Do you feel pain and bleed from your anus while defecating? You might be worried about the sight of blood coming out of the anus. But there is no need to worry. It might just be a case of haemorrhoids. And yes, there is a treatment available. Most haemorrhoids get better on their own after a few days or weeks. However, some cases require medical intervention.

One of the effective treatment methods for treating haemorrhoids is haemorrhoidectomy. Haemorrhoidectomy is an invasive surgical procedure primarily reserved for severe cases of haemorrhoids in which a surgeon removes swollen blood vessels in the anus. In this article, we will discuss the purpose, types, complications as well as contraindications of haemorrhoidectomy.

Haemorrhoids, also known as Piles, are a common condition that causes inflammation and swelling of the blood vessels found in the anus and rectum. In fact, an epidemiological study by Johanson et al¹ in 1990 showed that 10 million people in the United States complained of haemorrhoids, corresponding to a prevalence rate of 4.4%.

According to the National Institute for Health and Care Excellence (NICE), community studies show that around 13-36 % of the general population in the UK suffer from haemorrhoids at some point in their life. However, the real number could be higher as these studies primarily rely on self-reported cases.³

Why do haemorrhoidectomy?

Sometimes, the haemorrhoids become too complicated and severe to be treated by non-surgical methods. Haemorrhoidectomy is usually reserved as a last resort when all other medical interventions have failed. Some of the common reasons for choosing haemorrhoidectomy are as follows:^2,8

• Haemorrhoids are too large for non-surgical treatment
• In cases of symptomatic grade III, IV, and mixed external and internal haemorrhoids
• Severe thrombosed haemorrhoids
• If internal haemorrhoids become strangulated
• If the patient has additional underlying anorectal conditions that require surgery along with haemorrhoids
• In cases where other non-surgical and minimally invasive treatments have failed 

Things to do before haemorrhoidectomy

Before carrying out an invasive procedure like haemorrhoidectomy, several precautionary steps should be taken by the patient to minimise future complications.³

These include:

• Do a full blood count to rule out anaemia or existing systemic infection
• Rule out any underlying autoimmune disease such as diabetes and thyroid disorder
• If the patient is on blood thinners such as aspirin, it should be consulted with the doctor before proceeding with the surgery
• As anal cancer may look similar to prolapsed haemorrhoids, NICE recommends investigations such as faecal immunochemical tests (FIT) and other guidelines to be followed to rule out anal cancer before doing a procedure³
• Stop smoking and drinking 
• You may require an enema to empty your stomach one day before the surgery
• Do not eat anything solid or drink anything 12 hours before surgery or as advised by your doctor

Types of haemorrhoidectomy

Closed haemorrhoidectomy

Closed haemorrhoidectomy, also known as the Ferguson technique, is an invasive procedure done under general anaesthesia involving the excision of enlarged blood vessels by surgeons and closing the wound using an absorbable suture (dissolvable stitches).

This is also the most common technique for haemorrhoidectomy in the United States.^2,8 This kind of procedure is more effective than non-invasive procedures primarily in cases of external haemorrhoids.

Open haemorrhoidectomy

Open haemorrhoidectomy, also known as the Milligan-Morgan technique, is similar to the Fergurson technique and involves the excision of enlarged blood vessels in the anus. However, in this method of haemorrhoidectomy, the wound is left open without any sutures.

Although the wound takes longer to heal compared to a closed haemorrhoidectomy, the post-operative pain and discomfort are significantly less than the closed method. This kind of technique is more common in the UK.^2,8

Stapled haemorrhoidopexy

Stapled Haemorrhoidopexy is a relatively modern technique compared to conventional surgical excision techniques. This is mostly done in the cases of internal haemorrhoids. Many clinicians argue this to be a separate form of haemorrhoid management rather than a type of haemorrhoidectomy.

In this procedure, anal haemorrhoidal vessels are not excised but are lifted above the anal verge (where the anus opens at the lower end) and attached. This blocks the blood supply to the haemorrhoidal veins and ultimately provides symptomatic relief. Although this procedure is quite painless and the patient has a very short recovery time, it has a very high possibility of recurrence.^3,8

Laser haemorrhoidoplasty

This is a relatively new method of treatment for haemorrhoids in which a laser probe is placed at the neck of the haemorrhoids. The laser probe then produces intense heat and cauterises (closes off) the blood vessels. This blocks off blood supply to the blood vessels causing the haemorrhoids to shrink. The procedure is significantly less painful and also has a faster recovery time, with fewer potential risks and complications compared to its counterparts.^4,5

Haemorrhoidal artery ligation and rectoanal repair (HAL-RAR)

Haemorrhoidal artery ligation and rectoanal repair (HAL-RAR) is a relatively newer minimally invasive procedure in which a surgeon identifies the inflamed blood vessel with the help of a device known as a Doppler. This device ties off the hemorrhoidal arteries, reducing blood flow to the haemorrhoids. Additionally, rectoanal repair is performed to address any associated anatomical defects.

This minimally invasive technique aims to alleviate symptoms such as bleeding, pain, and prolapse, providing a potential alternative to traditional haemorrhoidectomy with faster recovery times and less postoperative discomfort.⁶

Dietary and lifestyle adjustments after the procedure

After undergoing a hemorrhoidectomy, it's important to make certain dietary and lifestyle adjustments to promote healing, prevent complications, and reduce the risk of recurrence. Keep in mind that individual needs may vary and it's crucial to follow your doctor's recommendations. Here are some general guidelines:⁷

Dietary changes

• Fibre Intake: Increase your fibre intake to soften stools and make bowel movements more comfortable. Foods such as fruits, vegetables, whole grains, and legumes contain high amounts of fibre
• Hydration: Drink plenty of water to stay hydrated and help soften stools. You should drink at least eight glasses of water per day
• Avoid constipating foods: Limit or avoid foods that can contribute to constipation, such as processed foods, dairy products, and low-fiber foods
• Small, frequent meals: Eating smaller more frequent meals daily may help regulate bowel movements and prevent straining

Lifestyle adjustments

• Gentle cleaning: After a bowel movement, use gentle, unscented, and alcohol-free moist wipes or a peri-bottle with warm water to clean the anal area. Avoid harsh or scented toilet paper
• Warm baths: Take warm baths to soothe the area and promote relaxation. This can also help reduce swelling and discomfort
• Avoid straining: Avoid straining during bowel movements. Take your time and allow stools to pass naturally. If needed, use a stool softener as recommended by your doctor
• Physical activity: Engage in light physical activity, such as walking, to promote healthy bowel function. However, avoid strenuous activities that may pressure the surgical area excessively
• Avoid prolonged sitting: If your job or lifestyle involves prolonged sitting, try to take breaks and move around regularly to reduce pressure on the surgical site
• Avoid heavy lifting: Refrain from heavy lifting, as it can strain the surgical area

Medications

• Pain management: Take prescribed pain medications as directed by your doctor. Over-the-counter pain relievers like acetaminophen may also be recommended
• Stool softeners: If necessary, use stool softeners or laxatives as recommended by your doctor to prevent constipation

Potential risks and complications

Haemorrhoidectomy is a relatively safe procedure. However, it does have some risks and complications, especially in the early days of recovery. Some of the more common risks are shown below.²

Early complications: 

• Bleeding from the incision site
• Difficulty urinating including urinary retention
• Formation of clots including thrombosis
• Sepsis
• Abscess formation

Late complications:

• Faecal incontinence
• Anal stenosis
• Recurrence or prolapse
• Skin tags
• Late haemorrhage

Contraindications for haemorrhoidectomy

Hemorrhoidectomy is generally considered safe when other treatments for haemorrhoids have failed. However, certain contraindications and considerations may affect the decision to perform a hemorrhoidectomy.

It's important to note that medical guidelines and recommendations may change, and individual cases can vary. Always consult with a healthcare professional for the most up-to-date and personalized information. Here are some contraindications and considerations for hemorrhoidectomy:²

• Presence of rectocele
• Preexisting inflammatory bowel diseases including ulcerative colitis and Crohn’s disease
• Severe anaemia and bleeding disorder
• Presence of rectal varices with portal hypertension
• Presence of faecal incontinence
• In cases of medical comorbidities prohibiting going under general anaesthesia
• In cases of pregnancy unless absolutely necessary due to potential risk to the foetus
• Patients with significant psychological and anxiety issues should be evaluated for additional consideration and counselling

FAQs

What are the best haemorrhoid removal options?

The choice of haemorrhoid removal options depends upon the severity. Generally, non-invasive procedures are recommended for grade I, II and III haemorrhoids. However, in cases of grade IV, prolapsed, thrombosed, and severe haemorrhoids surgical management is the treatment of choice. Some of the common haemorrhoid treatment types are as follows: 

• Rubber band ligation: A small rubber band is placed around the base of the haemorrhoid to cut off the blood supply
• Sclerotherapy: A chemical solution is injected into the blood vessels around the haemorrhoid to make it shrink
• Hemorrhoidectomy: Surgical removal of haemorrhoids, typically for severe cases
• Laser or infrared coagulation: Uses laser or infrared light to create scar tissue and shrink haemorrhoids
• Stapled haemorrhoidopexy (PPH): Uses staples to remove a portion of the rectum and pull haemorrhoids into their normal position
• Doppler-guided hemorrhoidal artery ligation (HAL): Uses a special instrument to tie off blood vessels supplying haemorrhoids

What is the new procedure for haemorrhoidectomy?

Hemorrhoidal Artery Ligation and Rectoanal Repair (HAL-RAR) is one of the newer procedures for the treatment of haemorrhoids. HAL-RAR involves the ligation of haemorrhoidal arteries, reducing blood flow to the haemorrhoidal cushions, and a rectoanal repair to lift and secure prolapsed haemorrhoidal tissue. It is often considered a less invasive option compared to traditional haemorrhoidectomy, with potentially reduced postoperative pain and faster recovery.

Is a stapled haemorrhoidectomy better than a haemorrhoidectomy?

The choice between stapled haemorrhoidectomy and traditional haemorrhoidectomy depends on factors such as the type and severity of haemorrhoids, the patient's overall health, and the surgeon's expertise.

Stapled may have less pain but a higher recurrence risk; traditional methods may be more effective for large haemorrhoids but have more postoperative pain and a longer recovery period. 

Which haemorrhoid surgery is less painful?

Laser haemorrhoidoplasty is a minimally invasive procedure that uses laser energy to shrink and remove haemorrhoidal tissue. It is often associated with less pain and a quicker recovery compared to traditional haemorrhoidectomy.

However, it's effectiveness and long-term outcomes may vary, and it may not be suitable for all types of haemorrhoids. 

Summary

In conclusion, a hemorrhoidectomy is a surgical option for severe cases of haemorrhoids when non-surgical methods prove ineffective. The procedure's type depends on the severity, with options ranging from closed and open techniques to newer methods like stapled haemorrhoidopexy and laser haemorrhoidoplasty. Before undergoing the procedure, thorough assessments, lifestyle adjustments, and proper pre-operative preparations are essential.

Post-operatively, dietary and lifestyle changes, along with prescribed medications aid in healing and prevent complications. While the procedure is generally safe, potential risks and contraindications exist, emphasizing the importance of individualized medical advice. Newer procedures such as HAL-RAR offer a less invasive alternative. Ultimately, the choice between surgical methods depends on factors like haemorrhoid severity, patient health, and desired recovery outcomes.