Internal Hemorrhoids Treatment in Dibrugarh, Procedure And Aftercare

Stapled hemorrhoidectomy is a surgical procedure used for treating internal hemorrhoids that have protruded out of the anus and are visible to the human eye (grade 3 and 4  hemorrhoids). Hemorrhoids are abnormally enlarged and inflamed veins present within the rectum (the last part of the large intestine, present close to the anus) or just outside the anus (an opening of the rectum to the outside of the body). These abnormal lumps of tissues develop as a result of increased pressure in the veins within the rectal and anal region. They can occur due to:

• Chronic (long-lasting) strained bowel movements
• Pregnancy
• Obesity
• Lifting heavy weights
• Consuming a low-fiber diet
• Chronic diarrhea or constipation

Conservative methods like medications, lifestyle modifications, Sitz baths, etc. can treat hemorrhoids. When these treatments fail, surgical interventions, like stapled hemorrhoidectomy, are required to treat internal hemorrhoids (hemorrhoids inside the rectum). To understand the procedure better, let us explore this advanced surgical method in detail. 

Stapled hemorrhoidectomy, also known as stapled haemorrhoidopexy or Procedure for Prolapse and Hemorrhoid (PPH), is a minimally invasive (involves less trauma and bleeding with quick recovery) procedure for the removal of internal hemorrhoids. However, it is a misnomer since the surgery does not involve removing hemorrhoids. Instead, the abnormally loose and expanded surrounding tissue is removed (which had allowed hemorrhoids to prolapse or protrude outside the anus). A special stapler-like device is used to suture the expanded hemorrhoidal tissues after the normal vascular structure is pushed back into its original position. Thus, the blood supply to the hemorrhoid tissues is cut off, reducing their size.

Hemorrhoids are classified into 4 grades according to their severity, which includes:

• Grade I- Internal hemorrhoids that bleed but do not protrude (prolapse) outside the anus.
• Grade II- Hemorrhoids that bleed and protrude outside the anus but return spontaneously.
• Grade III- Hemorrhoids that protrude through the anus but must be manually pushed inside.
• Grade IV- Severe and extremely painful hemorrhoids that protrude outside the anus but cannot be pushed inside.

Grade I and II hemorrhoids can be easily treated at home through dietary changes and medications; severe grade III and IV internal hemorrhoids require surgical treatment. Stapled hemorrhoidectomy is recommended in such cases to remove prolapsed hemorrhoids effectively. It is also indicated when minor hemorrhoids do not respond to conservative treatments.

Open and closed hemorrhoidectomy was the standard surgical procedure initially; however, due to an increased incidence of post-operative pain and complications, stapled hemorrhoidectomy is recommended as an alternative procedure to conventional surgical methods.

You need to consult a proctologist who specializes in diagnosing and treating diseases associated with the colon, rectum, and anus.

• Your doctor will record a detailed medical history to determine the severity of your symptoms (duration of pain, amount of bleeding during bowel movements).
• A digital examination will be conducted to evaluate the presence of hemorrhoid, its size, and its location. Your doctor will insert a gloved and lubricated finger inside your anus to evaluate the presence of any abnormal lump.
• A visual examination of your rectum or lower part of the large intestine will be conducted through an anoscope, proctoscope, or sigmoidoscope. These tube-like instruments with a small light source at the tip help determine hemorrhoid's exact location. 
• It is important to bring to your surgeon's notice that you are suffering from any medical condition like diabetes (increased blood sugar levels), asthma, heart or kidney disorders, thyroid disease, or any blood disorders.
• Inform the surgeon about the medications you have been taking and if you need to stop them. You are most likely asked to discontinue medications like blood thinners, anti-inflammatory drugs, and other herbal or vitamin supplements 2 weeks before the procedure.
• Smoking must be discontinued at least 1 to 2 weeks before the procedure since it may delay wound healing. 
• 2 to 3 days before the procedure, you will need to undergo routine blood and urine tests, chest X-ray, and ECG (Electrocardiogram) to evaluate your overall health.
• You will be scheduled for an appointment with the anesthesiologist to determine the type of anesthesia required. 
• If the surgery is performed under general anesthesia, you will be advised to fast overnight before the procedure.
• A mild enema will be given to wash out your stomach and intestines to facilitate a better view during the procedure.

You need to arrive 2 to 3 hours before your scheduled time of surgery, where a nurse will monitor your vitals, like blood pressure, blood sugar levels, heart rate, pulse, and oxygen level.

• You will be shifted to the operating theatre and made to lie down in a lithotomy position (a position where you lie flat on the table and bend your knees at 90 degrees and lift them to or a little above the level of your hips).
• You will be administered local, spinal, or general anesthesia as your anesthesiologist decides.
• A urinary catheter (a tube with a bag for urination) will be placed, and the surgical area will be disinfected.
• Your surgeon will manually dilate (expand) the anal canal and place a hollow tube.
• A suture will be positioned and inserted through this tube, woven inside the anal canal above the existing internal hemorrhoid.
• The suture ends can be seen from the anus through the hollow tube.
• A stapler (non-reusable instrument with a stapling device) is positioned on the hollow tube with the suture ends hanging out. The ends will be pulled through the hollow tube.
• Pulling the suture ends eventually pulls the extended, loose hemorrhoid-supporting tissues to the jaws of the stapler.
• The blood vessels are retracted (pushed) to their normal position inside the anal canal.
• The stapler is then fired, and while doing so, it reduces the circumference of the extended hemorrhoid tissues trapped inside the stapler, thereby closing the abnormal opening and sealing the area.
• Your surgeon may place a surgical pack for healing and managing any post-surgical discharge.
• The procedure takes around 30 to 45 minutes.

Post-procedure, you will be kept under observation in a recovery room until the effect of the anesthesia wears off. 

• Once you are stabilized, you will be shifted to your room, where you may need to stay for 1 to 2 days.
• The urinary catheter will be removed on the 2nd-day post-surgery.
• You will be given bland, semi-solid, and easily digestible food to prevent constipation.
• It is normal to experience some post-operative pain and discomfort, which can be easily managed with the help of painkillers.
• You will be prescribed antibiotics and painkillers for at least 3 to 5 days post-procedure. 
• You will be prescribed a laxative syrup for 15 days to prevent constipation.  
• Recovery may take around 2 weeks. 

Although stapled hemorrhoidectomy is an alternative choice of hemorrhoid treatment owing to minimal post-op pain and quick recovery, there are a few early and late complications associated with the procedure.

• Early complications
  
  • Failure of the stapling gun- May be caused due to staplers being displaced.
  • Urosepsis- Sepsis caused by severe urinary tract infections, bladder, and kidneys.
  • Rectal perforation- A hole caused due to injury to the bowel mucosa.
  • Fournier gangrene- It is a necrotizing (flesh-eating disease) that affects the penis, scrotum, or perineum.
  • Pneumomediastinum- A condition where the air is present between the mediastinum ( a space in your chest that holds your heart).
  • Submucosal hematoma- A form of swelling caused due to blood clot formation.
  • Early fecal urgency- When you cannot hold feces in the rectum (fecal incontinence). This leads to fecal leakage.
     
• Late complications
  
  • Recurrence of hemorrhoids
  • Persistent bleeding during bowel movements
  • Anal stenosis- An abnormal narrowing of the anus.
  • Pruritus - Irritation of the anal skin with severe itching.
  • Anal fissures- A small tear in the lining of the anus.
  • Proctitis- It is an inflammation of the lining of the rectum.
     

Stapled hemorrhoidectomy is an effective alternative to traditional surgical methods with greater benefits than the associated risks.

Benefits

• No external incisions (cuts) or scarring involved
• Minimal post-operative pain
• Shorter hospital stay
• Shorter recovery period
• Early return to work and other activities
• Does not require extensive post-op care of the surgical wound

Risks

• Recurrence of hemorrhoids as early as 2 weeks post-op
• Severe post-op pain and bleeding from the surgical site
• Fetal incontinence- Also known as fecal leakage
• Anal stenosis- Narrowing of the anus

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