Haemorrhoidectomy Mr Graham Williams Consultant Surgeon Royal Wolverhampton Hospitals

Haemorrhoidectomy Symptomatic haemorrhoids – 3 rd degree – 2 nd degree not responding to other Rx – Acutely thrombosed haemorrhoids Indications for Haemorrhoidectomy

Haemorrhoidectomy Remove swollen haemorrhoidal tissue Remove associated external element Preserve uninvolved anoderm and perianal skin Avoid damage to sphincters Principles of Operation

Haemorrhoidectomy Whitehead Open – Milligan Morgan Closed – Ferguson – Parks’ submucosal Techniques

Open Haemorrhoidectomy Injecting local anaesthetic and 1:200,000 adrenalin

Open Haemorrhoidectomy Isolating each haemorrhoid

Open Haemorrhoidectomy Commencing excision of haemorrhoid

Open Haemorrhoidectomy Preserving internal sphincter

Open Haemorrhoidectomy Ligating pedicle of haemorrhoid

Open Haemorrhoidectomy Excising haemorrhoid

Finished operation Open Haemorrhoidectomy

Closed Haemorrhoidectomy Fansler Retractor

Closed Haemorrhoidectomy

AuthorNumberFollow up Parameters Compared OpenClosedPainHealingMorbidity Ho et al mthNo diffOpenNo diff Hosch et al wksNo diff Closed Carapeti et al wksNo diff Arbman et al yrNo diffClosedNo diff Gençosmanoglu <40mthOpenClosedOpen Arroyo et al yrClosed No diff You et al wksClosed No diff Haemorrhoidectomy Open vs Closed

Haemorrhoidal Disease Acute Thrombosis Will eventually resolve completely Often minimal residual problems Patients often other medical problems – MI, Stroke, Late pregnancy Theoretical risk portal pyaemia Conservative vs operative treatment

Haemorrhoidectomy Acute Thrombosis Injection of local anaesthetic

Haemorrhoidectomy Acute Thrombosis

Haemorrhoidectomy Pain – Laxatives, Metronidazole – Dilatation /sphincterotomy GTN / Botox Bleeding – 1 o / 2 o – Foley catheter / antibiotics Urinary retention – Males, previous obstructive symptoms – Caudal, Over hydration Infection – Rare, Submucosal abscess / fistula – Beware of increasing pain Complications - 1

Haemorrhoidectomy Fissure – Unhealed wound – Rx as common garden variety Stenosis – Excess removal of anoderm – Dilatation / advancement flap anoplasty Incontinence – Soiling (<30% late soiling in some series) – Loss of sensitive anoderm – Change in symmetry of anal canal – Sphincter damage Complications - 2

Haemorrhoidectomy Painful!! Effective operation Attention to detail to avoid complications Symptoms can recur Still has a place in 21 st Centruy Summary

Thank You