Do I need surgery and what will it be like?

For the most severe cases (usually grades 3-4 with frequent/severe symptoms) GPs are able to refer patients to a specialist NHS service, where they will be assessed and, if appropriate, added to the waiting list for surgery on their haemorrhoids.

There are a few different surgical methods commonly used, each with its own benefits and risks. The most commonly performed surgery is that of haemorrhoidectomy where the piles are surgically removed. Alternatives to this include PPH (Procedure for Prolapsing Haemorrhoids, also known as stapling) and haemorrhoidal artery ligation (sometimes called THD or HALO). Read more about the surgical options available.

Haemorrhoid surgery in the UK is an expanding field with increasing diversity. If other treatments haven’t worked or your haemorrhoids are not suitable for non-surgical procedures, then surgery for haemorrhoids may be an option. There are a number of procedures available, but the main ones are set out below.

What is Haemorrhoid Surgery?

In short, these treatments involve the assistance of a surgeon, usually to physically remove the offending haemorrhoid(s). Haemorrhoid surgery is almost always done under anaesthesia. Surgical procedures are likely to remove most haemorrhoids. Balanced against this is the potential discomfort and invasive nature of such treatments.

How Long Does Hemorrhoid Surgery Take?

This varies depending on the type of haemorrhoid surgery which you choose to undertake. Other questions such as “how long does it take to recover from haemorrhoid surgery?” and “what should I expect after haemorrhoid surgery” fall into this same boat. The type of surgery which you undergo as well as the type and size (or grade) of your piles both have a bearing on the answer. Read on to learn more.

What Are the Risks of Any Haemorrhoid Surgery?

The risk of any serious problems is small, but complications are not unheard of. These can include:

• Bleeding or passing of blood clots after the operation leading to either delayed discharge or readmission following discharge, depending on the timing of the bleed
• Unsatisfactory pain control
• Post-operative nausea and vomiting
• Infections that can lead to an abscess – usually treated with antibiotics or, in some cases, further surgery.
• Difficulty in emptying your bladder (urinary retention)
• Involuntary passing of gas or stools (gas or faecal incontinence)
• A small anal fistula – a channel that develops between the anal canal and the skin near the anus.

There are other risks as well, including strictures, the need for a colostomy, etc. (some particular ones associated with stapling are mentioned below.)

All of the above are treatable but we’d advise talking to your surgeon who will be able to explain the risks in more detail.

Haemorrhoidectomy

What Is Involved With the Operation?

A haemorrhoidectomy is carried out under a general (or spinal) anaesthetic. The operation involves opening the anus so that the haemorrhoids can be cut out. The operation is usually carried out under general anaesthetic and you will need to take at least a week or two off work to recover. There are variations on the actual technique used in terms of the cutting instruments employed for haemorrhoid surgery, and afterwards in either closing the resultant wounds using stitches or leaving the wounds open to heal naturally.

After the operation

Patients will experience variable amounts of pain during the initial haemorrhoid surgery recovery period, but your medical team should supply you with strong pain killers to help this. After the haemorrhoid surgery, you may be in some level of discomfort for a few weeks, but this residual pain can usually be controlled with milder over the counter pain killers.

Transanal Doppler-Guided Haemorrhoidal Artery Ligation

What Is Involved With the Operation?

This haemorrhoid surgery is designed to reduce the blood flow to your haemorrhoid(s). It is usually carried out under a general (or spinal) anaesthetic and involves a small ultrasound probe being inserted into your anus, which creates high frequency sound waves allowing the surgeon to locate any blood vessels that are supplying blood to the haemorrhoid so that they can be targeted. Once the blood vessels feeding into the haemorrhoid are located, a needle and surgical thread is used to stitch them closed, to cut off the blood supply to the haemorrhoid, causing it to shrink. Other haemorrhoids present are similarly targeted.

After the operation

The National Institute of Health and Care Excellence (NICE) recommends this procedure as an alternative to haemorrhoidectomy or stapled haemorrhoidopexy as it causes less pain and recovery time is improved. There is a low risk of bleeding when passing stools and of the haemorrhoid prolapsing. A systemic review of this treatment revealed pain relief being needed in 0-38% of patients, bleeding postoperatively in 5% and an overall reintervention rate of 6.4%.

Stapling – Haemorrhoidopexy

What Is Involved With the Operation?

This procedure is carried out under a general (or spinal) anaesthetic to treat prolapsing or prolapsed haemorrhoids. The treatment itself involves removing a section of the large intestine and stapling the ends back together. This results in the haemorrhoids being less likely to prolapse. It also reduces the supply of blood to the haemorrhoid, causing it to shrink.

After the operation

It has a shorter recovery time than a conventional haemorrhoidectomy and on average you can return to work after a week. It also tends to be a less painful experience.

But, it is reported that more people experience another prolapsed haemorrhoid after this operation compared to alternative surgical haemorrhoid procedures. Other complications include severe pain, and an increased risk of a stricture (a tightening of the anal canal) developing, as well as bleeding, skin tags, haemorrhoidal thrombosis, faecal urgency, gas and faecal incontinence.

In addition to the various complications listed above, rare but potentially life-threatening complications have also been described, including anovaginal fistula (a connection between the anal canal and the vagina), anastomotic leakage with associated pelvic sepsis (the stapling line leaking bowel contents into the pelvis leading to infection), and Fournier’s gangrene (tissue death in the groin and perianal area).

For any haemorrhoid questions or to organise an appointment with an eXroid consultant, please call us on 0800 999 3777 or click here for all other queries.

Sources:

• Pucher PH, Sodergren MH, Lord AC, Darzi A, Ziprin P. Clinical outcome following Doppler-guided haemorrhpoidal artery ligation: a systemic review. Colorectal Dis 2013 Jun; 15(6): e284-294.

• Liu H, Yang C, Chen B, Wu J, He H. Clinical outcomes of Doppler-guided haemorrhoidal artery ligation: a meta-analysis. Int J Clin Exp Med 2015; 8(4): 4932-4939.

• Figueiredo MN, Campos FG. Doppler-guided hemorrhoidal dearterialization/transanal hemorrhoidal dearterialization: Technical evolution and outcomes after 20 years. World J Gastrointest Surg 2016 Mar 27; 8(3): 232-7.

• Watson AJM, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A, Norrie J, Bruhn H, Cook JA, and the eTHoS study group. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet 2016 Nov 12; 388(10058): 2357-2385.

• Yang J, Cui PJ Han HZ, Tong DN. Meta-analysis of stapled hemorrhoidopexy vs Ligasure hemorrhoidectomy. World J Gastroenterol 2013 Aug 7; 19(29): 4799-807.

• Yeo D, Tan K-Y. Hemorrhoidectomy – making sense of the surgical options. World J Gastroenterol 2014 Dec 7; 20(45): 16976-16983.