SURGICAL PROCEDURE

Name of Procedure: HEMORRHOIDECTOMY

Description: Hemorrhoidectomy refers to the removal of the hemorrhoidal tissues,

including the enlarged veins within. Hemorrhoids may be treated with con- comitant anal
conditions, such as fissure (anal ulcer) and fistula. Numerous modalities are employed for
internal hemorrhoids and associated rectal mucosal prolapse (latex band ligation, sclerosing
injections, laser, cryother- apy, and others), most often performed as an office procedure
without anesthetic (not to include external hemorrhoidal tissue). A circular intraluminal
stapler, as used for intestinal anastomosis, can be employed for rectal mucosal prolapse
performed as a formal transanal surgical procedure.

The types of hemorrhoidectomy procedures include:

 Excisional hemorrhoidectomy removes the hemorrhoidal tissue by cutting it.

Your surgeon may choose to leave the tissue wound open (open excisional
hemorrhoidectomy) or close it with stitches (closed excisional hemorrhoidectomy).
Most surgeons prefer the closed technique.
 Stapled hemorrhoidopexy removes only a portion of the hemorrhoidal tissues.
The remaining hemorrhoidal tissues are lifted back up into the anal canal and
stapled into place with a special stapling device. This procedure tends to cause
less postoperative pain and has a shorter recovery period. It is not effective for
large external hemorrhoids, and hemorrhoids tend to recur more often.

Purpose/s:
To relieve the symptoms associated with hemorrhoids that have not responded to
more conservative treatments.

Preparations:
1. Medications (Preoperative, Intraoperative, Postoperative)
 Pre-operative- Lactulose, Antibiotic Prophylaxis, Magnesium Citrate
 Intra-operative- Enema
 Post-operative –Anaglesia, antibiotics (metronidazole), bulk laxatives,stool softener

2. Sutures (Sutures must be written from internal to external layer)

SUTURES LAYERS NEEDLES
2.0 Vicryl Suture External Hemorrhoid 1 ¼ inch needle
Plexus
Transfixation suture Hemorrhoidal Venous
Cushions/ Hemorhhoidal
Plexus
Hemorrhoid Pedicle
Vascular Pedicle
4.0 Vicryl Suture Mucocutaneous junction
Mucosa
 Submucosa

3. Instruments and paraphernalia

INSTRUMENTS PARAPHERNALIA
Retractors Volkman Retractor 4 Prongs Sharp

Anascopes, Speculum, and Probes Hirschman Anascopes Large,

Hirschman Anascopes Medium,
Hirschman Anascopes Small, Sims
Straight Speculum Fenestrated Blades
With Set Screw 6", Pratt Crypt Hooks
Narrow 8 1/2", Pratt Straight Probe 11",

Forceps Haemostatic Forceps, Allis Tissue

Forceps 4x5 Teeth 6", Foerster Sponge
Forceps Straight 9 1/2" Serrated Jaws,
Halstead Mosquito Forceps Straight 5",
Thumb Tissue Forceps 1x2 Teeth 5 1/2
"
Dressing Forceps 5 1/2" Serrated,
Yeoman Biopsy Forceps 4x8mm Bite
Complete Ring Handle 14", Allis Tissue
Forceps 5x6 Teeth 7 1/2", Pennington
Tissue Grasping Forceps 5 1/4",
Rochester Pean Forceps Curved 6
1/4", Crile Rankin Hemostatic Forceps
Straight 6 1/4", Dressing Forceps 6"
Serrated,

cautery, laser, or cold instruments Electrocautery (Cuatery Pencil),Laser

Knife, Blades Scalpel, Knife Handle No 3, No. 15 or
No. 10 scalpel blade and blade handle

Other Surgical Accessories Gloves, Stirrups or pillow and roll for

positioning, ESU, Buie Suction Tube
With Finger Valve 15 Fr, Backhaus
Towel Clamp, Minor Basin Set,
Lubricants,
Surgical scissors Blunt nosed scissors, Metzenbaum
Scissors Curved 5 1/2" - Tungsten
Carbide, Operating Scissors Sharp
Blunt Straight 5 1/2", Mayo Scissors
 Tungsten Carbide Curved 6 3/4", Mayo
Scissors Tungsten Carbide Straight 6
3/4", Mayo Scissors Tungsten Carbide
Curved 5 1/2"

Wound closure instruments Allis clamps,clips and clamps, needles,

needle holder, circular stapling device,
surgical adhesives, 4x4 gauze,
Infection Control Products PPE, Sterilization trays, disinfectants,
autoclaves, dry sterilizers

Medicated bandage
Anesthesia (types and agents used)
 General anesthesia is a combination of intravenous (IV) medications and gases
that put you in a deep sleep. You are unaware of the procedure and will not feel
any pain. You may also receive a peripheral nerve block infusion in addition to
general anesthesia. A peripheral nerve block infusion is an injection or continuous
drip of liquid anesthetic. The anesthetic flows through a tiny tube inserted near your
surgical site to control pain during and after surgery.
 Regional anesthesia is also known as a nerve block. It involves injecting an
anesthetic around certain nerves to numb a large area of the body. You will likely
have sedation with regional anesthesia to keep you relaxed and comfortable.

Position during Surgery:

 Prone Jackknife. Folded towels and a laparotomy sheet. Tapes are attached to
table sides.
 Lithotomy. Drape sheet under buttocks, leggings, folded towels, drape sheet over
abdomen. Tapes are attached to stirrups.
 Modified Lateral/Sims. Folded towels and a laparotomy sheet. Tapes are attached
to table sides.

Preoperative Nursing Goal and Interventions

Preoperative Care
a. Psychological Care

 Teach your patient to do the following:

o Think positively
o Practice relaxation exercises
 Perform deep-breathing exercises
 Use visualization and imaging techniques
o Learn about managing pain after surgery
o Share questions and concerns with doctor

b. Health Instructions
  Stick to healthy foods. Your body needs good nutrition to fight infection and heal
following surgery. This is NOT a time for dieting.
 Avoid dehydration. Drink at least six 8-ounce glasses of fluid per day, preferably
water.
 Practice the post-operative exercises your doctor recommends. The patient will need
to do them during and after your hospital stay.

c. Physical preparation
c.1. Diet
 Let the patient eat and drink healthily, such as eating fruit, vegetables and protein.
But if lost weight or are underweight, have regular high energy/protein snacks. If the
patient is a smoker and/or drinks alcohol above the recommended guidelines (14
units a week), try to cut down and stop if possible.
 Eat a light breakfast and lunch. Avoid greasy foods and red meat.
 Increase patient’s fiber intake

c.2. GIT preparation

 Patients should not eat or drink anything for 8-12 hours before the surgery. This
includes chewing gum. Fasting is necessary before surgery to ensure that the bowel
prep is not ruined and helps prevent aspiration, nausea, and vomiting.
 For their last meal before fasting, instruct patients to go easy and not eat a large
meal. Instead, have them eat a light meal of soup or salad, which is quicker for the
body to digest. If they have been instructed to take their prescription medication
before surgery, they may take it with a small sip of water. If a patient is taking
prescription medication, have them bring them with them to the hospital. That way, if
they were ordered not to take them before the surgery, they may do so afterwards.
 Empty patient colon with enema or laxatives

c.3. Skin preparation (Illustration)

c.4. Fluid administration

 Drink only clear liquids (no pulp, no dairy) after lunch.
 Do not let the patient drink anything the last 4 hours before surgery.
Nursing Diagnosis/es:
 Pain (acute or chronic) related to rectal swelling and prolapse
 Constipation related to ignore the urge to defecate during defecation
 Anxiety related to plan surgery

Intraoperative Period Activities and Care (Steps of the Procedure):

Steps Rationale
The patient is placed in the jackknife prone, Proper positioning allows the surgeon
lithotomy, or left lateral decubitus position. accessibility to the surgical site as well as
The perianal skin is visualized by having an for anesthetic administration
assistant separate the buttocks or by taping
the buttocks apart. The anal canal can be
visualized using an Ive's anoscope coated
with 2 percent lidocaine jelly. The extent of
the hemorrhoidal disease should be
assessed and coexisting anal pathology
excluded before initiating the procedure.
Alternately, anoscopy can be performed
after anesthetic administration (injection)
when the thrombosed hemorrhoids are
exquisitely tender
The perianal skin and anal canal are Skin prep aids in preventing surgical site
cleansed with povidone-iodine solution. The infection by removing debris from, and
base of the hemorrhoid is infiltrated with at cleansing the skin, bringing the resident
least 5 mL of 1 percent lidocaine, using a and transient microbes to an irreducible
25-gauge, 1¼-inch needle. minimum, and hindering the growth of
microbes during surgical procedure.
Lidocaine helps in reducing pain or
Avoid making multiple needle sticks in the discomfort caused by the
anal tissues. hemorrohoidectomy.

The puncture sites can bleed after needle

removal. Warn the patient about impending
needle insertion into the tender tissues.

A fusiform (elliptic) excision is made into the Vigorous bleeding may accompany this
anal skin overlying the thrombosis. It is incision and can be controlled with direct
preferable to make a radial incision pressure or electrocautery if needed.
extending out from the anal canal if the
entire hemorrhoid plexus is removed; some
physicians prefer a circumferential incision
that exposes more clots by crossing over
more of the hemorrhoidal sinusoids
beneath.
A clamp can be placed on the fusiform skin The clamp can help to reveal the
 island and traction applied to the skin. The hemorrhoid below.
entire hemorrhoid is sharply excised with a The anal sphincter is a ring of muscle that
no. 15 blade or scissors. The entire opens and closes at the bottom of your
hemorrhoidal plexus usually can be anus and plays a large role in controlling
removed as one piece attached to the bowel function. When the muscle is cut or
fusiform skin island. Avoid cutting into the is damaged or weakened it can cause
muscle sphincter below the hemorrhoidal incontinence—accidental loss of stool.
vessels.

Once the hemorrhoidal plexus and clot The residual blood clot impedes blood flow.
have been removed, the base of the wound
is examined for residual small clots. Wound closure can reduce bleeding and
Additional hemorrhoidal tissue or clots can discomfort at the surgical site. Alternatively,
be sharply excised. Some physicians chose some physicians prefer to leave the wound
to close the deep wound with open.
subcutaneous, absorbable, buried 4-0 Vicryl
sutures to avoid significant postprocedure The suture ends are not buried in the skin
bleeding. The sutures should be completely but exposed outside, which can increase
subcutaneous and not penetrate external to the risk of contamination.
the anal skin.
The wound should be inspected for Hemostasis is important to the success of the
adequate hemostasis. If epinephrine is procedure, as well as to patient outcomes.
used to anesthetize the wound and the
wound is unsutured, late bleeding (up to The role of topical antibiotics is to reduce
several hours postprocedure) can develop the microbial contaminant exposure
once the effect of the epinephrine wears off. following the surgical procedure. 
Topical antibiotic ointment is applied to the
surgical site, and 1inch of 4 × 4 gauze is
applied over the site between the buttocks.
The patient can be given additional gauze
for use at home.

Special Consideration/s:
Chances of problems may be higher for:
 Patient with Myocardial Infarction within recent 6 months

Nursing Responsibilities:
Before the Procedure/Examination:
 Assess patient for the presence of hemorrhoids, discomfort or pain
associated with hemorrhoids, diet, fluid intake, and presence of constipation.
 Instruct patient and/or family regarding causes of hemorrhoids, methods of
avoiding hemorrhoids, and treatments that can be performed.
 Instruct patient and/or family regarding all procedures required.
  Instruct patient and/or family in comfort measures to use with the presence of
hemorrhoids.

During the Procedure/Examination:

 Note for the time the surgery and the general anaesthesia started.
 Ensure the IV fluids given to the patient.

After the Procedure/Examination:

 Monitor the patient closely in the recovery room.

 IV fluid should be monitored if working well and enough fluids.
 Give medications as indicated.
 Provide warm sitz bath as appropriate
 Cleanse rectal area with mild soap and water or wipes after each stool and provide
skin care.
 Encourage patient to move around to prevent breathing and circulation problems

Postoperative Nursing Assessment

1. Immediate Postoperative (Postanesthetic Period)

a. Nursing Assessment
 Assess air exchange status and note patient’s skin color
 Verify patient identity. The nurse must also know the type of operative procedure
performed and the name of the surgeon responsible for the operation.
 Monitor the patient upon waking up, the patient may feel pain or upset stomach.
 Give medications as prescribed.
 Check for the IV fluids if it is working well and have enough fluids.
 Encouraged to do deep breathing and circulation exercises.

b. Nursing Diagnosis
 Impaired Urinary Elimination related to the fear of postoperative pain
 Deficient knowledge related to the lack of information about home care
 Impaired Urinary Elimination related to the fear of postoperative pain
 Risk for infection related to inadequate primary defenses

c. Goal of Care and Nursing Responsibilities

Pain is Relieved or Controlled
 Encourage patient to report pain
 Encourage patient to assume position of comfort
 Review factors that aggravate or alleviate pain
 Provide comfort measures
 Provide warm sitz bath as appropriate
To accurately verbalize understanding of causes of hemorrhoids, methods of preventing the
worsening of hemorrhoids, and comfort measures to employ.

 Teach the importance of a high-fiber diet (20-35 grams/day) and a fluid intake of at
least 2-3 L/day (unless this is contraindicated by a renal, hepatic, or cardiac
disorder).
 Instruct patient and/or family regarding causes of hemorrhoids, methods of avoiding
hemorrhoids, and treatments that can be performed.
 Instruct patient and/or family regarding all procedures required.
 Instruct patient and/or family in comfort measures to use with the presence of
hemorrhoids

To help the patient to establish and maintain normal bowel habits

 Encourage daily fluid intake of 2000 to 3000 ml per day, if not contraindicated
medically (Suggest drinking warm, stimulating fluids (tea, hot water) to promote soft
stool).
 Encourage increased fibre in diet (raw fruits, fresh vegetables) to improve
consistency of stool and facilitate passage; a minimum of 20 gm of natural dietary
fibre per day is recommended.
 Encourage patient to consume prunes, prune juice, cold cereal, and bean products.
 Encourage physical activity and regular exercise.

Maintenance of Circulation
 Obtain patient’s vital signs as ordered and report any abnormalities.
 Monitor intake and output closely.
 Recognize early symptoms of shock or hemorrhage such as cold extremities,
decreased urine output – less than 30 ml/hr, slow capillary refill – greater than 3
seconds, dropping blood pressure, narrowing pulse pressure, tachycardia – increased
heart rate.

2. Immediate Postoperative Care

a. Nursing Responsibilities
 Maintaining adequate body system functions
 Restoring body homeostasis.
 Pain and discomfort alleviation.
 Preventing postoperative complications.
 Promoting adequate discharge planning and health teaching.

References and Suggested Readings:

Agbo SP. Surgical management of hemorrhoids. J Surg Tech Case Rep. 2011;3(2):68-75.
doi:10.4103/2006-8808.92797

Goldman, M. A. (2020). Pocket guide to the operating room. Philadelphia, PA: F.A. Davis
Company.
Goto, S., Hida, K., Furukawa, T. A., & Sakai, Y. (2016). Subcuticular sutures for skin closure
in non‐obstetric surgery. The Cochrane Database of Systematic Reviews, 2016(3),
CD012124. https://doi.org/10.1002/14651858.CD012124

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Lewis, S. (2020, November 01). Your complete guide to hemorrhoid removal. Retrieved April
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