Hemorrhoids are enlarged or dilated veins located in and around the rectum and anus. There are two types: external and internal. External hemorrhoids occur below the anal sphincter and protrude at the anus. Thrombosed hemorrhoids contain clotted blood and can cause pain. Thrombosis usually occurs in external hemorrhoids but does occur in both types. Thrombosed external hemorrhoids can be incised and the clot evacuated.
Internal hemorrhoids occur above the anal sphincter and are classified as first-degree, second-degree, third-degree, and fourth-degree. First- and second-degree hemorrhoids may bleed with defecation, and second-degree hemorrhoids protrude with defecation but return once the patient stops straining. Third- and fourth-degree internal hemorrhoids may become enlarged and drop down (prolapse) through the anus. Third-degree hemorrhoids protrude with straining and can be pushed back through the anus manually. Fourth-degree cannot be managed manually and may be thrombosed.
Surgical removal of hemorrhoids (hemorrhoidectomy) is recommended for third- and fourth-degree internal hemorrhoids (with or without external hemorrhoids) when conservative treatment measures fail to alleviate severe burning, itching, swelling, protrusion, bleeding, and pain. It is also recommended for external hemorrhoids when medical treatment has failed and symptoms persist.
Hemorrhoidectomy may be performed under general anesthesia (the patient is rendered unconscious), under spinal anesthesia (the patient is numbed from the waist down), or under local anesthesia (the immediate area is injected with a numbing agent similar to that used at the dentist's office). The choice of anesthesia depends on the extent of surgery, the patient's health and personal preference, and surgical standards of the facility.
The patient lies on the operating table face down with the buttocks slightly elevated or on their back with their legs up in stirrups, so the anus and rectal area are exposed. After the anesthesia has taken effect, the area is cleaned with an antiseptic solution. The hemorrhoids are clamped, tied off, and cut away. The wound is then sutured. After the operation, the surgeon packs the anus with gauze or applies antibiotic ointment. A hemorrhoidectomy takes about 1 to 1 1/2 hours to perform.
Newer methods for hemorrhoid removal are being used. One method involves using an ultrasonic scalpel to cut away hemorrhoids. This method is quicker and does not require sutures. Another innovation is the stapled hemorrhoidectomy, in which tissue from further in the anus is used to close the wound with surgical staples after the hemorrhoids are removed. Patients may recover faster and have less postoperative pain, but some research has shown an increase in complications with this procedure.