Haemorrhoidectomy

Author: Michael Edwards Last Edited: May 25, 2014

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  CHAPTER 1. THIS SCRIPT COVERS
  
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  CHAPTER 2. THIS SCRIPT DOES NOT COVER
  
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  CHAPTER 3. LAY OUT OF OPERATION SECTIONS AND STEPS
  
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  CHAPTER 4. ANATOMY AND PATHOLOGY REVIEW
  
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  CHAPTER 5. POSTOPERATIVE HAZARDS
  
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  CHAPTER 6. OPERATION OVERVIEW
  
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  CHAPTER 7. OP SECTION 1.00. PRELIMINARIES AND WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT
  
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  CHAPTER 8. OP SECTION 2.00. ANAESTHESIA
  
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  CHAPTER 9. OP SECTION 3.00. POSITION
  
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  CHAPTER 10. OP SECTION 4.00. STANCE
  
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  CHAPTER 11. OP SECTION 5.00. SKIN PREPARATION
  
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  CHAPTER 12. OP SECTION 6.00. TOWELLING UP
  
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  CHAPTER 13. OP SECTION 7.00. SPHINCTER STRETCH
  
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  CHAPTER 14. OP SECTION 8.00. IDENTIFYING THE PILES
  
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  CHAPTER 15. OP SECTION 9.00. AIMS, METHOD AND SEQUENCE OF THE OPERATION
  
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  CHAPTER 16. OP SECTION 10.00. EXPOSING THE FIRST PILE
  
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  CHAPTER 17. OP SECTION 11.00. EXPOSING THE 3 AND 11 O’CLOCK PILES
  
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  CHAPTER 18. OP SECTION 12.00. DISSECTING THE FIRST PILE
  
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  CHAPTER 19. OP SECTION 13.00. DISSECTING THE 3 O’CLOCK PILE
  
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  CHAPTER 20. OP SECTION 14.00. DISSECTING THE 11 O’CLOCK PILE
  
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  CHAPTER 21. OP SECTION 15.00. CHECK HAEMOSTASIS
  
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  CHAPTER 22. OP SECTION 16.00. FINAL TOUCHES AND WHO SAFE SURGERY CHECKLIST SIGN OUT
  
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  CHAPTER 23. OP SECTION 17.00. EQUIPMENT AND MATERIALS
  
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  CHAPTER 24. FURTHER READING
  
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  CHAPTER 25. WE WELCOME YOUR COMMENTS
  

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  Haemorrhoidectomy for primary internal haemorrhoids +/- external haemorrhoids.
  
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  Open Milligan-Morgan technique for:
  
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  Grade II piles Prolapsing and spontaneously reducing.
  
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  Grade III piles Prolapsing and manually replaceable.
  
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  Grade IV piles, prolapsed and irreducible.
  
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  Unless greatly inflamed, when a gentle sphincter stretch and reduction is a preferred initial treatment.
  
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  Mucosal prolapse.
  
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  Failed sclerotherapy, banding, cryotherapy or stapling for haemorrhoids.
  

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  Open haemorrhoidectomy for:
  
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  Rectal prolapse.
  
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  Anal Crohn’s disease.
  
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  External haemorrhoids alone.
  
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  Closed Ferguson haemorrhoidectomy.
  
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  Operation for secondary haemorrhoids.
  
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  Eg. Secondary to portal hypertension.
  

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  This masterscript consists of an unlimited number of Chapters.
  
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  The Chapters describing the operation itself are called Op Sections.
  
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  Each Op Section is divided into an unlimited number of very small Steps.
  
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  Each Step contains an unlimited amount of supporting information (pantinos).
  

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  ANATOMY
  
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  The anal canal plays a major role in the controlled passage of faeces, fluid and flatus from the body.
  
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  It is about 4 cm. long.
  
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  It runs from the anal margin up to where the bowel is gripped by the pubo-rectalis sling of the pelvic floor.
  
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  It is a specially adapted part of the lower bowel (endoderm), where it joins embryological ectoderm.
  
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  The circular muscle of the bowel is adapted to form a complex sphincter muscle.
  
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  An internal sphincter consisting of smooth muscle.
  
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  An external sphincter consisting of striped muscle.
  
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  The external sphincter relaxes away from the operating field and is not encountered here.
  
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  The longitudinal muscle has degenerated into a thin fascial layer.
  
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  The anal canal’s lining of columnar epithelium merges with the squamous epithelium of the anal skin.
  
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  Between the epithelium and the internal sphincter lie prominent vascular cushions. These soft cushions help maintain continence.
  
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  Two lines are commonly mentioned running round the lining of the anal canal.
  
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  One line marks the lower end of lax columnar epithelium.
  
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  Above this, the mucosa is folded longitudinally by underlying veins into the “anal columns”.
  
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  The line itself is irregular, hence its name dentate (tooth-like) or pectinate (like the teeth of a comb).
  
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  It is not an important feature in haemorrhoid surgery.
  
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  The second line (Hilton’s white line), marking the lower end of the longitudinal muscle/ fascia, is a rarely prominent line.
  
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  It is more significance for lymphatic drainage in cancer surgery than in haemorrhoid surgery.
  
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  However, two other “lines” are useful landmarks in haemorrhoid surgery.
  
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  The anal margin and the internal sphincter (anal ring)
  
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  PATHOLOGY
  
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  Piles are localised enlargements of the normal fibro-vascular cushions.
  
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  They are named piles after the Latin pila meaning a ball.
  
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  Piles bleed easily, hence the alternative name haemorrhoids, from the Greek meaning to pour blood.
  
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  They are divided into:
  
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  External haemorrhoids lying under the sensitive squamous anal skin.
  
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  They may thrombose and be painful.
  
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  “Hot marble syndrome”.
  
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  They usually settle down and form one type of skin tag.
  
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  Internal haemorrhoids lie under the insensitive transitional epithelium higher up in the anal canal.
  
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  Transitional means a thinned squamous layer between columnar and squamous proper.
  
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  (Not to be confused with the specific transitional epithelium of the urothelium.)
  
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  Piles prolapse through the internal and external anal sphincters with varying levels of effort.
  
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  In their most severe form, they can be strangulated by the anal sphincters and become very congested and infected.
  
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  External and internal haemorrhoids merge together in severe cases.
  
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  One, two, or three piles may be seen, or the whole lining of the anal canal may be prolapsed – a mucosal prolapse.
  
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  A mucosa prolapse is different from a rectal prolapse:
  
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  In the latter, not just the mucosa, but the whole muscular wall of the rectum prolapses out of the anal canal.
  
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  As seen by the surgeon facing the patient placed in the lithotomy position, typically 3, 7 and 11 o’clock piles can be identified.
  
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  This is conveniently, but incorrectly, explained by the arterial blood supply from the left superior rectal artery (3 o’clock pile) and two terminal branches of the right superior rectal artery (7 and 11 o’clock piles).
  
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  Nevertheless, the arterial blood supply to the piles is vigorous.
  
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  The vessels need to be ligated securely with strong sutures to prevent bleeding at the time of operation and afterwards.
  
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  The veins of the piles, draining into the superior rectal veins, require similar secure ligation.
  
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  When there is a mucosal prolapse, the individual “piles” coalesce.
  
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  The operation consists of excising tissue at the 3, 7 and 11 o’clock sites, just as for haemorrhoids.
  
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  Haemorrhoids are very common and may coexist with other diseases in the large bowel.
  
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  These other diseases must be excluded before assuming that the patient’s symptoms, especially rectal bleeding or anaemia are due to the haemorrhoids.
  

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  The operation is often classified as “minor”, but unless correctly performed in every detail it can lead to serious complications.
  
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  Eg. Pain.
  
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  Bleeding.
  
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  Incontinence of faeces, fluid, or flatus.
  
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  Anal stenosis.
  
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  Recurrence of haemorrhoids.
  

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  The operation consists of:
  
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  Identifying the haemorrhoids (or prolapsed mucosa).
  
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  Dissecting the haemorrhoids free from the surrounding internal anal sphincter.
  
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  Transfixing and excising the haemorrhoids.
  
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  Leaving the skin wounds open to heal by secondary intention.
  
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  This differs from the closed Ferguson procedure, commonly seen in the USA, where the skin wounds are closed so as to heal by primary intention.
  

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  Step 1.01. CHECK YOU HAVE THE CORRECT PATIENT.
  
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  Step 1.02. CHECK PROPER INVESTIGATIONS HAVE BEEN PERFORMED, INCLUDING A COLONOSCOPY.
  
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  Step 1.03. CHECK PREVIOUS SURGERY OR TRAUMA TO THE PERINEUM OR ANAL CANAL.
  
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  Ie. Risk of incontinence after the haemorrhoidectomy.
  
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  Step 1.04. CHECK FOR HIP PROBLEMS.
  
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  Eg. Stiff hips, unstable hips or hip joint prostheses.
  
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  Avoid lithotomy position.
  
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  Consider left lateral or jack knife positions.
  
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  Step 1.05. CHECK THERE IS NO OTHER PROCEDURE TO DO.
  
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  Step 1.06. CHECK THERE IS A DIATHERMY PAD.
  
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  Step 1.07. CHECK THE PERIANAL SKIN IS SHAVED.
  
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  From the anterior border of the anal canal to the coccyx and from one gluteal fold to the other.
  
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  Step 1.08. CHECK BOWEL PREPARATION.
  
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  Laxative 2 tablets Sennacot .
  
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  Wash out one hour before the operation.
  
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  WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT.
  

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  GENERAL /SPINAL /EPIDURAL according to circumstances.
  

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  Step 3.01. LITHOTOMY PREFERABLY.
  
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  Use Lloyd Davis stirrups.
  
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  Have 2 non-scrubbed staff flex the hips and place the feet in the stirrups in unison.
  
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  Check the coccyx overhangs the end of the operating table to get access to the anal canal.
  
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  Check the stirrup linkages are tightened to prevent the lower limbs sinking during the operation.
  
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  Hold the scrotum upwards out of the operating area on a sling of 4 inch Elastoplast.
  
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  Step 3.02. DO A SIGMOIDOSCOPY IF NOT ALREADY DONE.
  

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  Sit on a stool facing the patient's perineum.
  
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  Have one assistant on your left and the scrub nurse on your right.
  

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  Clean the skin from the perineum to the coccyx and from one mid thigh to the other.
  
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  Use two swabs on sticks with 0.5% Chlorhexidine in 70% propanol, followed by one to dry off.
  
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  Make sure there is no pooling of the antiseptic, particularly in the vagina.
  

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  Step 6.01. Apply sterile leggings.
  
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  Step 6.02. Tuck a towel firmly under the buttocks to display anus.
  
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  Step 6.03. Lay an anterior towel down to the anterior margin of the anus.
  
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  Step 6.04. Fix the towels with towel clips.
  
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  Step 6.05. Attach diathermy to towels and test it works.
  
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  Step 6.06. Attach an operating tray to the operating table.
  

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  Step 7.01 PERFORM A MILD SPHINCTER STRETCH.
  
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  Do this only if the anal canal is less than 2 cms. in diameter.
  
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  Ie. to give access to the anal canal.
  
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  Be particularly gentle if the patient has any incontinence.
  
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  Use 4 fingers inserted 5 cm. so that you can feel the ring-like internal sphincter.
  
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  Stretch the sphincter muscle in an antero-posterior direction so that the SIDES of the sphincter stretch.
  
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  This will prevent the anal skin splitting posteriorly to form a fissure.
  

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  Classical piles are 3 bluish 2cm. swellings.
  
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  They bulge out of the anal canal in the 3, 7, and 11 o'clock positions as you look at the patient.
  
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  They are covered with mucosa and skin.
  
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  Sometimes there are only one or 2 internal piles.
  
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  There may be 3 or more skin tags from previous thrombosis of external piles.
  
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  All the anal lining bulges out if the piles are strangulated or if there is a mucosal prolapse.
  
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  Sometimes skin tags predominate.
  

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  Step 9.01. AIMS OF THE OPERATION.
  
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  To minimise the amount of denuded anal skin.
  
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  This will minimise postoperative pain and speed healing.
  
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  To leave skin bridges at least 1cm. wide between the denuded areas.
  
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  These will promote healing without stenosis.
  
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  Eg. If the anal orifice is 3cm. in diameter:
  
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  It will have a circumference of about 9cm. (pi X diameter).
  
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  If each of the 3 pile excision sites occupies no more than 1.5cm. of the circumference:
  
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  There will be ample circumference tissue to make each of the 3 skin bridges 1.5cm. wide.
  
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  To avoid damage to the internal anal sphincter.
  
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  Step 9.02. METHOD OF THE OPERATION.
  
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  Expose the piles and hold them ready for dissection.
  
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  Make a C shaped incision 3/4 way round the pile. Do this in 3 steps.
  
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  1. In the line of the circumference of the anal canal.
  
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  2. A radial extension of the lower limb of the C towards the anal canal.
  
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  3. A radial extension of the upper limb of the C towards the anal canal.
  
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  Dissect the outer side of the pile off the internal sphincter.
  
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  Transfix the remaining 1/4 of the pile and excise it.
  
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  Repeat for the other two piles with the addition of skin bridges.
  
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  Step 9.03. SEQUENCE OF THE OPERATION.
  
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  To avoid blood, sutures and artery forceps from one pile obscuring the operating fields of the other piles:
  
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  Operate in turn on whichever pile is the lowest.
  
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  Ie. Normally the 7 o’clock pile first, then the 3 o’clock pile and finally the 11 o’clock pile.
  

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  Step 10.01. CLIP THE 7 O'CLOCK EXTERNAL PILE OR SKIN TAG (if present).
  
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  This is the lowest pile.
  
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  Use an artery forceps.
  
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  Step 10.02. EXPOSE THE 7 O’CLOCK INTERNAL PILE.
  
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  Pull on the forceps away from the lumen of the anal canal.
  
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  The internal pile, a dark blue venous swelling covered with thin mucosa will be seen 1-2 cm. inside the anal canal.
  
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  Step 10.03. CLIP THE 7 O'CLOCK INTERNAL PILE.
  
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  Use another artery forceps.
  
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  Step 10.04. RETRACT THE WHOLE PILE AWAY FROM THE ANAL CANAL.
  
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  Pull on both forceps.
  
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  Step 10.05. HOLD THE PILE AWAY FROM THE ANAL CANAL.
  
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  Clip the two forceps to the drapes on the same side of the anal orifice.
  
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  Use a towel clip.
  

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  Step 11.01. REPEAT AS ABOVE FOR THE 7 O'CLOCK PILE (if present).
  
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  IE GO BACK TO Step 10.01. CLIP THE 7 O'CLOCK EXTERNAL PILE OR SKIN TAG.
  
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  Step 11.02. REPEAT AS ABOVE FOR THE 11 O'CLOCK PILE (if present).
  
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  IE GO BACK TO Step 10.01. CLIP THE 7 O'CLOCK EXTERNAL PILE OR SKIN TAG.
  

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  Step 12.01. DETAILS OF DISSECTING THE PILES.
  
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  You will be making the C shaped incision into the 3/4 of the skin and mucosa at the site of each pile.
  
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  The fourth side will be transfixed with a suture.
  
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  At the same time, you will need to preserve three skin bridges between the excision sites.
  
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  The skin bridges are not created uniformly.
  
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  There is no skin bridge to preserve around the 7 o’clock excision site.
  
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  There is one skin bridge to preserve between the 7 and 3 o’clock excision sites.
  
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  There are two skin bridges to preserve between the 7 and 11 o’clock and the 3 and 11 o’clock excision sites.
  
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  After this, you will be excising each pile without damaging the internal sphincter.
  
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  Start with the lowest pile to keep the operating field free from blood, instruments and suture material.
  
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  Step 12.02. RELEASE FROM THE DRAPES THE 2 ARTERY FORCEPS FROM THE 7 O’CLOCK PILE.
  
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  Step 12.03. INCISE THE SKIN AND MUCOSA OF THE 7 O’CLOCK PILE.
  
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  Display the outer side of the pile.
  
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  Pull on the 2 artery forceps centrally to do this.
  
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  Start making the C shaped skin incision.
  
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  Make the first cut in a circumferential direction lateral to any skin tag or external pile.
  
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  Make it in the line of the circumference of the anal canal.
  
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  Make the cut 1cm. long normally.
  
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  Use round ended scissors to snip through the skin.
  
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  Avoid excising non-piles skin, because it is unnecessary and very painful during the healing period.
  
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  Extend the incision.
  
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  Make the next cut from the lower edge of the circumferential incision, snipping immediately in a radial direction towards the anal orifice.
  
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  Snip into the mucosa of the anal canal for 2cm. or until you are proximal to the internal pile.
  
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  For a MUCOSAL PROLAPSE:
  
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  Extend this incision 5cm. to remove enough mucosa.
  
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  Go back to the upper end of the circumferential incision.
  
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  Make the second radial cut from the upper end of the C incision.
  
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  Run it down towards the anal canal.
  
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  Finish the cut 2cm. from the end of lower radial incision.
  
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  This will complete the C shaped incision 3/4 of the way round the pile.
  
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  The intervening mucosa will be stitched off very soon.
  
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  Step 12.04. DISSECT THE 7 O’CLOCK PILE OFF THE INTERNAL SPHINCTER.
  
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  Peel the internal sphincter off the pile.
  
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  Use firm dissection with a gauze.
  
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  Show up the fibres of the sphincter muscle.
  
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  Stretch the pile over a finger, pressing from the mucosal side of the pile.
  
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  The internal sphincter muscle will be felt as a firm 1-2 cm. ring outside the ellipse incisions.
  
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  Its fibres are light brown, fleshy strands when displayed through the incisions.
  
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  They run circumferentially in the subcutaneous tissues lateral to the pedicle of the pile.
  
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  They are often thinned out where they cover the pile.
  
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  It is essential that these fibres are clearly seen and are swept laterally.
  
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  This will prevent incontinence after the operation.
  
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  You should end up with only the mucosa of the pile together with its nutrient artery stretched over your finger.
  
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  The sphincter will lie laterally.
  
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  You can ignore minor bleeding vessels in the internal sphincter.
  
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  Use diathermy cautiously to control venous bleeding.
  
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  With spinal, caudal, or epidural anaesthesia, the internal sphincter may well relax more than during a general anaesthetic.
  
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  It will lie more lateral than usual.
  
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  Nevertheless, be absolutely certain that you have removed all the sphincter fibres from the pedicle of the skin tag and pile before transfixing the pedicle.
  
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  Step 12.05. TRANSFIX THE PEDICLE OF THE PILE.
  
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  Use eg. an O silk transfixion stitch (Ethicon W334).
  
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  Insert the needle between the sphincter muscle and the pile.
  
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  Be absolutely certain that you have not included any sphincter muscle in the stitch.
  
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  Pass the needle through the pile towards the lumen of the anal canal.
  
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  Bring the needle out of the mucosa, further up the pile than the anal canal.
  
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  Tie the suture round half the pile with a triple knot.
  
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  Wrap the suture round the other half of the pile.
  
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  Tie the end of the suture to the first triple knot with another triple knot.
  
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  Make sure the suture does not nip the internal sphincter.
  
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  Clip the loose ends of the suture 5 cms. from the knots with an artery forcep.
  
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  The long ends will assist finding the pile if the wound needs to be explored for bleeding postoperatively. Cut off redundant piles tissue.
  
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  Leave 1cm. of pile tissue distal to the stitch to prevent the stitch slipping.
  
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  Cut off the more distal ends of the stitch.
  

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  This is the same as for dissecting the 7 o’clock pile.
  
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  PLUS preserve one skin bridge between the 7 and 3 o’clock pile wounds must be preserved.
  
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  Step 13.01. RELEASE FROM THE DRAPES, THE 2 ARTERY FORCEPS ON THE 3 O’CLOCK PILE.
  
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  Step 13.02. IDENTIFY A SKIN BRIDGE.
  
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  This will run between the wound of the 7 o’clock pile and the planned wound round the 3 o’clock pile.
  
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  It should be at least 1cm. wide.
  
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  The skin will run continuously from the perianal area into the anal canal.
  
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  Step 13.03. INCISE THE SKIN AND MUCOSA OF THE 3 O’CLOCK PILE.
  
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  Ie. The same as Step 12.03 INCISE THE SKIN AND MUCOSA OF THE 7 O’CLOCK PILE.
  
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  PLUS make the lower radial incision at least 1cm. away from the 7 o’clock pile to preserve a skin bridge.
  
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  If the skin bridge is less than 1cm.:
  
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  Be extra careful to make the other two skin bridges more than 1.5 cm. wide to compensate for this error.
  
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  Step 13.04. DISSECT THE 3 O’CLOCK PILE OFF THE INTERNAL SPHINCTER.
  
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  Ie. The same as Step 12.04 DISSECT THE 7 O’CLOCK PILE OFF THE INTERNAL SPHINCTER.
  
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  Step 13.05. TRANSFIX THE PEDICLE OF THE PILE.
  
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  Ie. The same as Step 12.05 TRANSFIX THE PEDICLE OF THE PILE.
  

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  This is the same as dissecting the 7 and 3 o’clock piles.
  
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  PLUS preserve TWO skin bridges.
  
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  Ie. Between the 11 o’clock pile and the wounds of the other two piles.
  
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  Step 14.01. RELEASE FROM THE DRAPES, THE 2 ARTERY FORCEPS ON THE 11 O’CLOCK PILE.
  
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  Step 14.02. IDENTIFY THE TWO REMAINING SKIN BRIDGES.
  
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  These will run between the wounds of the 7 o’clock and 3 o’clock piles, and the planned wound round the 11 o’clock pile.
  
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  They should be at least 1cm. wide.
  
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  The skin will run continuously from the perianal area into the anal canal.
  
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  Step 14.03. INCISE THE SKIN AND MUCOSA OF THE 11 O’CLOCK PILE.
  
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  This is the same as Step 12.03 INCISE THE SKIN AND MUCOSA OF THE 7 O’CLOCK.
  
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  PLUS make the two radial incisions at least 1cm. away from the 7 o’clock and 3 o’clock pile wounds to preserve two skin bridges.
  
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  If either skin bridge is less than 1cm. wide:
  
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  There is a risk of a postoperative anal stricture.
  
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  Consider suturing the piles wounds to encourage healing by primary intention rather than healing by repair with fibrosis.
  
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  Step 14.04. REVIEW PROGRESS.
  
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  You should now have:
  
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  3 excision sites.
  
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  3 intact skin bridges.
  
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  3 transfixed pedicles.
  
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  3 sets of ends of silk held by 3 artery forceps.
  

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  Step 15.01. INSPECT EACH EXCISION SITE FOR BLEEDING.
  
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  Minor oozing will stop by itself.
  
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  Diathermy venous bleeding as necessary to obtain haemostasis.
  
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  For arterial bleeding:
  
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  Re-transfix the pile.
  
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  Step 15.02. CUT THE ARTERY FORCEPS OFF THE SUTURES.
  
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  Step 15.03. INFILTRATE THE WOUNDS WITH 10ML 0.5% BUPIVACAINE.
  
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  Step 15.04. DRESS THE WOUNDS.
  
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  Place a 5cm. square of Paraffin gauze on each excision site.
  
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  Cover the anus with 10 gauze swabs.
  
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  Hold the gauzes in place with elastic pants.
  
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  Step 15.05. CHECK THERE IS NO OTHER PROCEDURE TO DO.
  

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  Step 16.01. CHECK THE HIPS ARE UNFLEXED CAREFULLY AND IN UNISON.
  
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  Step 16.02 WRITE LEGIBLE OPERATION DETAILS.
  
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  Step 16.03. FILL IN THE SURGICAL AUDIT FORM.
  
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  Step 16.04 PRESCRIBE CALCIUM HEPARIN.
  
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  5000 UNITS BD subcutaneously until the patient leaves hospital if he/she is over 40 years.
  
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  Step 16.05. DICTATE AN OPERATION LETTER TO THE GENERAL PRACTITIONER PLUS A COPY TO THE REFERRING PHYSICIAN.
  
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  WHO SAFE SURGERY CHECKLIST SIGN OUT.
  

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  GENERAL SET +
  
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  1 PROCTOSCOPE
  
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  1 BLUNT CURVED SCISSOR
  
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  DIATHERMY FORCEPS AND LEAD
  
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  SUTURES :- W 334
  
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  PIECES JELONET
  
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  DRESSING GAUZE-WOOL
  
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  NETELAST KNICKERS
  

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  http://www.fascrs.org/physicians/education/core_subjects/2008/hemorrhoids_fissure_in_ano/
  

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