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