HEMORRHOIDS
Hemorrhoids (piles) are not confined to the so called developped world. Plenty of patients complain of more or less severe problems with this condition. There is no place for luxury surgery of minor tags or internal hemorrhoids – the standing order is that only hemorrhoids the size of a fist should be referred to the surgeon.
The main indication for surgery is large prolapsed and/or thrombosed hemorrhoids. The procedure of choice is the classical Milligan’s with isolation, high ligation and excision of the hemorrhoids. To delay surgery with conservative treatment such as sit baths, antibiotics, hemorrhoid ointments etc. is a waste of time and money. Immediate surgery for prolapsed and inflamed hemorrhoids is surprisingly easy technically, and does not cause any unwanted side effects or complications.
The only instruments I use are one artery forceps to grasp the hemorrhoid, a pair of scissors for dissection and a needle holder to suture-ligate the hemorrhoid. The secret is to dissect mainly bluntly with only a snip of the scissors now and then until the external sphincter is clearly seen and totally separated from the mucosal peduncle. To avoid causing a postoperative stricture it is crucial to leave a bridge of skin and mucosa in between the three excisional wounds.
Prolapsed hemorrhoid in the classical 3 o’clock, 7 o’clock and 12 o’clock positions
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Starting with the 3 o’clock positioned hemorrhoid, isolate, ligate and excise it.
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Then the hemorrhoid at 7 o’clock position is treated the same way
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Finally the remaining 12 o’clock positioned hemorrhoid is dealt with
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The wounds are left open.
Remember: “When it looks like a clover – the trouble is over”
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In case a ligature slips, it can cause a lot of bleeding which often is confined in the rectum and doesn’t reveille itself externally until the patient has lost a lot of blood and shows signs of shock. Therefore I always leave a gauze pack in the anus as a sort of drainage which will lead eventual bleeding to the exterior - a telltale for the staff.
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