Preoperative Preparation

Phosphate enema. Metronidazole at induction.

Anaesthesia

General or spinal

Position

Lithotomy or jack-knife

Procedure

• After procto-sigmoidoscopy, identify the haemorrhoids that need to be excised - usually a left lateral, right posterior & right anterior.
• Expose the left haemorrhoid with an anal retractor, Parks or Eisenhammer.
• Bupivicaine & adrenaline is infiltrated around the haemorrhoid for resection.
• Apply an artery forceps to the gaemorrhoid at the anal margin for restraction.
• Using scissors or diathermy make a v-shaped incision in the perianal skin at the distal extent of the haemorrhoidal tissue.
• The haemorrhoid is then dissected from the underlying internal sphincter.
• As the pedicle of the haemorrhoid is reached, vessels are controlled by diathermy or an absorbable transixion stitch, taking cre not to include the internal sphincter.
• The haemorrhoid is excised & the process is repeated for each haemorrhoid. Take care to leave skin & muscosal bridges between each resection to prevent anal stenosis.
• Some surgeons leave the wounds open & some close them with an absorbable suture.

Postoperative Management

• Encourage regular baths.
• Prescribe analgesics & a laxative to offset constipation.
• Continue oral metronidazole for five days.

Main Postoperative Complications

Pain, haemorrhage, constipation & urinary retention.