Surgical Intervention
Principles of Surgical Therapy
- The need for treatment of hemorrhoids is based on the patient’s symptoms and not on the appearance of the hemorrhoids
- Surgical hemorrhoidectomy is considered the most effective treatment for hemorrhoids in general and particularly for grades III-IV hemorrhoids
- Outpatient ablative (non-surgical) procedures are preferred when possible because surgery is associated with more complications, pain and postoperative disability
Indications for Surgical Hemorrhoidectomy
- Patients that do not respond to or cannot tolerate ablative office-based procedures
- Patients with large grade III or IV hemorrhoids, symptomatic external hemorrhoids including those who have symptoms from skin tags
- Acutely incarcerated and thrombosed hemorrhoids
- Combined external and internal hemorrhoids (grade III-IV) with significant prolapse
Options for Surgical Therapy
Open or Closed Hemorrhoidectomy
- May be performed using a surgical scalpel, laser, ultrasonic scalpel or diathermy
- Involves any of the following:
- Excising internal and external components
- Suturing or banding internal hemorrhoids and excising external component
- Performing a circular excision of internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line
- Thrombosis of external hemorrhoids which has been present for <48-72 hours is best treated by local excision of the external component
- May be done as an office procedure but may sometimes require an operating room setting because of large hemorrhoid size, extension within the canal or patient anxiety
- Complications of surgery are usually minor but may occur frequently
- These include bleeding, incontinence, urinary retention, infection, and anal stenosis
Stapled Hemorrhoidectomy
- Newer alternative for patients with significant prolapse
- Goals are the re-suspension of prolapsing tissue back within the anal canal and interruption of arterial blood flow that goes through the excised segment of redundant rectal mucosa
- Uses a modified, circular, anastomotic stapler
- Ineffective against large external hemorrhoids and skin tags or thrombosed hemorrhoids
- Rates of complication are similar with excisional hemorrhoidectomy