Haemorrhoidectomy

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Haemorrhoidectomy

• Mr Graham Williams
• Consultant Surgeon
• Royal Wolverhampton Hospitals

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Haemorrhoidectomy
Indications for Haemorrhoidectomy

• Symptomatic haemorrhoids
• 3rd degree
• 2nd degree not responding to other Rx
• Acutely thrombosed haemorrhoids

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Haemorrhoidectomy
Principles of Operation

• Remove swollen haemorrhoidal tissue
• Remove associated external element
• Preserve uninvolved anoderm and perianal skin
• Avoid damage to sphincters

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Haemorrhoidectomy
Techniques

• Whitehead
• Open
• Milligan Morgan
• Closed
• Ferguson
• Parks submucosal

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Open Haemorrhoidectomy
Injecting local anaesthetic and 1200,000
adrenalin
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Open Haemorrhoidectomy
Isolating each haemorrhoid
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Open Haemorrhoidectomy
Commencing excision of haemorrhoid
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Open Haemorrhoidectomy
Preserving internal sphincter
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Open Haemorrhoidectomy
Ligating pedicle of haemorrhoid
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Open Haemorrhoidectomy
Excising haemorrhoid
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Open Haemorrhoidectomy
Finished operation
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Closed Haemorrhoidectomy
Fansler Retractor
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Closed Haemorrhoidectomy
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Closed Haemorrhoidectomy
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Closed Haemorrhoidectomy
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HaemorrhoidectomyOpen vs Closed
Author Number Number Follow up Parameters Compared Parameters Compared Parameters Compared
Author Open Closed Follow up Pain Healing Morbidity
Ho et al 1997 34 33 8.7mth No diff Open No diff
Hosch et al 1998 17 17 12 wks No diff No diff Closed
Carapeti et al 1999 17 18 6 wks No diff No diff No diff
Arbman et al 2000 39 38 1 yr No diff Closed No diff
Gençosmanoglu 2002 40 40 lt40mth Open Closed Open
Arroyo et al 2004 100 100 1yr Closed Closed No diff
You et al 2005 40 40 3wks Closed Closed No diff
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Haemorrhoidal DiseaseAcute 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

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HaemorrhoidectomyAcute Thrombosis
Injection of local anaesthetic
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HaemorrhoidectomyAcute Thrombosis
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Haemorrhoidectomy
Complications - 1

• Pain
• Laxatives, Metronidazole
• Dilatation /sphincterotomy GTN / Botox
• Bleeding
• 1o / 2o
• Foley catheter / antibiotics
• Urinary retention
• Males, previous obstructive symptoms
• Caudal, Over hydration
• Infection
• Rare, Submucosal abscess / fistula
• Beware of increasing pain

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Haemorrhoidectomy
Complications - 2

• Fissure
• Unhealed wound
• Rx as common garden variety
• Stenosis
• Excess removal of anoderm
• Dilatation / advancement flap anoplasty
• Incontinence
• Soiling (lt30 late soiling in some series)
• Loss of sensitive anoderm
• Change in symmetry of anal canal
• Sphincter damage

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Haemorrhoidectomy
Summary

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

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Thank You