Hemorrhoidectomy

Anatomical rationale and indications for surgery

The development of the disease is based on the pathology of cavernous bodies, which are normally located in the submucosal layer of the anal canal. These structures can present as either small or large vascular clusters. The blood supply to this anatomical zone is provided by branches of the inferior rectal artery. A crucial topographic landmark for the surgeon is the typical localization of enlarged cavernous bodies. When the patient is placed in the supine position, they project strictly at 3, 7, and 11 o'clock on an imaginary clock face.

Surgery is indicated for severe courses of the disease:

• Presence of regular hemorrhoidal bleeding leading to the development of anemia.
• Frequent prolapse of enlarged hemorrhoids if complicated by their inflammation and strangulation.

Important to remember: the presence of acute inflammation and strangulation at the time of examination is an absolute contraindication to surgical treatment.

Preparation and local anesthesia

To perform the intervention, the patient is placed in the classic position used for any perineal surgery. General anesthesia or multi-stage local anesthesia may be used for pain relief.

The technique of local infiltration anesthesia includes several consecutive steps:

1. First, anesthesia of the skin and subcutaneous adipose tissue directly around the anus (in the area of the transitional fold) is performed.
2. Then, blockade of the rectal mucosa is carried out.
3. The next step is injecting the procaine solution into the thickness of the sphincter. The surgeon must perform this action under strict control of a finger inserted into the lumen of the anal canal.
4. Anesthesia is completed by deep administration of the solution into the ischioanal fossa (the needle is advanced to a depth of up to 7 cm).

Technique of hemorrhoid ligation

This is a less traumatic variant of intervention, the essence of which is the ligation of the base of the cavernous body without its immediate excision.

• The operation begins with careful dilation of the external sphincter with the fingers of both hands of the surgeon.
• Enlarged hemorrhoids are grasped with special fenestrated forceps and pulled down.
• The mucosa is circularly incised at the border with the pathological hemorrhoid.
• The base of each hemorrhoid, which is under the clamp, is transfixed with a strong suture (thick silk is used).
• A tight tissue ligation is performed on both sides for reliable hemostasis.
• At the end, the clamps are removed, and the long ends of the ligature threads are cut.

In the postoperative period, the devascularized necrotic hemorrhoids independently slough off on days 6–7.

Excision of hemorrhoids (classic hemorrhoidectomy)

This technique involves the complete removal of pathological tissues with the formation of a wound defect.

1. The anus is dilated horizontally using a rectal speculum.
2. The hemorrhoids are securely fixed and pulled down with four Allis forceps.
3. A Billroth hemostatic clamp is applied to the isolated vascular pedicle of the hemorrhoid.
4. The surgeon incises the mucosa around the formation. A critically important rule: the incision must not extend onto the perineal skin.
5. The hemorrhoid is excised strictly above the applied clamp. As a result, a triangular-shaped wound is formed at the site of the removed tissue. Its apex points into the lumen of the rectum, and its base is located at the border with the perineal skin.
6. As the final step, the pedicle of the hemorrhoid is transfixed and ligated, ensuring definitive hemostasis.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the ischioanal fossa and its fascial spaces.
• Blood supply to the rectum: portosystemic anastomoses and arterial basins.
• Innervation of the anal canal and the mechanism of the sphincter apparatus function.
• Types of surgical instruments for perineal operations (Allis forceps, Billroth clamps, fenestrated forceps).
• Complications of local anesthesia in the perianal region.

Other topics in the section «Pelvic and Perineal Surgery»

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