Hemorrhoids Update Review » Surgery

Thrombosed external hemorrhoids

admin — Sun, 06 Jun 2010 02:48:11 +0000

Thrombosis is a fairly common complication of hemorrhoids disease. Most patients give no history of straining or physical exertion and do not have histories of hemorrhoids disease. The complication develops with an abrupt onset of anal mass,hemorrhoids and pain that peaks within 48 hours. Usually, the pain becomes minimal after the fourth day. Occasionally, the skin overlying the hematoma becomes necrotic, causing bleeding and discharge or infection, which causes further necrosis and more pain. Treatment should be aimed at relief of severe pain, prevention of recurrent clot, and prevention of residual skin tags. If the patient is experiencing severe pain of hemorrhoids at the time of examination, excision should be performed. Conversely, if the pain is already subsiding and the clot is starting to shrink, thrombosis may be managed conservatively with warm sitz baths for comfort, proper anal hygiene, and bulk-producing agents such as bran or psyllium seed. The procedure can often be performed with the use of local anesthesia, and the wound can be left open without packing. Relief of pain is usually immediate. Postoperative care is simple and is aimed at keeping the wound clean with warm sitz baths and washing. An analgesic drug may be required during the first 24 hours. Patients must be warned of a relatively high recurrence rate about 6% after excision and 25% with noninvasive treatment.

Stapled Hemorrhoidectomy, a New Treatment

admin — Mon, 07 Dec 2009 03:46:28 +0000

A new entry into the arena of excisional hemorrhoidectomy is the circular stapled hemorrhoidectomy .The technique uses a circular, transanally placed pursestring suture 4 cm from the dentate line and within the enlarged internal hemorrhoids. A 31-mm stapler is then placed transanally to perform a circumferential excision of the hemorrhoidal tissue and a repositioning and fixation of the anoderm to its proper location in the anal canal. The results appear promising, with decreased postoperative pain, shorter periods of convalescence, and similar complication rates compared with other forms of excisional hemorrhoidectomy.

Rubber Bands Ligation in Hemorrhoids Treatment

admin — Mon, 07 Dec 2009 03:43:21 +0000

Barron was the first to describe hemorrhoidal banding with rubber bands in 1963.Since this original description, there have been a number of reports that have documented the efficacy banding offers for the management of the majority of patients with bleeding stage II and III internal hemorrhoids.The procedure is generally well tolerated without the need for prescription analgesia if the band is placed above the level of the dentate line. The technique is demonstrated in the picture below . It is important to ask the patient if he or she experiences any pain during placement of the bander, before deployment of the band. Discomfort immediately after band placement may be reduced by the injection of a local anesthetic agent, but this does not appear to be a long-lasting benefit. Banding is associated with the rare but frequently fatal complication of postbanding sepsis, which is heralded by the symptoms of increasing rectal pain, fever, and inability to void.It is essential to treat these symptoms early and aggressively with early antibiotic treatment coupled with surgical drainage

Bayer et al. reported a series of 2934 patients in whom 79% of patients achieved complete relief of symptoms after a single session of banding at only one or two locations. With this approach, patients required multiple sessions for control of symptoms (two sessions, 32%; three sessions, 17%; four sessions, 25%; and five or more sessions, 20%). Only 2% of patients required hemorrhoidectomy. It may be possible to achieve a similar outcome with a shorter duration of therapy, albeit at the expense of greater post-treatment pain, by banding all symptomatic hemorrhoidal sites at the initial visit.Banding techniques appear to be durable after initial control of symptoms, with 69% of patients maintaining long-term relief and only 8% ultimately requiring excisional hemorrhoidectomy.

Type of Hemorrhoidectomy Treatment

admin — Mon, 07 Dec 2009 03:42:14 +0000

Options for hemorrhoidectomy include the techniques of Milligan-Morgan hemorrhoidectomy, closed Ferguson hemorrhoidectomy, Whitehead hemorrhoidectomy, and the stapled hemorrhoidectomy. The procedures are usually performed in the operating room after minimal preoperative preparation of the bowel. Lasers have no role to play in excisional hemorrhoidectomy, and in fact they cause delayed healing, increased pain, and increased cost.Anesthetic management is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective. The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention.

The Milligan-Morgan hemorrhoidectomy, which is widely practiced in Europe, was originally described in 1937, and its efficacy has been subsequently documented in many series.This technique includes resection of the entire enlarged internal hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.[33] The distal anoderm and external skin is left open to minimize the risk of infection in the wounds. This technique is safe and effective. However, the fact that the external wounds are left open can be a cause of considerable discomfort and prolonged morbidity.

The closed Ferguson hemorrhoidectomy was proposed as an alternative to the Milligan-Morgan technique and has a similar large body of reported experience. This technique involves an hourglass-shaped (centered at the midportion of the anoderm) excision of the entire internal/external hemorrhoidal complex, preservation of the internal and external anal sphincters, and primary closure of the entire wound. Occasionally, it is necessary to undermine flaps of anoderm and perianal skin to allow removal of intermediate hemorrhoidal tissue while preserving the bridges of anoderm between pedicles. This technical adjustment avoids postoperative strictures.

The Whitehead hemorrhoidectomy, described in 1882, was devised to eradicate the enlarged internal hemorrhoidal tissue in a circumferential fashion and to relocate the prolapse dentate line, which is often a component of prolapsing hemorrhoids. Although this technique was used widely, it was subsequently largely abandoned because of the high rates of mucosal ectropion and anal stricture.The technique has had renewed support, with several authors who documented minimal stricture rates and no occurrences of mucosal ectropion.Despite these promising reports, the Whitehead procedure is technically demanding because of the need to accurately identify the dentate line and relocate it to its proper position

Hemorrhoids Surgery – Hemorrhoidectomy

admin — Mon, 07 Dec 2009 03:40:00 +0000

The decision to excise the hemorrhoidal plexi requires acceptance by the physician and patient that medical and non-excisional options have either failed or are not appropriate. The usual clinical symptoms that lead to excision are frequent prolapsing of the internal hemorrhoids that results in discomfort and anal seepage. Alternatively, the thickened and prolapsing internal/external hemorrhoidal complexes may make anal hygiene difficult for the patient and may make excision preferable. The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids. It is apparent, however, that hemorrhoidectomy can be performed using standard closed hemorrhoidectomy techniques without undue complications. Specifically, the risk of stenosis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites. In the case of limited external hemorrhoidal thromboses, surgical excision is warranted for more rapid pain relief and avoidance of a residual skin tag.External thromboses are usually easily managed in an office setting with local anesthesia

A, Thrombosed external hemorrhoid in the right lateral quadrant. B, Allis clamp applied to apex of thrombosis and elliptical incision made. C, Thrombosis dissected free of sphincter. D, Appearance of wound after thrombectomy.

Hemorrhoidectomy Complication

admin — Mon, 07 Dec 2009 03:36:57 +0000

Regardless of the excisional technique used for the treatment of advanced hemorrhoids, the key to effective patient management is avoiding postoperative complications. Pain is the most frequent complication and the most feared sequela of the procedure from the patient’s perspective. A variety of analgesic regimens have been recommended, usually consisting of a combination of oral and parenteral narcotics.The use of local infiltration of bupivicaine into the wounds and perianal skin has been variably successful in long-term pain reduction.Conversely, ketorolac has demonstrated considerable efficacy in the management of posthemorrhoidectomy pain.The use of alternative administration routes for narcotics by either patch or subcutaneous pump has been successful in controlling pain, but the management of these routes of administration can be risky in the outpatient setting because of the risk of narcotic-induced respiratory depression. The most appropriate regimen after outpatient hemorrhoidectomy appears to be the intraoperative use of ketorolac, sufficient doses of oral narcotic analgesics for home administration, and supplementation of the narcotics with oral nonsteroidal medication.

Urinary retention is a frequent postoperative problem after hemorrhoidectomy, ranging in incidence from 1 to 52%. A variety of strategies have been used to treat the problem, including parasympathomimetics, alpha-adrenergic-blocking agents, and sitz baths.The best approach, however, seems to be prevention that includes limiting perioperative fluid administration to 250 ml, an anesthetic approach that avoids the use of spinal anesthesia, the avoidance of anal packing, and an aggressive oral analgesic regimen.

Early postoperative bleeding (<24 hours) occurs in approximately 1% of patients and represents a technical error that requires return to the operating room for resuturing of the offending wound.Delayed hemorrhage occurs in 0.5 to 4% of cases of excisional hemorrhoidectomy at 5 to 10 days postoperatively.The cause is likely early separation of the ligated pedicle before adequate thrombosis in the feeding artery can occur.In this scenario, the bleeding is usually significant and requires some method for the control of ongoing hemorrhage. Options include return to the operating room for suture ligation or tamponade at the bedside with Foley catheter or anal packing. The subsequent outcome after the control of secondary hemorrhage is generally good with virtually no risk of recurrent bleeding. It may be helpful to irrigate the distal colorectum with posthemorrhage enemas or at the time of intraoperative control of bleeding to avoid confusion when the residual clots pass per anum.

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Thrombosed external hemorrhoids

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