Haemorrhoid: surgical treatment

If haemorrhoids do not respond or insufficiently respond to non-surgical treatments, a more drastic treatment may be necessary. There are various options for this as well. At the Maria Middelares General Hospital, a choice is made among various techniques based on the type of haemorrhoids, the type of symptoms and some patient-specific characteristics:

1. Haemorrhoidectomy

This technique, which has been available for a long time, used to be the only surgical option for serious haemorrhoids. During this procedure, the haemorrhoids are excised under general anaesthetic with the remaining wound left open or only partially sutured. The wound will then gradually close by itself. Single or multiple haemorrhoids can be removed using this technique.

Although haemorrhoids rarely recur after haemorrhoidectomy, the technique has a few disadvantages. Most patients experience significant anal pain in the first few weeks after the procedure, especially during bowel movements. Loss of wound exudate over a prolonged period of time is possible too. Because the healing wounds result in shrinking scars, this technique may cause anal stricture if multiple haemorrhoids are removed. For patients who only have a single large haemorrhoid, this treatment method is a good option.

2. Stapled haemorrhoidectomy

This procedure is also known as the ‘Longo procedure’ or ‘procedure for prolapse and haemorrhoids (PPH)’. It is suitable for symptomatic circumferentially prolapsed haemorrhoids. This technique involves the use of a special stapler to remove the swollen haemorrhoids and pulling the prolapsed healthy mucous membrane back in. No open wounds result from this technique, but a circular row of staples is placed in the bottom part of the rectum.

Due to the absence of wounds, most patients have less pain after the procedure, and there are fewer complaints of loss of wound exudate. Because of swelling of the row of staples, bowel movements may be difficult or fragmented in the first few weeks. This will improve by itself.

3. Transanal ligation of haemorrhoid blood vessels

This technique involves the transanal insertion of a Doppler probe (a device that uses ultrasound to detect the blood flow in the blood vessels) to locate the arteries that are responsible for the swelling of the haemorrhoids. These arteries are then tied off to reduce the swelling. This THD procedure (transanal haemorrhoidal dearterialisation) also allows for selective suturing of the prolapsed mucosa.

This technique does not result in open wounds around the anus either, although substantial swelling in the anus may occur in the first few days, resulting in difficult and painful bowel movement. This technique is less suitable for very extensive prolapsed haemorrhoids due to the higher risk of recurrence.

Preparation

These procedures are usually performed in the outpatient clinic and you do not have to stay in hospital overnight. If you are in too much pain or if there are problems immediately after the procedure (such as blood loss or urinary retention (difficulty/inability to urinate)), an overnight stay may be needed.

Go to the Admission Department the morning of the procedure, after having fasted. Clear, sugary drinks may be consumed up to two hours before the procedure. In specific cases, the attending physician may give you permission to have a light breakfast the morning of the procedure; always inform the anaesthetist at the time of the general anaesthetic.

You may take your usual medication with a sip of water unless the physician has told you in the preparatory consultation that you should stop certain medications. For instance, blood thinners need to be stopped a week before the operation; please inform your physician in advance!

Any specific preparations are not usually required, you do not have to give yourself an enema. If this is required however, your physician will inform you of this in advance.

Aftercare

• At the end of the surgical procedure, an anal compress is often inserted. These compresses must not be removed, they will disappear by themselves with the first bowel movement. After stapling the haemorrhoids, your physician will usually insert a larger bandage to prevent bleeding in the first post-operative hours. This bandage must be removed by the nurse of your ward, a few hours after the procedure.
• Before you are discharged, you will be given details at the ward about pain relief and suitable wound care by your attending physician or their assistant. In some cases, it is advisable to apply an ointment; you will also be informed of this at your discharge. You will be given the necessary prescriptions as well as a letter for your GP. Sometimes, a certificate for home nursing care is required.
• Due to the presence of wounds in and/or around the anus, bowel movements may be painful at first. Try to avoid constipation by drinking enough fluids and eating enough fibre. If necessary, laxatives will be advised for the time being. If bowel movements become too liquid, this medication can of course be stopped.
• A check-up in the outpatients clinic is scheduled for three weeks after the procedure. Pain is usually well controlled by then; the wounds may sometimes take up to six weeks to heal. If necessary a follow-up appointment is planned. Despite the proper treatment, haemorrhoids may cause problems again after months or years. Try to prevent this by following the lifestyle regimen.
• Afterwards, keep the general measures and lifestyle regimen discussed here in mind.

Every operation is associated with a risk of a number of general complications. This risk is very low for procedures for haemorrhoids since the general anaesthetic is only very brief.

However, a number of specific complications are possible:

• Anal blood loss usually stops by itself. If necessary, it may helpful to apply a covering pressure bandage. In rare cases, a second procedure is required to stop the bleeding. If in doubt, please consult a physician.
• Because the procedure was performed near the anus, you may have difficult urinating after the procedure. The patient absolutely must have urinated before they leave the hospital. In exceptional cases, we will place a temporary bladder catheter.
• As a result of the procedure, the tissue around the anus will be swollen. This may cause a sensation as if the haemorrhoids are still there (or partly there) when wiping. This swelling will disappear by itself in the first weeks after the operation.
• Pain symptoms are normal after a haemorrhoids procedure. If the pain after the procedure gradually increases instead of decreases, then contact a physician.
• If a patient develops a fever after the procedure, an infection must be ruled out. This may be a general infection (lung infection or urinary tract infection) but it may, of course, also be an infection in the operated area. Infections after a haemorrhoids procedure are rare, but they may be serious. Blood tests and potentially, targeted imaging will determine if antibiotics are required.
• Bowel movements may be slightly difficult for a while after the procedure. Due to the post-operative swelling, it may feel as if bowel movements are obstructed. If this does not improve after a few weeks, this could indicate constriction of the anus due to internal scarring. It may be necessary to temporarily stretch the wounds in the outpatient clinic (or under general anaesthetic if it would be too painful).

Latest publication date: 13/12/2023