Posts Tagged ‘hemorrhoid’
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.
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.
