Hemorrhoidectomy

Excerpt

Hemorrhoidal disease is a common disorder requiring surgical intervention in approximately 10% of cases. The prevalence is unknown because asymptomatic patients are less likely to seek medical help. About 4.4% of individuals in the United States exhibit symptoms, and those between 45 and 65 are most significantly impacted. Hemorrhoids, found within the anal submucosa, are columns of vascular connective tissue that assist in maintaining continence and bulk to the anal canal. Although the pathophysiology of hemorrhoids is not fully understood, one theory suggests that they may develop due to varicose veins in the anal canal. However, this concept is generally not well established. Many experts firmly believe the root cause of hemorrhoids is the deterioration or degradation of vascular cushions rather than any other potential factor. See Image. Hemorrhoidal and Middle Sacral Veins.

The 3 primary hemorrhoidal columns are in the left lateral, right anterolateral, and right posterolateral positions of the anal canal. The hemorrhoids can be internal or external based on their location relative to the dentate line. Internal hemorrhoids can be further graded from I to IV based on the degree of prolapse, guiding the treatment options. Patients presenting with symptomatic internal hemorrhoids complain of painless, bright red bleeding, described as streaks of blood in the stool, anal itching, pain, worrisome grape-like tissue prolapse, or a combination of these symptoms. External hemorrhoids are asymptomatic in most patients except for thrombosed external hemorrhoids, which cause significant pain due to their innervation by somatic nerves.

Conducting a comprehensive history and physical examination specific to the disease is important, focusing on assessing the severity and duration of symptoms and identifying any relevant risk factors. Hemorrhoids can be treated with medical and surgical interventions depending on their degree of prolapse and whether they are internal or external. Hemorrhoids can undergo treatment with both medical or surgical interventions depending on the degree of prolapse and their locations. One of the first and foremost conservative recommendations is a high-fiber diet. Garg recommends adding 4 to 5 teaspoons of fiber daily, corresponding to 20 to 25 g of supplemental fiber. For this method to be effective and not cause abdominal cramping, an adequate amount of water (500 mL) must be consumed simultaneously with the fiber supplement to absorb the water and result in soft stools. This intervention has proven to stop progression and help decrease the size of prolapse.

Rubber band ligation and infrared coagulation are indicated for grade 1 and 2 hemorrhoids that fail medical management. The reported number of rubber banding sessions is 1, occasionally 2, with a waiting period of 4 weeks between visits. When comparing the 2, long-term success favors rubber banding, whereas infrared coagulation is associated with less pain, likely due to lack of mucopexy during the procedure. The failure rate for rubber band ligation is 4 times less than that seen in infrared coagulation. Surgical excision is the most effective treatment for recurrent, symptomatic grade III or IV hemorrhoids. Surgical procedures primarily include closed, also called Ferguson hemorrhoidectomy, the most common technique in the United States, or the open, also called Milligan-Morgan hemorrhoidectomy, used in the United Kingdom and Europe.