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Hemorrhoidectomy

  1. Introduction
  1. Hemorrhoids are consider the natural anal cushions
  2. They are made up of  arterio-venus communication, smooth muscle & elastic connective tissue in submucosa that normally reside in the left lateral, right posterolateral & right antero lateral anal canal.
  1. Classification
  1. Internal Hemorrhoids
  1. Reside above the dentate line & are covered by transitional and columnar epithelium.
  2. Grading

Grade 1 – Painless bleeding with defecation

Grade 2 – Hemorrhoids protrudes through anal canal at the time of defecation but spontaneously reduce.

Grade 3 – Protrudes bleeds but they must be manually reduced.

Grade 4 – Permanently fixed below dentate line & cannot be manually reduced.

  1. External Hemorrhoids

Dilated vascular plexus located below the dentate line & covered by squanous epithelium.

  1. Mixed – Composed of both internal & external.
  2. Anal skin tags are discrete folds of skin located at the anal verge, they are end results of resolved thrombased external hemorrhoids or more rarely may be associated with inflammatory bowel disease.
  1. Evaluation
  • Internal hemorrhoids are most common source of rectal bleeding.
  • Internal hemorrhoids cannot be detected by digital examination diagnosis can only be made by anoscopy.
  • In high patient like age >40 years, family h/o colorectal neoplasm or change of bowel habits, colonoscopy is mandatory.
  1. Treatment
  1. Initially regulation of diet & avoidance of prolonged straining at the time of defecation comprise the treatment of symptoms of bleeding & protrusion.
  2. Increase fiber content of diet at least 25-35 gm daily with raw vegetables, fruits , whole grain etc.
  3. If bleeding & protrusion persist, however, the hemorrhoids should be treated surgically.
  4. Circular stapled hemorrhoidectomy is a newer technique indicated for the elective treatment of circumferential 3rd & 4th degree hemorrhoids that are not permanently prolapsed due to scar.
  5. Steps
  1. Place a purse – string suture incorporating the muscosa of the anal canal with a stapled circumferential muscosectomy at a level 4-5 cm above dentate line.
  2. This is performed under regional anesthesia with minimal morbidity in experienced hands.
  3. Complications
  • Bleeding if stapled line is incomplete
  • Pain if staple line is to close to the dentate line.
  • Rectovaginal fistula if purse string captures the rectovaginal septum.
  • Complete closure of rectum
  • Return of symptoms if purse string is incomplete.
  1. Thrombased internal hemorrhoids will sclerose & may not require surgery. If symptoms persist , a three quadrant hemorrhoidectomy may be necessary. If necrstic tissue is present at time of acute thrombosis, emergent excisional hemorrhoidectomy is necessary.
  2. Thrombosed external hemorrhoids
  • External venous plexus is located at the anal verge & encircles the anal canal.
  • A segmental thrombosis is contined to the anoderm & perianal skin & does not extend above the dentate line.
  • The problem present with c/o painful perianal mass. The overlying skin may be stretched to 2 cm or more. Pain usually peaks within 48 hours & generally becomes minimal after 4th day.
  • If untreated, the thrombus is absorbed within a few weeks. The pressure of underlying clot will occasionally cause the adjacent skin to become necrotic & clot will be extruded through the area of necrosis.
  • Patient of thrombosed hemorrhoid is aimed at relief of pain. For mild symptoms, mild analgesia, sitz bath, proper anal hygiene & bulk producing agents will suffice.
  • For serve pain, excision of thrombosed hemorrhoids may be beneficial.
  • As numerous vessels are involved, it is necessary to excise the entire mass along with overlying skin & soft tissue,. The wound is left open without packing
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