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II.

DRAPING:
A. Anesthesia: Hemorrhoidectomy may be performed under general anesthesia (the patient is rendered unconscious), under spinal anesthesia (the patient is numbed from the waist down), or under local anesthesia (the immediate area is injected with a numbing agent). The choice of anesthesia depends on the extent of surgery, the patient's health and personal preference, and surgical standards of the facility. B. Draping and Positioning: Put the patient in Jackknife position (as seen below). Folded towels and a laparotomy sheet. Tapes are attached to table sides.

C. Preparation of the Patient: Antiembolitic hose may be applied to the legs. A Foley catheter may be inserted. Bony prominences and areas vulnerable to skin and neurovascular trauma or pressure are padded. Apply electrosurgical dispersive pad.Tincture of benzoin is applied to the buttocks over which wide adhesive is applied prior to sigmoidoscopy. D. Skin Preparation Begin inside tape margins, discarding each sponge after wiping the anus. E. Aftercare Patients may experience pain after surgery as the anus tightens and relaxes. The doctor may prescribe narcotics to relieve the pain. The patient should take stool softeners and attempt to avoid straining during both defecation and urination. Soaking in a warm bath can be comforting and may provide symptomatic relief. The total recovery period following a surgical hemorrhoidectomy is about two weeks.

III. DISCUSSION OF THE PROCEDURE:
Hemorrhoidectomy refers to the removal of the hemorrhoidal tissues, including the enlarged veins within.Hemorrhoids may be treated with concomitant anal conditions, such as fissure (anal ulcer) and fistula or excision of the veins of the anus and associated overlying skin and anoderm (externally) and mucous membrane(internally).Numerous modalities are employed for internal hemorrhoids and associated rectal mucosal prolapse (latex band ligation, sclerosing injections, laser, cryotherapy, and others), most often performed as an office procedure without anesthetic (not to include external hemorrhoidal tissue).A circular intraluminal stapler, as used for intestinal anastomosis, can be employed for rectal mucosal prolapse performed as a formal transanal surgical procedure.

A. Background Hemorrhoids are amongst the common anal disorders. Patients may complain of bleeding, prolapse, personal discomfort and minor anal leakage. Where traditional palliative measures such as rest, suppositories and dietary advice fail to improve the condition, there is then a choice of further treatments. Opinion on the best management for patients varies considerably. While many treatments for hemorrhoids may be performed without anaesthetic, the lasting effect of these conservative therapies has been questioned. Many patients treated with rubber band ligation or injection sclerotherapy require multiple treatments and there is high recurrence rate following these procedures. Conventional hemorrhoidectomy provides permanent symptomatic relief for most patients, and effectively treats any external component of the hemorrhoids. However, the wounds created by the surgery are usually associated with considerable post-operative pain which necessitates a prolonged recovery period. This can put a stress on a general practitioner¶s resources, may alienate the patient and delays the patient¶s return to a full, normal lifestyle and the workplace. Because of this, surgeons will generally reserve formal excision for the most severe cases of prolapse, or for patients who have failed to respond to conventional treatments.

B. Procedure The patient lies on the operating table face down with the buttocks slightly elevated or on their back with their legs up in stirrups, so the anus and rectal area are exposed. After the anesthesia has taken effect, the area is cleaned with an antiseptic solution. The hemorrhoids are clamped, tied off, and cut away. The wound is then sutured. After the operation, the surgeon packs the anus with gauze or applies antibiotic ointment. A hemorrhoidectomy takes about 1 to 1 1/2 hours to perform.

Newer methods for hemorrhoid removal are being used. One method involves using an ultrasonic scalpel to cut away hemorrhoids. This method is quicker and does not require sutures. Another innovation is the stapled hemorrhoidectomy, in which tissue from further in the anus is used to close the wound with surgical staples after the hemorrhoids are removed. Patients may recover faster and have less postoperative pain, but some research has shown an increase in complications with this procedure.

C. Summary: The proximal portions of the hemorrhoidal complex are suture-ligated, and the hemorrhoid is excised by scalpel, electrosurgery, or laser. Less often, cryosurgery is employed (usually reserved for limited outpatient procedures). If the anus is stenotic, the distal internal sphincter may be incised. A mucous membrane flap and/or skin flaps may be employed to cover denuded areas. The surgical area may be sewn closed or left open. Medicated gauze covers the wound. Care is taken not to excise too much skin, anoderm, or mucous membrane and to avoid injury to the sphincter mechanism.

D. Risks As with other surgeries involving the use of a local anesthetic, risks associated with a hemorrhoidectomy include infection, bleeding, and an allergic reaction to the anesthetic. Risks that are specific to a hemorroidectomy include stenosis (narrowing) of the anus; recurrence of the hemorrhoid; fistula formation; and nonhealing wounds.

Hemorrhoids can occur inside the rectum, or at its opening .To remove them, the surgeon feeds a gauze swab into the anus and removes it slowly. A hemorrhoid will adhere to the gauze, allowing its exposure. The outer layers of skin and tissue are removed, and then the hemorrhoid itself . The tissues and skin are then repaired.