Anorectal: Hemorrhoidal Procedures

Hemorrhoid Banding

Procedure

  • Placement:
    • Site: Above Dentate Line
    • Band: Redundant Mucosa Only
      • Leave Underlying Pile
  • Mucosa Will Slough Off After 5-7 Days
  • *If Taking Anticoagulation – Band & Then Hold Anticoagulation for 1 Week to Prevent Excess Bleeding with Mucosa Slough

Complications

  • Misplaced Band (Below Dentate)
    • Sx: Immediate Pain
    • Tx: Remove
  • Pelvic Sepsis
    • Sx: Delayed Pain, Urinary Retention and Sepsis
    • Tx: ABX & Debridement

Hemorrhoid Banding 1

Hemorrhoid Banding 2

Hemorrhoidectomy

Technique

  • Closed Excision (Ferguson Technique)
    • Elliptical Excision of the Hemorrhoidal Bundle
      • Harmonic Shown to Have Decreased Pain and Bleeding than Monopolar
    • Deep Suture Ligation of the Vascular Pedicle at the Proximal Apex
    • Close with a Running-Locked Absorbable Suture
    • Consider Leaving the Distal End Open to Allow Drainage
  • Open Excision (Milligan-Morgan)
    • Elliptical Excision of the Hemorrhoidal Bundle
    • Do Not Close – Heals by Secondary Intention
    • No Difference in Results Between Open/Closed
  • Circumferential Stapled (Whitehead Hemorrhoidectomy)
    • By Transanal Circular Stapler
    • Only for Internal Hemorrhoids Proximal to the Dentate Line
    • Lower Pain & Recovery
    • Higher Recurrence & Incontinence Risk

Complications

  • Urinary Retention (Most Common Complication)
    • Cause: Muscle Spasms of Pelvic Floor
    • Tx: Temporary Foley
  • Pelvic Sepsis
    • Pain, Fever & Urinary Retention
    • Tx: ABX & Exam Under Anesthesia (EUA)
      • Rule Out Necrotizing Infection
  • Bleeding
    • < 24 Hours
      • Cause: Poor Suture Technique
      • Tx: EUA & Suture Ligation
    • > 5 Days
      • Cause: Eschar Sloughing
      • Tx: Nothing, EUA if Severe
  • Anal Stenosis
    • Resecting More Than 2 Hemorrhoids at Once Increases the Risk
    • Tx: Laxatives & Dilation
      • If Fails: Anoplasty

Hemorrhoidectomy 1

References

  1. Bafford AC, Bleday R. UCSF Dept Surgery. (License: CC BY-3.0)
  2. Misauno MA, Usman BD, Nnadozie UU, Obiano SK. Experience with rubber band ligation of hemorrhoids in northern Nigeria. Niger Med J. 2013 Jul;54(4):258-60. (License: CC BY-NC-SA-3.0)