7 Hemorrhoidal surgery Dan R Metcalf and Anthony J Senagore CHALLENGING CASE A 38-year-old man presents to your office after receiving an urgent hemorrhoidectomy 1 year previously. He had continued pain and bleeding with bowel movements. He feels his anus is “too tight” and continues to be symptomatic despite attempts at dilatation, daily fiber, and stool softeners. Examination reveals three healed incisions and anal stenosis. The anus will only admit the tip of your finger with discomfort. CASE MANAGEMENT The patient has anal stenosis due to removal of an excessive amount of anoderm with his surgery. The management of refrac- tory posthemorrhoidectomy stenosis usually requires some type of flap repair. The choice of flap repair selected will depend on the degree of stenosis and the surgeon’s experience. The editors have found one or multiple house advancement flaps to be the most common option chosen in our practice. INTRODUCTION Few diseases are more chronicled in human history than sympto- matic hemorrhoidal disease.(1, 2) Citations of hemorrhoidal dis- ease have been noted in historic texts dating back to Babylonian, Egyptian, Greek, and Hebrew cultures.(1, 2) A multitude of treat- ment regimens have been offered including anal dilation, vari- ous topical liniments, and the often feared red hot poker.(3, 4) Although few people have died of hemorrhoidal disease, some patients wish they had particularly after therapy and this fact led to the beatification of St. Fiachre, the patron saint of gardeners and hemorrhoidal sufferers.(5) This chapter will guide the practi- tioner to a more humane approach to hemorrhoidal disease with the emphasis on cost-effectiveness and obtaining superior short and long-term outcomes. ANATOMY/ETIOLOGY Hemorrhoidal cushions are located within the submucosa of the upper anal canal and are a normal component of the anorectal anatomy. These cushions are composed of blood vessels, smooth muscle (Treitz’s muscle), connective tissue, and elastic tissue.(6) (Figure 17.1) Anatomically, the hemorrhoidal cushions appear with marked predictability in the right anterior, right posterior, and left lateral positions, although there may be intervening secondary hemorrhoidal complexes which obscure this classic anatomy.(6) The blood supply to the anal cushions is derived from the superior rectal artery, a branch of the inferior mesenteric; the middle rectal arteries arising from the internal iliac arteries; and the inferior rec- tal arteries arising from the pudendal arteries. The venous drainage transitions from the portal venous system above the level of the dentate line to the systemic venous system below this level.(6) Anal cushions contribute to the maintenance of anal continence and allow the anal canal to dilate during defecation without tearing. (6) Consequently, in some patients hemorrhoidectomy may result in various degrees of incontinence or leakage. Hemorrhoidal disease occurs as the result of abnormalities within the connective tissue of these cushions producing bleeding with or without prolapse of the hemorrhoidal tissue.(7) This can occur as the result of exces- sive straining, chronic constipation, or low dietary fiber.(8) A clear understanding of the pathophysiology is important when consider- ing therapeutic interventions. At the earlier stages of disease, when the major manifestation is transudation of blood through thin walled damaged vascular channels, ablation of the vessels should be adequate. In contrast, when there is significant disruption of the mucosal suspensory ligament in the late stages of the disease, a tech- nique resulting in fixation of the mucosa to the underlying muscu- lar wall is necessary for effective therapy.(9) Internal anal sphincter dysfunction may play a role, as a number of investigators have dem- onstrated increased internal anal sphincter tone in patients with hemorrhoidal disease.(10–12) In reality, a combination of all of the above factors are important for the ultimate development of large prolapsing hemorrhoids. Hemorrhoids are divided into two groups, external and internal. External hemorrhoids are located distal to the dentate line and are covered by modified squamous epithelium (anoderm). In contrast, internal hemorrhoids are covered by columnar or transitional epi- thelium and are located proximal to the dentate line. Internal hem- orrhoids are further divided into grades based on size and clinical Figure 17.1 Sagital section of anal cushion showing internal and external hemorroids. hemorrhoidal surgery symptoms. Grade I internal hemorrhoids bulge into the lumen and produce bleeding; Grade II internal hemorrhoids protrude with bowel movements and reduce spontaneously; Grade III internal hemorrhoids protrude spontaneously or with bowel movements and require manual reduction: Grade IV internal hemorrhoids are permanently prolapsed and irreducible.(13) Mixed hemorrhoids are those with components of both internal and external hemorrhoids. Although there tends to be a correlation between symptoms and the grade of hemorrhoidal disease, therapeutic decisions should not be based solely on these criteria. As will be outlined later, it is impor- tant to consider the relative role of internal hemorrhoidal tissue in addition to external hemorrhoidal skin tagging when choosing a modality for complete resolution of the patient’s symptoms.(7) CLINICAL EVALUATION Among the most common symptoms associated with hemor- rhoidal disease are bleeding, protrusion, and pain. However, Mazier reported on a series of 500 patients with anorectal com- plaints they associated with their hemorrhoids and ultimately, only 35% of patients were found to have any significant hemor- rhoidal disease at all.(14) Hemorrhoidal bleeding is characteristi- cally painless and bright red and seen on the toilet paper or in the commode after a bowel movement. However, more vigorous bleeding can occur as the hemorrhoids enlarge, particularly in advanced stages when a portion of the complex is fixed externally, allowing the blood to drip or spurt into the commode. Generally, prompt reduction of the protruding mass will alleviate this symp- tom. Acute thromboses of internal or external hemorrhoids are usually associated with a palpable mass and severe pain. These patients typically present with extreme discomfort and on clinical examination the diagnosis is frequently obvious. Examination of the patient with hematochezia should be tai- lored by the age of the patient and include sufficient investigations to rule out a proximal source of bleeding such as inflammatory bowel disease or neoplasia. Hemorrhoidal bleeding as a cause of anemia is an uncommon occurrence with an incidence of 0.5 per 100,000 per year.(15) Consequently, hemorrhoids should not be dismissed as the cause of iron deficiency anemia. The authors examine patients in the left lateral position with the knees drawn up toward the chest as high as possible. This approach allows relative patient comfort and the ability to clearly inspect the perianal skin, perform anoscopy, and proctosig- moidoscopy. A careful digital examination of the anal canal and distal rectum should be performed with the addition of prostate examination in male patients. Examination with an anoscope is essential to adequately inspect the hemorrhoidal tissue and anal canal. Inspection of the three common locations for hemorrhoids should be performed with documentation of the size, friability, and ease of prolapse. Documentation of anal pathology should be described by anatomic position (anterior, posterior, etc.,) to avoid confusion regarding the position in which the patient was examined. Upon completion of this portion of the exam, a deci- sion should be made regarding the need for more proximal evalu- ation of the colon and rectum. However, rigid proctoscopy should be the minimum in all patients. After appropriately grading the hemorrhoidal disease, discussion can ensue with the patient regarding the various treatment options. NONEXCISIONAL OPTIONS The majority of patients with hematochezia attributable to hem- orrhoids can be managed conservatively without surgical inter- vention. Dietary and lifestyle modification, reduction of straining with defacation, sclerotherapy, infrared coagulation, and rubber band ligation are described in chapter 18. These options are considered before considering excisional options. EXCISIONAL HEMORRHOIDECTOMY Approximately 5–10% of patients will require surgical manage- ment of their hemorrhoids.(16) Excisional hemorrhoidectomy should be considered in those patients with extensive sympto- matic disease who have failed or are not candidates for medical and nonexcisional options. In addition to this, the customary indications for hemorrhoidectomy include frequent or per- sistent prolapse requiring manual reduction resulting in dis- comfort and anal seepage, and hemorrhoids associated with conditions such as fissure, fistula, ulceration, or extensive anal skin tags. The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids. It is apparent however that similar full excisional hemorrhoidectomy can be per- formed using standard closed hemorrhoidectomy techniques without undue complications. Specifically, the risk of steno- sis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites. In the case of limited external hemor- rhoidal thromboses, surgical excision may also be warranted for more rapid pain relief and avoidance of a residual skin tag. (17–20) Limited external thromboses can be easily managed in the office setting with local anesthesia and complete excision with or without skin closure.(Figure 17.2) Options for excisional hemorrhoidectomy include the follow- ing techniques: Milligan-Morgan hemorrhoidectomy; Ferguson Closed hemorrhoidectomy; Whitehead hemorrhoidectomy; sta- pled hemorrhoidectomy; and variations of the Milligan-Morgan and Ferguson techniques using alternative energy devices. The use of lasers for excisional hemorrhoidectomy offers no advantage and in fact causes delayed healing, increased pain, and increased cost.(21) The procedures are usually performed in the operating room after minimal preoperative bowel preparation. The choice of anesthetic is typically left to the anesthesiologist and patient, however local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective and short act- ing. The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention do to a higher intraop- erative administration of intravenous fluids. The Milligan-Morgan hemorrhoidectomy (Figure 17.3), which is widely practiced in Europe, was originally described in 1937 and its efficacy has subsequently been documented in many series.(22–24) This technique involves resection of the internal and external hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.(22) The distal ano- derm and external skin are left open to heal by secondary inten- tion to minimize the risk of infection. This technique has been proven to be a safe and effective means for managing advanced hemorrhoidal disease.(22) However, the open wounds typically 7 improved outcomes in colon and rectal surgery take 4–8 weeks to heal and can be a cause of considerable discom- fort and prolonged morbidity after this procedure. The closed Ferguson hemorrhoidectomy (Figure 17.4) was proposed as an alternative to the Milligan-Morgan technique and enjoys a similar large body of evidence regarding its safety and efficacy.(17–20) This technique utilizes an hourglass-shaped excision of the entire internal and external hemorrhoidal com- plex (centered at the midportion of the anoderm), preservation of the internal and external anal sphincters, and primary closure of the entire wound. Occasionally, it is necessary to undermine flaps of anoderm and perianal skin to allow excision of inter- mediate hemorrhoidal tissue, while preserving the bridges of anoderm between pedicles. This technical adjustment will avoid postoperative strictures. The Whitehead hemorrhoidectomy (Figure 17.5), described in 1882, involves a circular incision at the level of the dentate line with subsequent circumferential excision of the hemorrhoidal tissue and relocation of the dentate line which is often a com- ponent of prolapsing hemorrhoids.(25) Although this technique had a long period of widespread use in the United Kingdom, it was subsequently largely abandoned because of the high rates of mucosal ectropion and anal stricture.(26–29) However, using a modification of the original technique it has enjoyed renewed support by some surgeons in the United States with minimal stricture rates and no occurrences of mucosal ectropion.(30–31) Despite these promising reports, the Whitehead procedure is technically demanding because of the need to accurately identify the dentate line and relocate it to its proper location. Stapled hemorrhoidopexy is a relatively novel technique with growing acceptance as an alternative to excisional hemor- rhoidectomy for the treatment of grade III and grade IV hemor- rhoids. The technique, as described in 1998 by Antonio Longo (32), involves circumferential excision of the mucosa and submucosa above the hemorrhoids using a circular stapler resulting in reloca- tion and fixation of the internal hemorrhoids. Briefly, a circular anoscope is inserted into the anal canal to reduce the prolapsing tissue and allow placement of a circumferential purse-string suture 4 cm proximal to the dentate line into the mucosa and submucosa. A 33 mm hemorrhoidal circular stapler (EthiconEndo-Surgery; PPH03) with the anvil fully extended is then advanced proximal to the purse-string which is then gently tightened around the shaft of the stapler. The free ends of the suture are then threaded through the lateral channels of the stapler housing to provide traction on the purse-string as the stapler is closed and advanced into the anal canal. Once in position the stapler is closed and fired. The staple line should be inspected for hemostasis and bleeding controlled with an absorbable suture.(Figure 17.6) Numerous randomized controlled trials comparing stapled hemorrhoidopexy to conven- tional hemorrhoidectomy have substantiated the benefits of sta- pled hemorrhoidectomy, namely reduced operating room time, less pain and analgesic use, and earlier return to work with similar symptom control.(33–36) In a prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and closed hemorrhoidectomy Senagore et al. reported less pain, less pain at first bowel movement, less analgesic use and similar symptom con- trol using stapled hemorrhoidopexy in which 88% of patients were treated as outpatients.(36) As demonstrated in a recent systematic review of 25 randomized, controlled trials comparing stapled hem- orrhoidopexy to conventional hemorrhoidectomy, stapled hem- orrhoidopexy is a safe and effective procedure for the treatment symptomatic hemorrhoids with superior short-term outcomes. (37) This review indicates that the incidence of recurrent hem- orrhoids is significantly higher at one or more years after stapled hemorrhoidopexy (5.7% vs. 1%), however, the overall recurrence or persistence of hemorrhoidal symptoms was similar between the groups (SH vs. conventional: 25.3% vs. 18.7%, p = 0.07).(37) In a retrospective review of 291 patients submitted to stapled hemor- rhoidopexy with grade III and grade IV hemorrhoids, the overall recurrence rate after a minimum follow-up of 5 years was 18.2%. (38) They showed a tendency for higher recurrence in grade IV Figure 17.2 Excision of thrombosed external hemorrhoid. 7 hemorrhoidal surgery Figure 17.3 Open (Milligan-Morgan) hemorrhoidectomy. (A) External hemorrhoids grasped with forceps and retracted outward. (B) Internal hemorrhoids grasped with forceps and retracted outward with external hemorrhoids. (C) External skin and hemorrhoid excised with scissors. (D) Suture placed through proximal internal hemorrhoid and vascular bundle. (E) Ligature tied. (F) Tissue distal to ligature is excised. Insert depicts completed three bundle hemorrhoidectomy. (A) (B) (C) (D) (E) (F) Figure 17.4 Modified Ferguson excisional hemorrhoidectomy. (A) Double ellipitical incision made in mucosa and anoderm around hemorrhoidal bundle with a scalpel. (B) The hemorrhoid dissection is carefully continued cephalad by dissecting the sphincter away from the hemorrhoid. (C) After dissection of the hemorrhoid to its pedicle, it is either clamped, secured, or excised. The pedicle is suture ligated. (D) The wound is closed with a running stitch. Excessive traction on the suture is avoided to prevent forming dog ears or displacing the anoderm caudally. (A) (B) (C) (D) 7 improved outcomes in colon and rectal surgery Figure 17.5 Whitehead hemorrhoidectomy. (A) Suture placed through proximal internal hemorrhoid for orientation. Excision started at dentate line and continued to proximal bundle. (B) Internal hemorrhoidal tissue excised above ligated bundle. (C) Vascular tissue excised from underside of elevated anoderm. (D) End of anoderm reaproximated with sutures to original location of dentate line. (E) Completed procedure. (A) (B) (C) (D) (E) hemorrhoids with a significantly higher reoperation rate.(38) In some instances this was thought to be related to inappropriate patient selection. In a large series reported by Jongen et al. stapled hemorrhoidopexy with good patient selection was associated with a low rate (3.4%) of reoperation for persistent or recurrent hemor- rhoidal prolapse.(39) The data clearly indicate that stapled hemorrhoidopexy is a safe and effective option to treat symptomatic hemorrhoids with superior short-term outcomes. Although a higher rate of late recurrence is reported with this technique in the current literature, an appropriately designed randomized trial with adequate power and longer follow-up is needed to ultimately define the durability of stapled hemorrhoidopexy. Patient selection for stapled hemor- rhoidopexy may also play an important role in short and long term outcome analysis. Improper technique with PPH has led to significant complica- tions. Placement of the purse-string suture too high (cranial) or too deep has led to a full thickness excision and occasional anas- tomotic leaks with subsequent sepsis and some deaths. Placement of the purse-string suture too low may lead to impaired conti- nence (inclusion of sphincter muscle in staples) or pain. Chronic pain following PPH may respond to anti-inflammatory agents or time. Some success in refractory patients has been obtained with removal of residual staples (usually done under anesthesia) or injection of long duration steroids. In the quest to provide patients with the benefit of less post- operative pain, alternative devices such as the Harmonic Scalpel® and LigaSure™ have recently been used to perform excisional hemorrhoidectomy. There have been four randomized, controlled trials published in an attempt to assess the efficacy of Harmonic Scalpel® hemorrhoidectomy.(40–43) Although all studies indicate that the harmonic scalpel is an effective alternative with a simi- lar complication profile to more conventional methods, there is inconsistency regarding the short term benefits such as postop- erative pain across these studies. Multiple randomized, controlled trials evaluating LigaSure™ hemorrhoidectomy to conventional techniques have been performed; (44–50) Most of these stud- ies demonstrate a reduction in postoperative pain and operating time when using the LigaSure™. A multicenter, prospective, ran- domized study by Altomare et al. showed significantly less pain 12 hours after defacation, lower analgesic requirements, and faster return to work and normal activity with no difference in early or late complications.(48) Both instruments have been shown to be a safe and effective alternative to conventional hemorrhoidectomy. However, the added cost, conflicting short term outcomes, and lack of long term follow-up prelude recommendations for their routine use. At the present time, conventional methods of exci- sional hemorrhoidectomy remain the “gold standard”. POSTOPERATIVE COMPLICATIONS Regardless of the excisional technique used for treatment of advanced hemorrhoidal disease, the key to effective patient management is avoidance of postoperative complications. Pain The anoderm has a rich supply of sensory nerves and pain arises from involvement of the anoderm below the dentate line. Posthemorrhoidectomy pain is associated with reflex spasm of the urethral and anal sphincter muscles. Spasm of these muscles leads to difficulty voiding and urinary retention and difficulty with evac- uation and constipation. Both of which are covered later. From the patient’s perspective, pain is the most feared element of the pro- cedure. A variety of analgesic regimens have been recommended, usually consisting of a combination of oral and parenteral nar- cotics.(51–55) Local anesthetic agents such as 0.5% bupivacaine solution may provide analgesia for up to 6–8 hours after surgery. The use of ketorolac has demonstrated considerable efficacy in managing posthemorrhoidectomy pain.(51) Alternative adminis- tration routes for narcotics either by patch or subcutaneous pump have been successful in controlling pain, however due to the risk of narcotic respiratory depression, administration by these routes can be risky in the outpatient setting.(53–55) The most appropri- ate regimen following outpatient hemorrhoidectomy appears to be intraoperative use of ketorolac, sufficient doses of oral narcotic analgesics for home administration, and supplementation of the narcotics by an oral nonsteroidal medication. Urinary Retention Urinary retention is a frequent postoperative complication follow- ing hemorrhoidectomy with an incidence from 1–52%.(16, 56–58) 7 hemorrhoidal surgery A variety of strategies have been used to treat this problem includ- ing parasympathomimetics, alpha-adrenergic blocking agents, and sitz baths.(59, 60) However, prevention seems to be the best strategy by limiting perioperative fluid administration to 250 ml, avoiding the use of spinal anesthesia and anal packing, and prescribing an aggressive oral analgesic regimen.(56) Elderly men with obstructive uropathy are at increased risk for urinary retention. If catheteriza- tion becomes necessary, intermittent catherization under sterile conditions is the option of choice. Urologic consultation may be sought for patients with persistent symptoms of bladder outflow obstruction. Hemorrhage Early postoperative bleeding (<24 hours) occurs in approxi- mately 1% of cases and represents a technical error requir- ing return to the operating room for repair of the offending wound.(61) Occasionally bleeding may continue undetected, with blood accumulating in the capacious rectum. The first Figure 17.6 Stapled anoplasty (procedure for prolapse and hemorrhoids [PPH]). (A) Retracting anoscope and dilator inserted. (B) Monofilament pursestring suture (eight bites) placed using operating anoscope approximately 3–4 cm above anal verge. (C) Stapler inserted through pursestring. Pursestring suture tied and ends of suture manipulated through stapler. (D) Retracting on suture pulls anorectal mucosa into stapler. (E) Stapler closed and fired. (F) Completed procedure. (a) (d) (b) (e) (c) (f) 7 improved outcomes in colon and rectal surgery sign of this complication may be pallor, tachycardia, and hypo- tension. This patient requires fluid resuscitation and a return to the operating room for suture ligation or diathermy control of the bleeding site. Bleeding from the staple line when using a PPH can be con- trolled by oversewing the bleeding point of the staple line. This is less common with the second generation 33 mm hemorrhoidal circular stapler (Ethicon endosurgery; PPH03) which has a shorter stapler height. Delayed hemorrhage occurs in 0.5–4% of cases of excisional hemorrhoidectomy and often occurs at 5–10 days postoperatively. (62–64) The etiology has been held to be early separation of the ligated pedicle before adequate thrombosis in the feeding artery can occur.(65) Hemorrhage in this situation is frequently significant and requires some method for control of ongoing hemorrhage. Options include return to the operating room for suture ligation, or tampon- ade at the beside by Foley catheter or anal packing.(66–68) The out- come after control of secondary hemorrhage is generally good with virtually no risk of recurrent bleeding. It may be helpful to irrigate out the distal colon and rectum at the time of intraoperative control of hemorrhage to avoid confusion in the postoperative period. Constipation and Fecal Impaction Fecal impaction is a distressing complication of excisional hemo- rrhoidectomies. Postoperative pain, the patient’s fear of pain associated with defecation, and the constipating effects of nar- cotics are contributing factors. Hence, providing adequate anal- gesia and patient reassurance are important. Patients should be instructed on the importance of adequate hydration. Many sur- geons also recommend bulking agents and/or laxatives (e.g., pol- yethylene glycol solution), and topical anesthetics before a bowel movement to facilitate evacuation.(69) When fecal impaction is identified, early, simple irrigating enemas may help clear the anorectum of impacted feces. If the impactions are soft, an oral cleansing regime (17 gm of polyethelyene glycol solution in 4 oz of water every 15–20 minutes until the impaction is cleared) may be utilized.(70) In more severe cases, manual disimpaction under conscious sedation or general anesthesia may be necessary. Infection Infection of the urinary tract may result from either stasis of urine or instrumentation of the urinary tract. A 3% incidence has been reported from one institution following hemorrhoidal surgery. (16) A urine culture should be obtained before administration of appropriate antibiotics. The anoderm harbors an abundance of potentially pathologic bacterial microorganisms. Despite this, infective complications after hemorrhoidectomy are infrequent. Bacteremia and sepsis have been documented after hemorrhoidectomy, but abscess formation is rare unless a hematoma becomes infected. Isolated liver abscesses have been reported, and this very rare complica- tion should be considered in patients with postoperative fever. It is usually currently identified by abdominal CT scan. Another potential infectious complication is postoperative pel- vic sepsis. This can occur after any anorectal procedure includ- ing rubber band ligation and excisional hemorrhoidectomy. Classic findings include anorectal pain, fever, and difficulty with urination. A high index of suspicion is required as delay in diagnosis can have fatal consequences. As described in chapter 18, patients with suspected pelvic sepsis require resuscitation, diagnostic evaluations (pelvic CT scans and/or anoscopic evalu- ation), and treatment (broad spectrum antibiotics and debride- ment of necrotic tissue). Anal Stenosis Anal stenosis results from excessive stripping of anal mucosa, which may leave inadequate bridges of anoderm for healing to occur without stenosis.(71) Secondary hemorrhoids should be managed with either submucosal hemorrhoidectomy or conserv- ative methods such as sclerotherapy or rubber band ligation at a subsequent visit. In mild cases, stenosis may simply be a web that disappears with graduated anal dilatation in the office. In more severe cases, surgical intervention may be required to relive ste- nosis. Surgical correction may be accomplished by one of several reconstructive operations including skin and subcutaneous tissue flaps. These flap techniques are discussed in chapter 20. Mucosal Ectropion (Whitehead Deformity) Mucosal ectropion with the classic “Whitehead deformity” is commonly seen after an incorrectly performed procedure described by Whitehead.(22) As described previously, the oper- ation entails making a circumferential incision at the level of the dentate line, elevating a flap of anal mucosa, and performing a submucosal hemorrhoidal excision. Redundant mucosa is then excised, and the anal canal is reconstructed with sutures. If the reconstruction does not relocate the dentate line in the correct location in the anal canal, anal mucosal will be located in the distal anal canal or perineum. Persistent mucous discharge and perianal irritation may result. Correction requires resection of the mislocated anal mucosa and reconstruction, which usually requires flaps. Fecal Incontinence Incontinence of feces results chiefly from damage to the internal anal sphincter during hemorrhoidectomy.(72) The internal anal sphincter is a thin, whitish, smooth muscle composed of circular fibers located just beneath the anal mucosa. It is almost always absent at the anal verge because its inferior limit is a few milli- meters proximal to it. During surgery, the hemorrhoidal column should be lifted off the internal anal sphincter, which must be identified before excision of hemorrhoidal tissue. It is important to document the state of continence in patients before surgery. Soiling and fecal leakage are the chief impairments of continence resulting from internal anal sphincter damage. Treatment for soil- ing and leakage includes bulking agents and slowing agents (e.g., loperamide) and consideration of biofeedback therapy. Attempts to surgically repair damaged internal sphincter muscle have been disappointing. Anal Fistula Fistula in ano is an uncommon complication of hemorrhoidec- tomy and is thought to occur more commonly after a closed pro- cedure.(73) The fistula is usually a simple submucosal tract that may be treated by simple unroofing. 7 hemorrhoidal surgery Anal Tags Anal skin tags after hemorrhoidal excision are not uncommon. Usually these tags are edematous areas of anoderm that generally resolve spontaneously some weeks after surgery. Reassurance will help allay patient’s concerns. It the tags remain bothersome or are associated with symptomatic pruritis, they can be excised in the office using local anesthesia. SPECIAL SITUATIONS Postpartum Hemorrhoids Postpartum hemorrhoids that are refractory to conservative measures may require surgical management. Hemorrhoidectomy in this setting is safe, has a low prevalence of complications, and in many cases will minimize recovery time. Proper patient posi- tion (usually left lateral Sims) and good anesthetic techniques are important. As in other urgent hemorrhoidectomies, preservation of as much anoderm as possible is also critical. Anorectal Varices Unlike hemorrhoids, varices result from portal venous hyperten- sion. Differentiation from hemorrhoids is essential because exci- sion of varices may result in venous bleeding that may be difficult to control. A history of anal bleeding in a cirrhotic patient should arouse suspicion. Varices may be present in the rectum, anal canal, or anal verge.(74) Duplex Doppler ultrasonography of the anorec- tum may confirm the diagnosis. Active bleeding from varices will usually require oversewing with a continuous suture technique. CONCLUSION The management of symptomatic hemorrhoidal disease should be directed at the symptom complex of the patient. The major- ity of these patients can be effectively treated by reducing strain at defacation, correcting constipation, the use of any of a variety of anal ointments. For those patients with persistent symptoms, either injection or banding of the internal hemorrhoids offers predictably successful results. Only a minority of patients should require excisional hemorrhoidectomy by any of the described techniques. Stapled hemorrhoidopexy, Harmonic Scalpel®, and LigaSure™ all offer safe and effective alternatives to the tradi- tional open or closed excisional hemorrhoidectomy, however more long-term data is needed to provide recommendations for their routine use. REFERENCES 1. Holley CJ. History of hemorrhoidal surgery. South Med J 1946; 39: 536. 2. Madoff RD. Biblical management of anorectal disease. Presented at the Midwest Society of Colon and Rectal Surgeons’ meeting. Brechenridge, CO; 1991. 3. Dirckx JH. The Biblical plague of “hemorrhoids”. Am J Dermatopathol 1985; 7: 341–6. 4. Maimonides M, Rosner F, Munter S. trans. Treatise on Hemorrhoids. Philadelphia, JB Lippincott; 1969. 5. Rachochot JE, Petourand CH, Riovoire JO. 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