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.
