Hemorrhoid Surgery

Author: Scott C Thornton, MD; Chief Editor: John Geibel, MD, DSc, MA more...

Background
Hemorrhoids have plagued humankind since time immemorial, yet many misunderstandings regarding hemorrhoidal complaints and disease still exist. Many laypersons and clinicians do not understand the anorectal area and the common diseases associated with it. This article discusses internal and external hemorrhoids and their associated symptoms. For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articlesHemorrhoids, Inflammatory Bowel Disease, Rectal Pain, and Rectal Bleeding.

Recent studies
In a study of 198 physicians from different specialties, Grucela et al evaluated diagnostic accuracy for 7 common, benign anal pathologic conditions, including anal abscess, fissure, and fistula; prolapsed internal hemorrhoid; thrombosed external hemorrhoid; condyloma acuminata; and fullthickness rectal prolapse. Physicians in the study were shown images of these conditions, after which they provided written diagnoses. The investigators found the overall diagnostic accuracy among the physicians to be 53.5%, with the

accuracy for surgeons being 70.4% and that for the rest of the doctors being less than 50%. The rate of correct identification was greatest for condylomata and rectal prolapse and was lowest for hemorrhoidal conditions. The authors also found no correlation between diagnostic accuracy and years of physician experience. Grucela et al recommended that physician education concerning common, benign anal disorders be improved.[1]

Epidemiology
Frequency
Up to one third of the 10 million people in the United States with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions per year. The number of hemorrhoidectomies performed in hospitals is declining. A peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in 1987. Obviously, outpatient and office treatment of hemorrhoids account for some of this decline. Hemorrhoids plague all age groups, although they occur most often in individuals aged 46-65 years.

Etiology
Hemorrhoidal complaints are usually not associated with other medical conditions or diseases. However, patients with the following diseases and conditions have an increased risk of hemorrhoidal complaints:

Inflammatory bowel disease and hemorrhoidal problems occur frequently. Unusual hemorrhoidal presentations and findings should alert the clinician to the potential of inflammatory bowel disease. Ulcerative colitis and Crohn disease are associated with hemorrhoids. Pregnancy is associated with many anorectal problems.

Pathophysiology
The term hemorrhoid is usually related to the symptoms caused by hemorrhoids. Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal columns exist in utero. When these vascular cushions produce symptoms, they are referred to as hemorrhoids. Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. Most authors agree that low-fiber diets cause small-caliber stools, which result in straining during defecation. This increased pressure causes engorgement of the hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause hemorrhoidal problems, presumably by means of the same mechanism. Decreased venous return is thought to be the mechanism of action. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life.

Straining and constipation have long been thought of as culprits in the formation of hemorrhoids. This may or may not be true.[2, 3, 4] Patients who report hemorrhoids have a canal resting tone that is higher than normal. Of interest, the resting tone is lower after hemorrhoidectomy than it is before the procedure. This change in resting tone is the mechanism of action of Lord dilatation, a surgical procedure for anorectal complaints that is most commonly performed in the United Kingdom. Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the etiology is unknown. Notably, most patients revert to their previously asymptomatic state after delivery. The relationship between pregnancy and hemorrhoids lends credence to hormonal changes or direct pressure as the culprit. Portal hypertension has often been mentioned in conjunction with hemorrhoids.[5, 6, 7] Hemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than in those without it. Massive bleeding from hemorrhoids in these patients is unusual. Bleeding is very often complicated by coagulopathy. If bleeding is found, direct suture ligation of the offending column is suggested. Anorectal varices are common in patients with portal hypertension.[8] Varices occur in the midrectum, at connections between the portal system and the middle and inferior rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment is usually directed at the underlyingportal hypertension. Emergent control of bleeding can be obtained with suture ligation. Portosystemic shunts and transjugular intrahepatic

portosystemic shunts (TIPS) have been used to control hypertension and thus, the bleeding.[9]

Presentation
Most laypersons and many practitioners attribute all perianal symptoms to hemorrhoids. The astute clinician can often listen to a patient's description of symptoms and ascertain the source of the problem or condition before confirmatory examination. Nonhemorrhoidal causes of symptoms (eg, fissure,abscess, fistula, pruritus ani, condylomata, and viral or bacterial skin infection) need to be excluded. Hemorrhoidal symptoms are divided into internal and external sources. Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain.

This consternation of symptoms is referred to as acute hemorrhoidal crisis. It usually requires emergent treatment. Internal hemorrhoids most commonly cause painless bleeding with bowel movements. The covering epithelium is damaged by the hard bowel movement, and the underlying veins bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins can spurt. Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool contents can cause a localized dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders. External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually related to a specific event, such as physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distension of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With this resolution, the stretched anoderm persists as excess skin or skin tags. External thromboses occasionally erode the overlying skin and cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same site (because the underlying damaged vein remains there). Simply removing the blood clot and leaving the weakened vein in place, rather than excising the offending vein with the clot, will predispose the patient to recurrence.

External hemorrhoids can also cause hygiene difficulties, with the excess, redundant skin left after an acute thrombosis (skin tags) being accountable for these problems. External hemorrhoidal veins found under the perianal skin obviously cannot cause hygiene problems; however, excess skin in the perianal area can mechanically interfere with cleansing.

Indications
Treat hemorrhoids only when the patient complains of them. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient.

Relevant Anatomy
Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg, arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz muscle), and connective tissue lined by the normal epithelium of the anal canal. Hemorrhoids are present in utero and persist through normal adult life. Evidence indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is supported by the bright red color and arterial pH of the blood. Hemorrhoids are categorized into internal and external hemorrhoids. These categories are anatomically separated by the dentate (pectinate) line. External hemorrhoids are hemorrhoids covered by squamous epithelium, whereas internal hemorrhoids are lined with columnar epithelium. Similarly, external hemorrhoids are innervated by cutaneous nerves that supply the perianal area. These nerves include the pudendal nerve and the sacral plexus. Internal

hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain. At the level of the dentate line, internal hemorrhoids are anchored to the underlying muscle by the mucosal suspensory ligament. Internal hemorrhoids have 3 main cushions, which are situated in the left lateral, right posterior, and right anterior areas of the anal canal. Minor tufts can be found between the major cushions. External hemorrhoidal veins are found circumferentially under the anoderm; they can cause trouble anywhere around the circumference of the anus.

Contraindications
Care must be taken to ensure that symptoms are not caused by other perianal conditions (eg, fissure, fistula, infectious disease, inflammatory bowel disease, parasites). Obviously, treating hemorrhoids will not help these problems. Frequently, a thorough history can eliminate the above conditions. Inflammatory bowel diseases (eg, ulcerative colitis, Crohn disease) need to be ruled out as the cause of symptoms. Human immunodeficiency virus (HIV) infection and other immunosuppressive diseases also can alter treatment plans. Proceed to Workup

Laboratory Studies

Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected.

Coagulation studies are indicated if the history and physical examination suggest coagulopathy.

Imaging Studies

Barium enema study or virtual colonoscopy is suggested if proximal colonic and intestinal diseases must be excluded and if endoscopy is not helpful.

Diagnostic Procedures

Examination begins with inspection and examination of the entire perianal area. Warn the patient before any probing or poking. Because patient apprehension is great prior to any anal examination, go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags and the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation. Digital examination of the anal canal can identify any indurated or ulcerated areas. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft vascular structures, they are usually not palpable. Anoscopy is mandatory for viewing internal hemorrhoids. The anoscope should be a side-viewing one. When angled well by the examiner, the side-viewing anoscope allows the soft hemorrhoidal tufts to fill the beveled end of the scope and to be appropriately evaluated. Prolapse can be observed when the patient performs a Valsalva maneuver. Flexible sigmoidoscopy is performed to exclude proximal disease. Having a patient strain while sitting on a toilet may reproduce prolapse most accurately. Examining patients while they sit on a toilet can be very helpful in indeterminate

cases. Colonoscopy, virtual colonoscopy, and barium enema are reserved for cases of bleeding without an identified anal source. These symptoms are not attributable to hemorrhoids and are considered to be non outlet-type bleeding.

Histologic Findings
Routine histologic examination of hemorrhoidal tissue is usually unrewarding, especially if it is grossly examined by an experienced anorectal surgeon. Any suspicious tissue must be sent for microscopic evaluation. External hemorrhoids are classified by underlying pathology and symptoms, which include thrombosed veins, bleeding from eroded blood clots, and skin tags causing hygiene problems.

Staging
Internal hemorrhoids are grouped into 4 stages, as follows:

Stage I - Internal hemorrhoids that bleed Stage II Internal hemorrhoids that cause bleeding and prolapse with straining but return to their resting point by themselves Stage III - Internal hemorrhoids that bleed and prolapse with straining and require manual effort for replacement into the anal canal Stage IV - Internal hemorrhoids that do not return into the anal canal and are therefore constantly outside Proceed to Treatment & Management

Medical Therapy
Treatment is divided by the cause of symptoms, into internal and external treatments. Internal hemorrhoids do not have

cutaneous innervation and can therefore be destroyed without anesthetic. They are classified by symptoms and are grouped into 4 stages, as described in the Staging section. Because it is believed that straining and a low-fiber diet cause hemorrhoidal disease, conservative treatment includes increasing fiber and liquid intake and retraining in toilet habit.[10] Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, firstline treatment of all first- and second-degree (and many thirdand fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation. Psyllium seed significantly decreases bleeding and pain compared with placebo. The average American diet consists of 8-15 grams of fiber per day. A high-fiber diet includes more than 25 grams of fiber per day. Psyllium seed (Metamucil) and methylcellulose (Citrucel) are the most commonly used supplements. Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements. Antidiarrheal agents are sometimes required in patients with symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids. Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse,

thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. The author rarely recommends typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with antiinflammatory medications. Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. The author does not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub. Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids. Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. A wise professor once said, "You can't make

an asymptomatic patient feel better." Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome. Treatment of the underlying disease often relieves anal symptoms. Patients with ulcerative colitis can tolerate aggressive surgery if needed. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. Pregnancy is associated with many anorectal complaints. Treatment is directed at symptoms. Nonoperative treatment or office thrombectomy usually relieves complaints. Operative hemorrhoidectomy is safe in pregnant women.[11] HIV and anal disease often occur together. Again, conservative therapy is suggested, especially if immunosuppression is evident. Poor healing occurs with low CD4 counts, especially those of less than 200 cells/mm3. Numerous methods to destroy internal hemorrhoids are available; they include rubber band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection.[12, 13, 14] All of these methods (except stapled hemorrhoidectomy and surgical resection) are considered nonoperative treatments and should be the firstline treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy.

With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. All nonoperative treatments have approximately similar efficiency when administered by an experienced clinician. Rubber band ligation is most common in the United States, because it is the most commonly taught method in training programs.[15] Blaisdell and Barron described and refined ligation therapy.[16, 17] Lord dilatation is seldom used in the United States, and many colorectal surgeons condemn its use, because it is essentially an uncontrolled disruption of the sphincter mechanism. Sclerotherapy can provide adequate treatment of early internal hemorrhoids.[18, 19]Cryotherapy and sclerotherapy are infrequently used today. Most experienced surgeons use 1 or 2 techniques exclusively. Symptoms have historically been treated with dietary modifications, incantations, voodoo, quackery, and application of a hot poker. Molten lead has also been described as a treatment. The adverse effects of these treatments have a direct relationship to whether patients relay persistent or recurrent complaints to the clinician or return for further treatment.

Surgical Therapy
Operative resection is reserved for patients with third- and fourth-degree hemorrhoids, patients who fail nonoperative therapy, and patients who also have significant symptoms from external hemorrhoids or skin tags. Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths.

Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy.[20] The reader is referred to appropriate textbooks to see descriptions of techniques used.[21, 22] External hemorrhoids generally elicit symptoms due to acute thromboses, recurrent thromboses, or hygiene problems. Manage acute thromboses and recurrent thromboses in a similar fashion. Identify the offending vascular cluster. In the office or clinical setting, inject local anesthetic, and then perform excision of the overlying skin and underlying veins. Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel's solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone. Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), has become prominent.[23, 24, 25] It was first described in 1997-1998. During PPH, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosal and submucosal layers circumferentially, approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal

hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line. This results in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind, and interruption of the blood supply from above. PPH can be done as an outpatient procedure, using local anesthesia with intravenous (IV) sedation.[26, 27, 28, 29] PPH is mainly used to treat internal hemorrhoids that are not amenable to conservative and nonoperative therapies. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery. PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. Good results from PPH combined with judicial excision of occasional skin tags also have been reported. In patients receiving PPH, pain seems to be less severe and of shorter duration than it is in patients who undergo conventional surgery. The use of PPH is suggested in patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia, similar to the protocol used for conventional hemorrhoid surgery. The author has incorporated PPH into practice more frequently, with excellent results. Operative resection is reserved for patients with hygiene trouble caused by large skin tags, a history of multiple external thromboses, or internal hemorrhoid trouble. Perform the operation in the outpatient setting. Proper anesthetic care

(especially if local anesthesia with supplementary IV sedation), attention to perioperative fluid restriction, and careful postoperative instructions can ease the patient's recovery. Operative technique can be found in any colorectal surgical textbook. Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women.[11] Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.

Preoperative Details
Hemorrhoid surgery can usually be performed using local anesthesia with IV sedation. Regional or general anesthetic techniques also are used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is

required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas.

Intraoperative Details
The reader is referred to detailed surgical textbooks for specific details.[21, 22]

Postoperative Details
A liposomal form of the local anesthetic bupivacaine (Exparel) was approved by the US Food and Drug Administration (FDA) in October 2011. A single dose infiltrated into the surgical site produces postsurgical analgesia for hemorrhoidectomy. A total dose of 266 mg (20 mL) diluted with 10 mL of saline (for a total of 30 mL) is used once for hemorrhoidectomy. The mixture is divided into 6 aliquots (5 mL each). Perform the anal block by visualizing the anal sphincter as a clock face and slowly infiltrating 1 aliquot into each of the even numbers. Attention to regular and soft bowel movements is important. Bulk agents (eg, psyllium seed) and oral fluids are important. Bathing in tubs for comfort and hygiene is part of the routine. Judicious narcotic administration relieves pain.[30]

Follow-up
Monitor patients at regular intervals until they are healed and have no symptoms.

Complications
Well-trained surgeons should experience complications in fewer than 5% of cases. Complications include stenosis, bleeding, infection, recurrence, nonhealing wounds, and

fistula formation. Urinary retention is directly related to the anesthetic technique used and to the perioperative fluids administered. Limiting fluids and the routine use of local anesthesia can reduce urinary retention to less than 5%.

Outcome and Prognosis

Accurately classifying a patient's symptoms and the relation of the symptoms to internal and external hemorrhoids is important. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. PPH is an excellent alternative for treating internal hemorrhoids that have not been amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with PPH and skin tag excision. Operative resection is sometimes required to control the symptoms of internal hemorrhoids. External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), while operative resection is reserved for the latter. Remember that therapy is directed solely at the symptoms, not at aesthetics. When performed well, operative hemorrhoidectomy should have a 2-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually be

addressed with further nonoperative treatments.[15] Long-term results from PPH are unavailable at this time.[25, 31, 32]

Future and Controversies

The major controversies regarding the treatment of hemorrhoids center on the indications for treatment and the choice of operative versus nonoperative therapy. Most experienced surgeons are using office-based nonoperative therapies and are relying less on operative hemorrhoidectomy than they previously were. In the United States, rubber band ligation (compared with injection sclerotherapy) is the mainstay of conservative treatment. PPH, which has been gaining increasing favor in the United States, provides an excellent alternative to operative hemorrhoidectomy for patients with minimal external disease and large internal hemorrhoids.
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