Haemorrhoids

1. Cushions of dilated vascular tissue at anal verge
2. Anal cushions are required for full continence
3. Straining causes the cushions to slide down and become engorged - results in symptomatic haemarrhoids

Classification

1. First degre: small non-prolapsing
2. Second degree : prolapsing but reduce spontaneously
3. Third degre: prolapse that cannot be reduced

Treatment options

1. Asymptomatic
   • No treatment required
2. First degree
   • Stool-bulking agents
   • Injection sclerotherapy
3. Second degree
   • Banding
4. Third degree
   • Haemarrhoidectomy

Haemarrhoidectomy procedure

1. Prepared + consented + phosphate enema
2. Lithotomy position + GA
3. Skin or anus/perineum prepared + Parkes proctoscope passed PR
4. Gently draw haemorrhoid towards surgeon and then make V-shaped incision in anal skin at base of haemorrhoid
5. Raise haemorrhoid towards lumen away from sphincter fibres + transfixed and ligated with vicryl suture
6. Divide haemorrhoid 5mm distal to ligation and removed
7. Repeat for other haemorrhoids (3,7,11 position)
8. Pack anal canal with gauze or spone to keep mucocutaneous bridges flat against the internal sphincter (prevents an anal stricture forming)
9. Apply perineal pad and firm T-bandage

Post-op care

• daily bulking agents
• glycerin suppositories for faecal retnetion
• Analgesia 30 minutes before bowel movements and change of dressings
• External wounds managed with twice daily baths, irrigation and dressings
• 4 week outpatient review

complications

1. Bleeding
2. Constipation
3. Anal stenosis
4. Faecal incontinence due to damage of sphincter mechanism
5. Anal fissure
6. Recurrence
7. Perianal fistula