The ideal surgical treatment for hemorrhoids would pro-
vide permanent relief from symptoms but could be performed with the shortest
hospital stay, the minimum of discomfort, and little likelihood of complications.
Excisional hemorrhoidectomy has been an accepted part of the management of
hemorrhoids for a 100 years. This approach, while providing long-term relief of
symptoms for many patients, is associated with considerable pain and occasional
severe complications. However, while newer techniques appear to be less pain-
ful, long-term results are uncertain, and there is growing evidence to indicate that
recurrence rates are higher for these less invasive techniques than for conven-
tional hemorrhoidectomy. For these reasons, a patient with symptomatic hemor-
rhoids needs to be aware of the advantages and disadvantages of each surgical
approach. Surgeons treating patients with hemorrhoids need to be skilled in sev-
eral techniques and advise the patient on the approach that best suits their
situation.
33
2 Hemorrhoids
Key Points
Hemorrhoidal symptoms common cause of presentation to colorectal •
clinic.
Establish that there is not another explanation for symptoms. •
Investigations guided by combination of pattern of symptoms, duration of •
symptoms, and patient’s age.
Reassurance and advice about diet, fl uid intake, and perianal hygiene often •
all that is required.
Therapy determined by symptoms, not appearance of hemorrhoids. •
Rubber band ligation is probably more effective than injection sclerother-•
apy and works best for bleeding hemorrhoids and fi rst- and second-degree
hemorrhoids.
Hemorrhoidectomy is an effective but painful treatment for larger, symp-•
tomatic hemorrhoids.
Newer procedures (stapled hemorrhoidopexy and hemorrhoid artery liga-•
tion) are established as being less painful and effective in the short term.
Less certain long-term benefi t.
Few hemorrhoids need treatment – beware of overtreating the patient. •
Case Scenario Answers 1
The history is entirely compatible with hemorrhoidal disease, and there are
no red-fl ag symptoms, such as a change in bowel habit. Sigmoidoscopy was
performed to 20 cm, so an adequate view of the rectum was obtained. For
these reasons, further investigation is not required at this stage in this
41-year-old male, and it would be appropriate to assume that his symptoms
are related to his hemorrhoids once the initial examination has excluded an
anal fi ssure.
There are a number of options for treating his hemorrhoids, ranging from
outpatient treatment to hemorrhoidectomy. He has undergone injection scle-
rotherapy in the past with limited benefi t, and while rubber band ligation may
be more effective, given the size of his hemorrhoids, it is likely to be of only
temporary benefi t. The patient is receptive to the idea of one of the newer
surgical treatments for his hemorrhoids. Both hemorrhoid artery ligation with
plication and stapled hemorrhoidopexy could be considered in this situation.
However, the patient should be made aware that long-term outcomes are
uncertain for both procedures and that neither would deal with his skin tags,
which may be contributing to the anal irritation. Hemorrhoidectomy, either
open or closed, would deal with both the hemorrhoids and the skin tags but
would be more painful in the short and medium term.
34
J.G. Williams
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Although incontinence is a recognized complication of hemorrhoidectomy, it
is unusual and usually only becomes fully apparent when the wounds have
healed and the immediate postoperative symptoms have resolved. Incontinence
following hemorrhoidectomy is either caused by inadvertent damage to the
anal sphincters during excision of the hemorrhoid or to excessive removal of
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In this scenario, the incontinence is of loose stool and has developed soon
after the procedure. The increasing anal pain and minor bleeding is a clue to
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35
2 Hemorrhoids
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