This document discusses various procedures for treating hemorrhoids, including Barron's banding, open and closed hemorrhoidectomy, stapled hemorrhoidectomy, and transanal hemorrhoidal dearterialization (THD). Barron's banding is used for first and second degree hemorrhoids as an office procedure under local anesthesia. Open hemorrhoidectomy involves making a V-cut to dissect and remove third degree hemorrhoids, while closed hemorrhoidectomy uses an elliptical incision and ligation. Stapled hemorrhoidectomy uses a circular stapler to remove hemorrhoidal tissue. THD involves identifying and ligating the hemorrhoidal arteries through the anus to reduce blood

1. HEMORRHOIDECTOMY
DR.B.Selvaraj MS; Mch; FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
OPERATIVE SURGERY

2. HEMORRHOIDECTOMY
Barron’s Banding
Hemorrhoidectomy
- Open- Milligan & Morgan
- Closed- Ferguson
Stapled Hemorrhoidectomy
- PPH- Procedure for Prolapsed Hemorrhoids
US Guided Hemorrhoidal Arterial Ligation
- THD- Transanal Hemorrhoidal Dearterialisation

3. BARRON’S BANDING
• INDICATIONS:
- 1st & 2nd degree
hemorrhoids
• ANESTHESIA:
- No need/Concious sedation
- Daycare office procedure
• POSITION:
- Sim’s – Left lateral
- Lithotomy

4. BARRON’S BANDING
• Preparing the applicator and loading it • Applying the band to base of internal
hemorrhoid

5. SPACE BANDER- Conmed
• Preparing the bander and deploying it • Applying the band to base of internal
hemorrhoid

6. OPEN HEMORRHOIDECTOMY
• INDICATIONS:
- 3rd degree hemorrhoids
- Hemorrhoids with other anal
pathology like fissure or fistula
• ANESTHESIA:
- GA/Spinal
- Epidural/Local
• POSITION:
- Prone Jackknife
- Lithotomy
• Informed consent- risks of surgery:
- Injury to anal sphincter / incontinence 1%
- Rebleeding 1%
- Anal stenosis1%
• Pre-op preparation:
- Colonoscopy to exclude proximal colon pathology
- Enema on the evening before and on the day of
surgery

7. OPEN HEMORRHOIDECTOMY
• Position and exposure
- Prone jackknife
-Lithotmy
- Triangle of exposure
• Making a v cut in the skin
- Make V cut with blunt nosed scissors
- Dissect off the hemorrhoidal vascular cushion
off the sphincter muscles

8. OPEN HEMORRHOIDECTOMY
• Ligate the vascular pedicle & excise
- Transfix all 3 vascular pedicles with 2-O
vicryl
• Final look with enough skin bridge
- ‘If it looks like a clover the trouble is over, if it
looks like a dahlia, it is surely a failure.’

9. CLOSED HEMORRHOIDECTOMY
• Clamp hemorrhoidal cushion &
Elliptical incision
• Ligate,excise vascular pedicle & Close
mucosal defect- Use of Ligasure

10. CLOSED HEMORRHOIDECTOMY
• COMPLICATIONS
 Excise no more than three hemorrhoids at one
operative setting. Removal of excessive anal
tissue may lead to stricture.
Ensure in cases of rectal bleeding that other
sources of gastrointestinal bleeding, such as
colon cancer and diverticular disease, are
excluded before the hemorrhoidectomy.
Bleeding if severe and persistent need to be
controlled in OT
Anal incontinence if you injure the sphincter
during the dissection of haemorrhoids
Hepatic cirrhosis and other bleeding disorders
should be thoroughly corrected, or the planned
procedure should be aborted.
• POST-OP CARE
 Daily Sitz bath after each bowel movement
 Digital Rectal Exam at discharge and after one
week to prevent adhesions between raw areas
 Anal pack- surgeon’s preference. I keep non
adherent sponge to tamponade for few hours
 Local application of Lignocaine jelly
 Oral analgesic tablets as needed
 Mild oral laxatives for 2 to 3 weeks post-op
 Patients can be mobilised immediately
 Time off work- 1 week

11. STAPLED HEMORRHOIDECTOMY
• The equipment • Anal dilatation & fixing anal dilator

12. STAPLED HEMORRHOIDECTOMY
• Application of Purse-string suture • Introduction of Stapler into Anal canal

13. STAPLED HEMORRHOIDECTOMY
• Taking the suture through the slots • Firing the Gun & mucosal doughnut

14. THD- Transanal Hemorrhoidal Dearterialisation
• The Equipment • Various steps of the procedure

15. THD- Transanal Hemorrhoidal Dearterialisation
• Introducing the gadget & identifying
hemorrhoidal artery
• Ligating the artery & suturing mucosa