Haemorrhoids are a common condition caused by the dilatation of veins within the anal canal.
Internal haemorrhoids are generally painless but can cause significant bleeding. These can often be improved or resolve with banding or injection of the haemorrhoid and can be done in clinic at the time of initial consultation. Persistence of symptoms or very large haemorrhoids are best dealt with by surgical excision under general anaesthesia.
External haemorrhoids occur more towards the outside of the anus and are typically very painful particularly when acutely inflamed. The skin overlying external haemorrhoids are exquisitely sensitive and so these haemorrhoids usually not amenable to banding or injection. General anaesthesia is required for excision of external haemorrhoids.
What disorders can occur?
Internal haemorrhoids can cause significant bleeding particularly after defecation. Large haemorroids may prolapse outside the anal canal. In most cases they will recede spontaneously but occasionally require to be manually pushed back in to the anal canal.
External haemorrhoids are usually very painful and can thrombose or prolapse but are less likely to cause significant bleeding. Thrombosis of external haemorrhoids is caused by a blood clot which may form within the haemorrhoid after straining. This condition will usually resolve if managed non-operatively but may take more than a week to do so. Resolution of external haemorrhoids may result in the formation of anal “skin tags”.
Skin tags may remain after regression of a haemorrhoid. These are usually not symptomatic but can be an annoyance particularly with regards to hygine due to difficulty cleaning the anus with toilet paper after defecation.
Why do I need haemorrhoid Surgery?
Surgical excision of haemorrhoids is usually only recommended for symptomatic haemorrhoids. The most common indication for surgery is recurrent bleeding or for painful haemorrhoids. Occasionally patients will request removal of anal skin tags to help improve personal hygine.
What incision will I have?
The most common approach to haemorrhoidectomy is direct excision of the haemorrhoid(s) and associated venous plexus from the anus. Other recognized approaches include excision of haemorrhoids using an energy device (which is able to cut the haemorrhoid and seal the vessels without the need for sutures or staples), a stapling device (stapled haemorrhoidectomy), or ligation / plication of the haemorrhoid(s) without formal excision.
What will the scar look like?
Given the location of the haemorrhoids any resulting scar is usually not visible. Many surgeons will leave the excision site open whilst others will close the excision site bringing the skin edges together with a dissolving suture. My general practice is to close the excision site as I believe this results in less bleeing from the excision site and a neater result with less risk of skin tag formation. Excision of large haemorrhoids may occasionally result in small skin tags from residual skin at the excision site. If an anal skin tag(s) does happen to occur after healing is complete they can be simply excised if requested by the patient.
What complications can occur?
As with any surgical procedure haemorrhoidectomy does have a small risk of complication. The most frequent complication seen after haemorrhoidectomy is bleeding or infection at a rate of approximately 1%. Injury to the underlying anal sphincter muscle resulting in incontinence or anal stricture due to circumferential scarring around the anus are excedingly rare complications when surgery is performed by an appropriately trained surgeon. Inability to pass urine (urinary retention) requiring a temporary catheter can occur due to associated bladder sphincter spasm. Urinary retention is more common in older male patients particularly when an enlargement of the prostate is also present however will occasionally also occur in women and younger males. Recurrence of haemorrhoids over time can occur however if this occurs is usually less severe than the original presentation and can often be managed by banding or injection rather than re-excision.
Will I need to be on medications after my haemorrhoid surgery?
The discomfort associated with haemorrhoidectomy is often underestimated by patients and treating clinicians. Generous oral analgesia is usually required for the first week or so after surgery. A prescription for a mild laxative will be provided as defecation in the first few days after surgery is uncomfortable particularly if constipated. For larger excisions a short course of an oral antibiotic (Metronidazole) may also be recommended as some studies suggest this can reduce post-operative pain.
How long will I be in hospital and expected recovery time?
In the majority of cases patients can be discharged the same day of their procedure. Some patients may require an overnight if there is post anaesthesia nausea or vomiting, other medical conditions requiring overnight observation or any difficulty achieving adequate pain control in the early post-operative period. Most patients have comfortably returned to work after the first week from surgery although may find prolonged periods of sitting uncomfortable. Healing is usually complete within six weeks after surgery.