Hemorrhoidectomy

Question 1

What is the blood supply to the proximal rectum?

Answer 1

Superior hemorrhoidal (or superior rectal) from the IMA

Question 2

What is the blood supply to the middle rectum?

Answer 2

Middle hemorrhoidal (or middle rectal) from the hypogastric (internal iliac)

Question 3

What is the blood supply to the distal rectum?

Answer 3

Inferior hemorrhoidal (or inferior rectal) from the pudendal artery (branch of the hypogastric)

Question 4

What is the venous drainage of the proximal rectum?

Answer 4

IMV -> splenic vein -> portal vein

Question 5

What is the venous drainage of the middle rectum?

Answer 5

Iliac vein -> IVC

Question 6

What is the venous drainage of the distal rectum?

Answer 6

Iliac vein -> IVC

Question 7

What are hemorrhoids?

Answer 7

Engorgement of the venous plexuses of the rectum, anus, or both; with protrusion of the mucosa, anal margin, or both

Question 8

Why do we have “healthy” hemorrhoidal tissue?

Answer 8

It is thought to be involved with fluid/air continence

Question 9

What are the signs/symptoms of hemorrhoids?

Answer 9

Anal mass/prolapse
Bleeding
Itching
Pain

Question 10

Why type of hemorrhoid is painful?

Answer 10

External (below the dentate line)

Question 11

If a patient has excruciating anal pain and history of hemorrhoids, what is the likely diagnosis?

Answer 11

Thrombosed external hemorrhoid

Question 12

What are the causes of hemorrhoids?

Answer 12

Constipation/straining
Portal HTN
Pregnancy

Question 13

What is an internal hemorrhoid?

Answer 13

Hemorrhoid above the proximal dentate line

Question 14

What is an external hemorrhoid?

Answer 14

Hemorrhoid below the dentate line

Question 15

What are the 3 “hemorrhoid quadrants” (constant positions of hemorrhoids)?

Answer 15

Left lateral
Right posterior
Right anterior

Question 16

Define first-degree internal hemorrhoid.

Answer 16

Hemorrhoid that does not prolapse

Question 17

Define second-degree internal hemorrhoid.

Answer 17

Proapses with efecation but returns on its own

Question 18

Define third-degree internal hemorrhoid.

Answer 18

Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction

Question 19

Define fourth-degree internal hemorrhoid.

Answer 19

Prolapsed hemorrhoid that cannot be reduced

Question 20

Treatment options for hemorrhoids?

Answer 20

1. First-degree asymptomatic: bulking agents, avoid constipation, increase water intake, anal hygiene
2. First-degree symptomatic: as above + rubber-band ligation and/or infrared coagulation
3. Second-degree: conservative as above or rubber-band ligation
4. Third-degree: selected cases -> rubber-band ligation, mixed -> surgical hemorrhoidectomy
5. Fourth-degree: surgical hemorrhoidectomy
6. External: self-limited, resolves progressively over 7-10 days (creams, suppositories, topical adjuncts); if seen early (24-48 hours) -> excision of thrombosed hemorrhoid under local anesthesia. Ulceration of the overlying skin with bleeding is an indication for excision. Sitz baths and a mild non-narcotic analgesic are recommendd.

Question 21

What is a closed hemorrhoidectomy?

Answer 21

Closed (Ferguson) “closes” the mucosa with sutures after hemorrhoid tissue removal

Question 22

What is an open hemorrhoidectomy?

Answer 22

Open (Milligan-Morgan) leaves mucosa “open”

Question 23

What are the dreaded complications of hemorrhoidectomy?

Answer 23

Exsanguination (bleeding may pool proximally in lumen of colon without any signs of external bleeding)
Pelvic infection (may be extensive and potentially fatal)
Incontinence (injury to sphincter complex)
Anal stricture

Question 24

What condition is a contraindication for hemorrhoidectomy?

Answer 24

Crohn’s disease

Question 25

What must be ruled out with lower GI bleeding believed to be caused by hemorrhoids?

Answer 25

Colon cancer (colonoscopy)