Hemorrhoidectomy: Everything You Need to Know

Surgical removal of hemorrhoids

What Is a Hemorrhoidectomy?

Depending on the surgeon experience/preference and nature of the case, incision(s) may be made using a scalpel, scissors, electrocautery pen, or laser.

Symptoms of hemorrhoids may include pain, skin tasks, irritation and itching

emergent, elective

Bansal H, Jenaw RK, Mandia R, Yadav R. How to do Open Hemorrhoidectomy Unde Local Anesthesia and its Comparison with Spinal Anesthesia. Indian J Surg. 2012 Aug; 74(4): 330–333. doi:10.1007/s12262-012-0438-3

Surgical Techniques

There are several different surgical techniques for removing hemorrhoids.

External Hemorrhoids

For an external hemorrhoid, the surgeon usually cuts out and removes the hemorrhoid. Alternatively, an incisional technique may be used in which an incision is made over the skin of the hemorrhoid and just the clot within the hemorrhoid is removed.

An incisional hemorroidectomy is less likely to be successful if the patient has been experiencing pain for more than 48 hours. In addition, if the incision is too small, blood can reaccumulate, and form another clot inside the hemorrhoid tissue.

Internal Hemorrhoids

For internal hemorrhoids, the whole hemorrhoid is usually cut out and removed (as with an external hemorrhoid). This is called a conventional hemorrhoidectomy.

Alternatively, a procedure called a stapled hemorroidopexy may be performed. With this technique, no incision is made. Instead, the hemorrhoid is lifted and stapled back into the anal canal using a special circular stapling device.

People who have stapled a hemorrhoidectomy surgery may experience less post-surgical pain than the conventional approach. However, with a stapled hemorroidopexy, the hemorrhoids are more likely to return.

Moreover, conventional hemorrhoidectomy can be used to treat both internal and external hemorrhoids. A stapled hemorrhoidopexy, on the other hand, is really only effective for treating internal hemorrhoids.

Therefore, if a patient has both external and internal hemorrhoids, the conventional technique is typically used.

Lastly, for internal hemorrhoid removal, there is a surgical procedure called doppler-guided transanal hemorrhoidal artery ligation (HAL). With this procedure, the surgeon uses a special anoscope that contains a probe to locate each hemorrhoid artery blood supply. The blood supply is then "ligated" or closed off.

Open Versus Closed Hemorrhoidectomy

Once any hemorrhoid is removed, the wound may be sutured closed or left open to heal on its own. If multiple hemorrhoids are being removed, a combination may be used. Complications after an open versus closed hemorrhoidectomy are similar.

Contraindications

Relative contraindications to hemorrhoidectomy include:

Potential Risks

Potential risks of hemorrhoid surgery depend on the type and extent of surgical procedure being performed.

For example, risks associated with surgical removal of a thrombosed external hemorrhoid include:

Risks associated with surgical removal of internal hemorrhoids include bleeding and urinary retention. Rarely, rectal perforation (when a hole forms in the rectum), sepsis, or an abscess may form.

Also, later complications that may occur after a hemorrhoidectomy include:

  • Narrowing (stenosis) of the anal canal
  • Formation of a fistula (abnormal tract between the anal or rectal canal and another area, like the vagina)
  • Hemorrhoid recurrence
  • Rectal prolapse
  • Skin tags
  • Fecal incontinence

Purpose of Hemorrhoid Surgery

The purpose of hemorrhoid surgery is to remove external or internal hemorrhoids.

Even though hemorrhoidectomy is the most effective and definitive treatment for hemorrhoids, according to the American Gastroenterological Association (AGA), it's linked to significantly more pain and complications than non-surgical therapies.

Therefore, the AGA advises that surgery only be considered for a specific and small group of individuals.

As such, potential candidates for hemorrhoidectomy may include patients who:

  • Have failed (or cannot tolerate) medical and non-operative hemorrhoid therapies.
  • Have symptomatic (e.g., pain) third-degree, fourth-degree, or mixed internal and external hemorrhoids.
  • Have symptomatic hemorrhoids in the presence of a concomitant anorectal condition that warrants surgery.
  • Prefer surgery and have discussed therapy options with their referring doctor (e.g., primary care physician) and surgeon.

When hemorrhoid surgery is scheduled, various pre-operative tests for medical and anesthesia clearance will need to be run.

Such tests include:

How to Prepare

Once you are scheduled for hemorrhoid surgery, your surgeon will give you instructions on how to prepare.

Location

Hemorrhoid surgery may performed in a hospital, surgical center, office procedure room, or an emergency room by a general surgeon or colon and rectal surgeon.

Food and Drink

On the day before surgery, you may be asked to eat a light, non-greasy breakfast and lunch and only drink clear liquids (e.g., water, coffee without milk or cream, juice with no pulp) after lunch until up to four hours prior to your surgery, at which you cannot drink anything.  

Medications

You may be advised to stop taking certain medications prior to surgery, especially those that increase your risk for bleeding, such as nonsteroidal anti-inflammatory drugs (NSAIDs).

You will probably also be instructed to undergo a cleansing bowel regimen prior to the procedure. Typically, these colon cleansing products can be purchased over the counter.

An example regimen may include the following:

  • Drink one 10 ounce bottle of magnesium citrate in the afternoon on the day before your surgery. 
  • Take a sodium phosphate enema in the evening prior to your surgery
  • Take a second sodium phosphate enema in the morning, approximately one hour prior to leaving for the hospital or surgical center.

What to Wear and Bring

Pre-Op Lifestyle Changes

What to Expect on the Day of Surgery

Before the Surgery

After checking in, you will be taken to a holding area where you will change into a hospital gown.

A surgical nurse will review your medication list, record your vitals (heart rate, blood pressure, etc.), and place an intravenous (IV) line into a vein in your arm. You may receive an antibiotic through this IV at this time to help prevent post-operative infection. This IV will also be used for administering fluids and medications during and after surgery.

Your surgeon will then come to greet you and review the operation with you. Sometimes, at this point, the surgeon will perform an anoscopy (a small, firm tube is inserted a few inches inside your anus) to double-check the status of your hemorrhoids (e.g., location, volume, etc.).

From there, you will be wheeled into the operating room on a gurney where the anesthesia process and surgery will start.

During the Surgery

Hemorrhoid surgery takes around two to three hours and may be performed under general, regional, or local anesthesia.

  • General anesthesiaThe surgeon will inject a numbing medication (anesthetic) in the perianal region. Then, the anesthesiologist will administer inhaled or intravenous medication to put you to sleep. Once asleep, a breathing tube called an endotracheal tube will be inserted to allow for mechanically-assisted breathing during the operation.
  • Regional anesthesia: The surgeon will inject a numbing medication into your spine. You may feel a stinging sensation as the medication is being injected. You may be given a sedative to help you relax or fall asleep during the surgery.
  • Local anesthesia: The surgeon will inject a numbing medication into the skin around the hemorrhoid. An anesthetic is also usually injected into the fat next to your external sphincter (called an anal block). You may be given a sedative to help you relax or fall asleep during the surgery.

The surgical flow depends on whether an external or internal hemorrhoidectomy is being performed (or both, in some cases), and what technique is being used.

As an example, you can expect the following general steps with the excision of an external hemorrhoid:

  • Excision: An elliptical incision is made in the skin over the hemorrhoid and the hemorrhoid is carefully cut out. This step may be repeated if there is more than one hemorrhoid present.
  • Closure: The skin edges may be left open or closes with an absorbable suture. The anal area is covered with a dressing.

Likewise, for a conventional internal hemorrhoidectomy, you can generally expect the following steps:

  • Access: The hemorrhoid is grasped with a small clamp and pulled away from the anal sphincter muscles.
  • Excision: An elliptical or diamond-shaped incision is made in the rectal tissue around the hemorrhoid. The hemorrhoid is dissected away from the sphincter muscles, and the swollen bein inside of it is tied off with a suture (this prevents bleeding). The hemorrhoid is then removed. This step may be repeated if there is more than one hemorrhoid is present.
  • Closure: The skin edges may be left open or closes with an absorbable suture. The anal area is covered with a dressing.

After the Surgery

Recovery

A Word From Verywell

Surgery iA Word fsWhat typically the last type of treatment used to control the symptoms and complications that may be present with hemorrhoids. For most patients, the pain and irritation of hemorrhoids pass in one to two weeks. If your hemorrhoid symptoms persist beyond the two-week mark, seek the attention of a physician.

Surgery is considered if medications and less invasive hemorrhoid treatments are ineffective at improving the condition. These treatments range from home remedies, such as applying ice and witch hazel; prescription-numbing medications; and minimally invasive procedures, such as rubber band ligation or the injection of a solution into the blood vessel.

Most patients who qualify for surgery have very large internal hemorrhoids, a combination of internal and external hemorrhoids, very large external hemorrhoids, or hemorrhoids that have not responded favorably to other types of treatment.

The severity of your hemorrhoid(s), the types of hemorrhoids present (including external, internal or prolapsed hemorrhoids), the type of anesthesia you receive, and your general health will all contribute to your personal level of risk.

During Surgery

Hemorrhoid surgery is performed using one of two types of anesthesia: general anesthesia or spinal anesthesia, which is also known as regional anesthesia. Once you are in the operating room, the anesthesia provider, who may be a nurse or a physician, will give the medication to ensure that you feel no pain. You may be awake but feeling no pain if you elect spinal anesthesia, or asleep if you choose a general anesthetic.

Once the anesthesia medications are given, the procedure begins.

Once the procedure to remove the hemorrhoid is completed, but you are still under anesthesia, you will be given a local anesthetic, which will numb the surgical area for eight to 12 hours. This medication will significantly improve your pain level during the first few hours of your recovery.

You may stay in the hospital overnight, or you may be able to return home once you wake from anesthesia completely. You may experience some difficulty with urination after surgery. Some difficulty is expected, but a complete inability to urinate should be considered an emergency and treatment should be sought.

Recovering After Surgery

Pain is to be expected after hemorrhoid surgery, especially when having a bowel movement or urinating. It may be severe at times but should diminish steadily in the week following surgery.

Your surgeon may prescribe pain medication in addition to other methods of pain relief, including ice packs and sitz baths.

Approximately 5% of all patients have additional hemorrhoids develop after having surgical treatment. Many hemorrhoids can be prevented with lifestyle changes and other interventions. Your surgeon may recommend several ways to prevent future hemorrhoids from forming.

Hemorrhoids Doctor Discussion Guide

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