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Benign Anorectal: Hemorrhoids

  • Reference work entry
The ASCRS Textbook of Colon and Rectal Surgery

Abstract

Hemorrhoids are cushions of specialized, highly vascular tissue found within the anal canal in the submucosal space. The term “hemorrhoidal disease” should be reserved for those vascular cushions that are abnormal and cause symptoms in patients. These cushions of thickened submucosa contain blood vessels, elastic tissue, connective tissue, and smooth muscle.1 The anal submucosal smooth muscle (Treitz’s muscle) originates from the conjoined longitudinal muscle (see Figure 11-1). These smooth muscle fibers then pass through the internal sphincter and anchor themselves into the submucosa, thereby contributing to the bulk of the hemorrhoids and suspending the vascular cushions at the same time.2 Some of the vascular structures within the cushion when examined microscopically lack a muscular wall. The lack of a muscular wall characterizes these vascular structures more as sinusoids and not veins. Studies have shown that hemorrhoidal bleeding is arterial and not venous because hemorrhage from disrupted hemorrhoids occurs from presinusoidal arterioles that communicate with the sinusoids in this region. This is supported by the bright red appearance and the arterial pH of the blood. The venous plexus and sinusoids below the dentate line which constitute the external hemorrhoidal plexus drain primarily via the inferior rectal veins into the pudendal veins which are branches of the internal iliac veins. Venous drainage also occurs to a lesser extent via the middle rectal veins to the internal iliac veins. This overlying tissue is somatically innervated and is therefore sensitive to touch, pain, stretch, and temperature. The subepithelial vessels and sinuses above the dentate line which constitute the internal hemorrhoid plexus are drained by way of the middle rectal veins to the internal iliacs.

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Authors
  1. José R. Cintron
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  2. Herand Abcarian
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Editor information

Editors and Affiliations

  1. Professor of Surgery, Mayo Clinic College of Medicine, Chairman, Division of Colon and Rectal Surgery, Mayo Clinic Foundation, Rochester, MN, USA

    Bruce G. Wolff MD, FASCRS (Senior Editors) (Senior Editors)

  2. Professor of Surgery, Chief, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, MO, USA

    James W. Fleshman MD, FASCRS (Senior Editors) (Senior Editors)

  3. Chairman, Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA

    David E. Beck MD, FASCRS (Senior Editors) (Senior Editors)

  4. Professor of Surgery, Mayo Clinic College of Medicine, Consultant, Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, USA

    John H. Pemberton MD, FASCRS (Senior Editors) (Senior Editors)

  5. Chief of Staff, Cleveland Clinic Florida, Weston, FL, USA

    Steven D. Wexner MD, FASCRS (Senior Editors) (Senior Editors)

  6. Victor W. Fazio Chair of Colorectal Surgery, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA

    James M. Church BSc, MBChB, MMed Sci, FASCRS (Associate Editors) (Associate Editors)

  7. Professor of Surgery, Chief, Section of Colon and Rectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA

    Julio Garcia-Aguilar MD, PhD, FASCRS (Associate Editors) (Associate Editors)

  8. Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA, USA

    Patricia L. Roberts MD, FASCRS (Associate Editors) (Associate Editors)

  9. Professor of Surgery, Head, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, IL, USA

    Theodore J. Saclarides MD, FASCRS (Associate Editors) (Associate Editors)

  10. Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA

    Michael J. Stamos MD, FASCRS (Associate Editors) (Associate Editors)

Appendices

Appendix: Practice Parameters for Ambulatory Anorectal Surgery

Prepared by The Standards Task Force, The American Society of Colon and Rectal Surgeons

Drs. Ronald Place and Neal Hyman, Project Coordinators; Clifford Simmang, Committee Chairman; Peter Cataldo; James Church; Jeff Cohen; Frederick Denstman; John Kilkenny; Juan Nogueras; Charles Orsay; Daniel Otchy; Jan Rakinic; Joe Tjandra

Ambulatory Facilities

Anorectal Surgery May Be Safely and Cost‐Effectively Performed in an Ambulatory Surgery Center.

Level of Evidence—Class III (Appendix A). It has been estimated that 90% of anorectal cases may be suitable for ambulatory surgery. A wide variety of anorectal conditions including condylomata, fissures, abscesses, fistulas, tumors, hemorrhoids, pilonidal disease, and various miscellaneous conditions have been shown to be amenable to surgery on an outpatient basis. An admission rate of 2% has been reported. A reduction in hospital charges of 25%–50% has also been noted.

Patients with American Society of Anesthesiology (ASA) Classifications I and II Are Generally Considered Suitable Candidates for Outpatient Anorectal Surgery (Appendix B). Selected ASA Category III Patients May Also Be Appropriate Candidates.

Level of Evidence—Class III. Multiple factors must be considered in determining the appropriateness of performing anorectal surgery in the ambulatory setting. The ASA physical status classification is useful to determine the risk of anesthesia. The magnitude of the proposed surgery, type of anesthesia, availability of appropriate instrumentation, ability of the patient to follow instructions, distance of the patient's home from the surgical center, and home support structure all need to be considered.

Preoperative Evaluation

Preoperative Investigations (e.g., Laboratory Studies and Electrocardiograms) Should Be Dictated by History and Physical Examination.

Level of Evidence—Class III. Multiple studies have documented that patient history and physical examination are the key elements of an appropriate preoperative evaluation. Routine preoperative investigations that are not warranted on the basis of history and physical seem to provide little further information. There is clear evidence that nonselective preoperative screening yields few abnormal results.

One study of 1200 patients undergoing ambulatory surgery revealed that the vast majority of abnormalities could have been predicted by history and physical examination. These abnormalities did not predict perioperative complications or the need for hospital admission. A separate study of 1109 patients undergoing elective surgery revealed that 47% of laboratory investigations duplicated tests performed within the previous year. Meaningful changes in the repeat laboratory values were very rare. Such abnormalities were predictable by the patient's history. A further study of 5003 preoperative screening tests revealed 225 abnormal results. Only 104 were of potential importance and the abnormality caused action in only 17 cases. It was believed that only four patients could have had a conceivable benefit from their preoperative screening test.

Similar studies have been performed to investigate the value of specific tests. A study of 12,338 patients undergoing invasive procedures was performed to examine the value of determining activated partial thromboplastin time as a routine. Ninety‐two percent of the patients were believed to be at low risk (there were no clinical factors to suggest the bleeding tendency). In these patients, it was shown that no information was gained from activated partial thromboplastin time, and therefore, clotting studies had no role as a screening test in asymptomatic patients. Similarly, routine cardiac workup seems unjustified. The risk of a perioperative myocardial infarction in patients without clinical evidence of heart disease is 0.15%. This risk increases significantly in patients who had a previous myocardial infarction. History and physical examination are the cornerstones of appropriate preoperative evaluation.

Intraoperative Considerations

Most Anorectal Surgery May Be Safely and Cost‐Effectively Performed Under Local Anesthesia; Regional or General Anesthesia May Be Used Depending on Patient or Physician Preference.

Level of Evidence—III. The use of local anesthetics such as monitored anesthetic care for anorectal surgery is safer and has fewer complications than other anesthetic techniques. Perianal infiltration of local anesthetics is a simple procedure that is easily learned. Injection of the local anesthetics can be accomplished in less than 5 minutes and the operation begun immediately. However, the anesthetic technique used for any procedure should be the one that provides for maximal safety and efficacy.

Postoperative Considerations

Anorectal Surgery Patients May Safely Be Discharged from the Postanesthesia Care Unit.

Level of Evidence—II. The time course for recovery from anesthesia includes early recovery, intermediate recovery, and late recovery. Early recovery is the time interval for anesthesia emergence and recovery of protective reflexes and motor activity. The Aldrete score has been used for 30 years to determine release from phase 1 (early) recovery to a hospital bed or phase 2 (intermediate) recovery. Intermediate recovery is the period during which coordination and physiology normalize to an extent that the patient can be discharged from phase 2 recovery in a state of “home readiness” and be able to return home in the care of a responsible adult. The Post‐Anesthetic Discharge Scoring System has been shown to be efficacious for discharge.

Multiple Modalities May Be Used to Achieve Adequate Postoperative Pain Control.

Level of Evidence—II. If local anesthetics are not used as the primary anesthetic technique, their use will provide prolonged postoperative analgesia. Oral narcotics may be used as primary postoperative analgesia. The use of nonsteroidal antiinflammatory drugs, particularly intramuscular or intravenous Toradol® (Roche Pharmaceuticals, Nutley, NJ) or sulindac suppositories has also shown improved analgesia, lower narcotic usage, and lower rates of urinary retention. Although the effect is unknown, oral metronidazole shows improved postoperative pain control.

Postoperative Urinary Retention Can Be Reduced by Limiting Perioperative Fluid Intake.

Level of Evidence—III. Multiple studies have shown that limiting perioperative fluid lowers the incidence of postoperative urinary retention. These same studies show conflicting evidence over the relationship between gender, age, and the quantity of narcotic medication and urinary retention. Hemorrhoidectomy and the performance of multiple anorectal procedures have higher rates of urinary retention.

Postoperative Education Should Include Recommendations for Sitz Baths, Fluid Intake, and Activity Limitations.

Level of Evidence—III. Textbooks of anorectal surgery advocate consistent instructions before discharge from ambulatory surgery. Although derived from common sense, scientific justification does not exist. With appropriate communication, ambulatory anorectal surgery may be performed with a high degree of patient satisfaction.

Table 11‐A1. Levels of evidence
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Table 11‐A2. ASA physical status classification
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Cintron, J.R., Abcarian, H. (2007). Benign Anorectal: Hemorrhoids. In: Wolff, B.G., et al. The ASCRS Textbook of Colon and Rectal Surgery. Springer, New York, NY. https://doi.org/10.1007/978-0-387-36374-5_11

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