1. Haemorrhoidectomy Mr Graham Williams Consultant Surgeon Royal Wolverhampton Hospitals

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

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

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

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

6. Open Haemorrhoidectomy Isolating each haemorrhoid

7. Open Haemorrhoidectomy Commencing excision of haemorrhoid

8. Open Haemorrhoidectomy Preserving internal sphincter

9. Open Haemorrhoidectomy Ligating pedicle of haemorrhoid

10. Open Haemorrhoidectomy Excising haemorrhoid

11. Finished operation Open Haemorrhoidectomy

12. Closed Haemorrhoidectomy Fansler Retractor

13. Closed Haemorrhoidectomy

16. AuthorNumberFollow up Parameters Compared OpenClosedPainHealingMorbidity Ho et al 199734338.7mthNo diffOpenNo diff Hosch et al 199817 12 wksNo diff Closed Carapeti et al 199917186 wksNo diff Arbman et al 200039381 yrNo diffClosedNo diff Gençosmanoglu 200240 <40mthOpenClosedOpen Arroyo et al 2004100 1yrClosed No diff You et al 200540 3wksClosed No diff Haemorrhoidectomy Open vs Closed

17. 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

18. Haemorrhoidectomy Acute Thrombosis Injection of local anaesthetic

19. Haemorrhoidectomy Acute Thrombosis

20. 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

21. 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

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

23. Thank You