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HEMORRHOIDECTOMY

REASON FOR VISIT

•Internal hemorrhoids
•Internal hemorrhoids that still cause symptoms after nonsurgical
treatment.
•Large external hemorrhoids that cause significant discomfort and
make it difficult to keep the anal area clean.
•Both internal and external hemorrhoids.
•Had other treatments for hemorrhoids (such as rubber band
ligation) that have failed.
•Persistent itching
•Anal bleeding
•Pain
•Blood clots (thrombosis of the hemorrhoids)
•Infection

RISK ASSESSMENT

•Bleeding disorder
•Advanced age
•Prior anal surgery History of fecal incontinence (involuntary leaking
of stool)
•History of allergies to medication
•History of allergies to anesthesia.

PREPARATION OF THE PATIENT

• Blood tests
• Urine tests
• Chest x-ray
• Digital examination
• Anoscope
• Sigmoidoscopy and colonoscopy
• EKG/ECG
• Enema was given
• Aspirin and other blood thinning medications were stopped
before procedure
• Patient was on fasting for _____hrs before the procedure

ANESTHESIA:

• General anesthesia
• Spinal anesthesia
• Local anesthesia

POSITION OF THE PATIENT

Lithotomy position

Prone position

THE PROCEDURE:

Types:

• Stapled Hemorrhoidectomy
• Open Hemorrhoidectomy
• Closed Hemorrhoidectomy

STAPLED HEMORRHOIDECTOMY:

•A circular, hollow tube was inserted into the anal canal.


•Through this tube, a suture (a long thread) was placed, actually
woven, circumferentially within the anal canal above the internal
hemorrhoids.
•The ends of the suture were brought out of the anus through the
hollow tube.
•The stapler was placed through the first hollow tube and the ends
of the suture were pulled.
•Pulling the suture pulls the expanded hemorrhoidal supporting
tissue into the jaws of the stapler.
•The hemorrhoidal cushions were pulled back up into their normal
position within the anal canal.
•The stapler was then fired. When it fires, the stapler cuts off the
circumferential ring of expanded hemorrhoidal tissue trapped within
the stapler and at the same time staples together the upper and
lower edges of the cut tissue.

OPEN HEMORRHOIDECTOMY (MILLIGAN–MORGAN TECHNIQUE)

•The anal canal and lower rectum were manually cleaned by using
soft moist tissues, and antiseptic solution was applied to the
buttocks and anus.
•Adrenaline in bupivacaine or lignocaine injection was given at three
or four sites around the anus to constrict the blood vessels and
reduce bleeding.
•The hemorrhoids were teased out gently with the finger.
•Small forceps were clipped on the base of each hemorrhoid and the
pile was pulled out gently to expose the apex, onto which a second
forceps were clipped on.
•This produces a triangular shape, called “triangle of exposure”
which marks out the shape of the tissue to be cut.
•Starting at the wide base, then dissects the hemorrhoidal tissue
slowly from the underlying sphincter muscle. The wound was then
dried, by using diathermy /cauterization by electricity /ligature/
suturing.
•At the end of the dissection, three triangular-shaped wounds were
created with a wide base of approximately ___cm.
•At this time, the hemorrhoidal mass was still attached at the apex,
just above the dentate line. The excision of the hemorrhoid mass
was completed by first ligating the pedicle/ stalk with a fine surgical
suture.
•At the end of this step, three dry and clean triangular wounds are
left, separated by three skin bridges of 2.0 cm width or more.
•At the end of the operation, a single layer of non-adhesive gauze
was used to dress the wounds.

CLOSED HEMORRHOIDECTOMY

• Hill-Ferguson retractor was inserted into the anal canal.


• A plan for removing the affected hemorrhoid was then
established.
• A knife was used to make a circular incision starting at the
dentate line and extending well past the anal verge around the
hemorrhoid.
• Scissors were then used to lift the skin from the external
sphincter.
• The mucosa was freed from the internal sphincter cephalad
• The incisions will reveal the muscle of the Treitz anchoring the
internal sphincter to the mucosa.
• The mucosa suspensory ligament was divided using the scissors.
• The proximal part of the internal sphincter was cut free and the
hemorrhoid complex was removed.
• A partial and superficial internal sphincterotomy was performed
at the base of the wound.
• The wound was closed with sutures.

AFTER PROCEDURE

Patient was shifted to intensive care unit

DURATION

________hrs

POSTOPERATIVE CARE

•Take pain medication as prescribed


•Take antibiotics as prescribed
•Soaking in a sitz bath (a shallow bath of warm water) several times
a day helps ease the discomfort.
•Use a donut ring (cushion with a hole in the middle) can make
sitting upright more comfortable.
•Avoid constipation
•Eat a high-fiber diet and drink plenty of liquids.
•Avoid heavy lifting for 2 to 3 weeks.

COMPLICATIONS
• Constipation
• Excessive bleeding
• Excessive discharge of fluid from the rectum
• Inability to urinate or have a bowel movement
• Severe pain, especially when having a bowel movement
• Hematoma formation
• Infection of the surgical area
• fecal Impaction
• Stenosis of the anal canal
• Recurrence of hemorrhoids
• Fistula formation
• Rectal prolapse