What are the other Names for the Procedure?
- Closed Hemorrhoidectomy
- Open Hemorrhoidectomy
What is Hemorrhoidectomy surgical procedure?
- Hemorrhoidectomy is the surgical excision of a hemorrhoid (swollen veins in the rectum), which is performed in severe cases
- The surgical area may be sewn closed, in which case it is termed as a Closed Hemorrhoidectomy; or is left open, in which case it is known as an Open Hemorrhoidectomy.
What part of the Body does the Procedure involve?
A Hemorrhoidectomy procedure involves the anal canal and lower rectum.
Why is the Hemorrhoidectomy surgical procedure Performed?
A Hemorrhoidectomy procedure is performed in cases of severe symptomatic hemorrhoids that fail conservative management.
- Hemorrhoids are swollen and inflamed blood vessels located inside the rectum, or around the anus
- Hemorrhoids are classified into 2 types - internal hemorrhoids and external hemorrhoids
- These are differentiated by their position with respect to the dentate line (a line which divides the upper two-thirds and lower one-third of the anal canal)
- Internal hemorrhoids are those that originate above the dentate line and external hemorrhoids are those that originate below the dentate line
- Internal hemorrhoids usually present with painless, bright red, rectal bleeding during or following a bowel movement. The blood is on the toilet paper or drips into the toilet bowl. Usually, the stool itself appears normally-colored
- Other symptoms may include mucous discharge, a perianal mass, if they prolapse through the anus, itchiness, and fecal incontinence. They are usually only painful, if they become thrombosed or necrotic
- External hemorrhoids are generally painful when thrombosed - blood inside the hemorrhoid clots
Internal hemorrhoids are classified into 4 grades, based on the degree of prolapse:
- Grade I: No prolapse
- Grade II: Prolapse upon bearing down, but spontaneously reduces
- Grade III: Prolapse upon bearing down and requires manual reduction
- Grade IV: Prolapsed and cannot be manually reduced
What are some Alternative Choices for the Procedure?
- Other procedures include rubber band ligation, sclerotherapy, infrared coagulation, bipolar coagulation, and direct current electrotherapy, all of which are performed through the anoscope
- All of these techniques attempt to decrease the vascularity of the internal hemorrhoid, thereby making it to slough-off
What are the Recent Advances in the Procedure?
Transanal hemorrhoidal dearterialization is a recent advancement to the procedure:
- Doppler-guided, transanal hemorrhoidal dearterialization is a minimally invasive treatment for internal hemorrhoids
- It uses an ultrasound doppler to accurately locate the arterial blood inflow
- These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position
- It has a slightly higher recurrence rate, but fewer complications compared to a Hemorrhoidectomy
- Stapled hemorrhoidopexy is performed under general anesthesia
- The surgeon uses a stapling device to anchor the hemorrhoids in their normal position
- The patient goes home the same day, after the procedure
- Research is now under way comparing stapled hemorrhoidopexy with rubber band ligation and Hemorrhoidectomy as a first-line treatment for internal hemorrhoids.
What is the Cost of performing the Hemorrhoidectomy surgical procedure?
The cost of Hemorrhoidectomy surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.
In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.
When do you need a Second Opinion, prior to the Procedure?
- It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Hemorrhoidectomy surgical procedure and what needs to be done
- If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
- Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently
What are some Helpful Resources?
http://www.health.harvard.edu/newsweek/Hemorrhoids_and_what_to_do_about_them.htm (accessed on May 18, 2014)
http://www.mayoclinic.org/hemorrhoids/ (accessed on May 18, 2014)
http://colorectal.surgery.ucsf.edu/conditions--procedures/hemorrhoidectomy.aspx (accessed on May 18, 2014)
Prior to Hemorrhoidectomy surgical procedure:
How is the Hemorrhoidectomy surgical procedure Performed?
- A Hemorrhoidectomy procedure is normally performed in the operating room.
- Spinal or general anesthesia is given to the patient
- The patient is placed either in prone or supine position
- An elliptical incision is made around the internal or external hemorrhoidal complex
- The hemorrhoidal tissue is then dissected off, of the underlying sphincter muscles with scissors or scalpel
- The correct plane is essential to avoid injury to the sphincter muscle
- The hemorrhoid is then amputated and the wound closed with a running suture
- Sometimes, the mucosal defect is closed, but the skin incision is left open and it heals spontaneously in 4-8 weeks
Where is the Procedure Performed?
A Hemorrhoidectomy is usually performed in an out-patient surgery center facility or a hospital. Normally, the individual can go home, once the procedure is completed.
Who Performs the Procedure?
Hemorrhoidectomy is performed by a physician trained in general surgery.
How long will the Procedure take?
It usually takes about an hour to complete the Hemorrhoidectomy procedure.
What do you need to tell your Physician before the Procedure?
It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.
- Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
- If you are allergic to any specific medication or food items
- If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
- If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
- If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
- If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
- If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
- A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.
What Preparations are needed, prior to the Procedure?
- The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
- Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
- Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
- Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
- Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
- It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
- Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
- The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
- For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines
What is the Consent Process before the Procedure?
- A physician will request your consent for Hemorrhoidectomy procedure using an Informed Consent Form.
- Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.
- You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.
What Tests are needed, before the Hemorrhoidectomy surgical procedure?
Examination of anus and lower rectum is performed by the physician, with the help of an anoscope. The healthcare provider may perform other tests, as required.
What are some Questions for your Physician?
Some of the basic questions that you might ask your physician are as follows:
- What is a Hemorrhoidectomy procedure?
- Why is this procedure necessary? How will it help?
- What does the procedure involve?
- How soon should I get it done? Is there an emergency?
- Who are the medical personnel involved in this procedure?
- What are the risks while performing the procedure?
- What are the possible complications that might take place, during recovery?
- How long will it take to recover? When can I resume normal work?
- How many such procedures have you (the physician) performed?
- Are there any lifestyle restrictions or modifications required, after the procedure is performed?
- Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
- Is there any medication that needs to be taken for life, after the procedure?
- What are the costs involved?
During the Hemorrhoidectomy surgical procedure:
What kind of Anesthesia is given, during the Procedure?
Spinal or general anesthesia is administered for the Hemorrhoidectomy procedure.
How much Blood will you lose, during the Procedure?
- The Hemorrhoidectomy procedure requires only a small incision and hence, the amount of blood loss is minimal
- If complications arise during the procedure, it could lead to a further loss of blood
What are the possible Risks and Complications during the Hemorrhoidectomy surgical procedure?
There are general factors that increase the risk of getting complications during surgery and they include:
- Obesity: Generally greater the degree of obesity, greater is the surgical risk
- Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
- Advancing age
- Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
- Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
- Poorly functioning liver, as evidenced by increased blood liver function tests
- Hypertension (increased blood pressure), especially if it is poorly controlled
- Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
- Poor lung function, as evidenced by abnormal lung function tests
- History of bleeding disorders
- Longstanding illness, such as autoimmune disorders, chronic infections
- Poor immune system due to a variety of causes
The possible risks or complications that may arise during the surgery are:
- Local abscess
- Fecal incontinence
- Anal stenosis (narrowing of the anus)
- Urinary retention
What Post-Operative Care is needed at the Healthcare Facility after the Hemorrhoidectomy surgical procedure?
At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise.
After the Hemorrhoidectomy surgical procedure:
What are the possible Risks and Complications after the Hemorrhoidectomy surgical procedure?
Post Hemorrhoidectomy procedure, the following complications may arise:
- Pain and discomfort
What is the Prognosis after the Surgery?
- Surgical Hemorrhoidectomy with excision of internal and external hemorrhoids is the most effective treatment for hemorrhoids.
- But, it is also the most painful and has the highest complication rate
- For some patients, it is absolutely the best option
- Other patients do not require extensive surgery, and their operative therapy can be tailored to be less invasive and, in turn, less painful
- The key is to tailor the patient's surgery to his/her individual pathology, symptoms, and needs
When do you need to call your Physician?
Do contact your physician if you notice any of the following symptoms:
- Persistent anal pain
- Urinary retention
- Swelling and redness
- Signs of infection
What Post-Operative Care is needed at Home after the Hemorrhoidectomy surgical procedure?
At home, the following post-operative care is recommended, after a Hemorrhoidectomy procedure:
- Avoid any possibilities of constipation, take medications, if required to do so (per advise of physician)
- Take stool softeners, as straining during bowel movements can cause the hemorrhoids to recur
- Increase fiber content in the diet
- Take plenty of fluids
- Do expect some pain after surgery; take pain killers as prescribed
- Some bleeding is normal, especially with the first bowel movement after surgery
- Ice packs applied to the anal area may reduce swelling and pain
- Frequent soaks in warm water (sitz baths) help relieve pain and muscle spasms
How long does it normally take to fully recover, from the Procedure?
It may take anywhere between 2-3 weeks, to recover completely from the Hemorrhoidectomy procedure.
What happens to tissue (if any), taken out during the Procedure?
The Hemorrhoidectomy procedure does not involve the surgical removal of any tissue.
When should you expect results from the pathologist regarding tissue taken out, during the Procedure?
Since no tissue is removed during the Hemorrhoidectomy procedure, a pathologist does not get involved in the care of the patient.
Who will you receive a Bill from, after the Hemorrhoidectomy surgical procedure?
It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.
Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:
- the outpatient facility, physician’s office or hospital
- a family physician or a general surgeon
Individuals are advised to inquire and confirm the type of billing, before the Hemorrhoidectomy surgical procedure is performed.
Thanks and Gratitude:
We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.
Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA