Grade III and IV haemorrhoids
Failing / not tolerating office procedures

Special Preparation
Stop anticoagulants, blood thinners
Avoid operating on pts with incontinence without workup

Prophylactic antibiotics only if endocarditics risk.
GA or spinal
Tape buttocks open
Perianal block with local and adrenaline.
- four quadrants around anus
- both at superficial, submucosa and deep intersphincteric space.
- 30mL 0.25% bupivacaine

I perform a standard closed haemorrhoidectomy.
- prefer to the open Milligan Morgan as somewhat more haemostatic.
Expose anal canal with a Park's retractor.
Grasp and retract haemorrhoid with a hemostat.
Perform an elliptical excision around the haemorrhoid with diathermy.
Dissect off the underlying internal sphincter muscle, staying in plane beneath the haemorrhoid, and clearly visualizing the sphincter muscle aided by blunt dissection with a finger
3-0 vicryl suture at the pedicle site to control bleeding from the vascular complex.
Perform between 1-3 haemorrhoidectomies
- leaving at least 1cm skin bridges between incision lines.
- erring on side of caution and leaving residual haemorrhoidal tissue if necessary to avoid excessive excision.
Close with 3-0 greased vicryl running suture.
- tends to open anyway at first BM but good for controlling bleeding

Post-Operative Issues
Minor bleeding, drainage and a lot of pain are expected.
Sitz baths 20 minutes bd.
Paracetamol, NSAIDS, opiates
Stool softeners x2
- fecal impaction is a big problem and severely painful

Serious complications are rare.
Urinary retention is most common issue
- soaking in a bath can help and reduce pain.
Stenosis should be avoidable.
Passing clots is a significant problem that requires prompt evaluation.
- up to 2 weeks later
- foley catheter for immediate control, then definitive in OT

Alternatives and Controversies

Really a haemorrhoidopexy.
Requires specialist knowledge and skill.
33mm stapler resects distal recal mucosa and submucosa proximal to haemorrhoid; up and fixed to rectal wall.
Not described here as not a general surgical procedure; i do a closed haemorrhoidectomy.
12% rate of minor complication e.g. bleeding, discomfort, urinary retention
Staple line must not be in the anal canal
- else a chunk of sphincter can be taken.

Reduced post-operative pain and shorter recovery time (Level 1 evidence; meta-analysis)
But higher rate of recurrence (Level 1 evidence; Cochrane)

Haemorrhoidal Artery Ligation (HAL).
Special proctoscope with Doppler transducer to identify and ligate feeding arteries.
Average of six found and ligated.
Quite effective, much reduced pain, minimal complications.
Higher recurrence than haemorrhoidectomy; 10% 1 yr recurrence.