Total hemorrhoidectomy is the complete surgical removal of the hemorrhoid-bearing rectal mucosa. In effect, in this procedure, a circumference of the rectum is excised away. This procedure is rarely used, and should only be reserved for those who suffer from circumferential prolapsing mixed hemorrhoids.

History

It is interesting to note that the total hemorrhoidectomy dates back to the late 1800’s. It was a surgical technique introduced by Walter Whitehead (hence it's also known as the Whitehead Hemorrhoidectomy). Although Dr. Whitehead had successfully performed over 300 operations using this technique, fears of hemorrhage, anal stenosis or narrowing of the anal canal caused other doctors to shun the treatment. By early 1900s, total hemorrhoidectomy has fallen out of favor and almost disappeared as a treatment option.

Contraindications

Those who should not get the total hemorrhoidectomy are:

• Those with minimal hemorrhoids.
• Those who have large scars in the area due to previous operations or some type of disease
• Those who have a tight and thin anoderm (lining of the anal canal)
• Those who suffer from chronic diarrhea.
• Those who suffer from inability to control their bowel movement and have anal incontinence.
• Patients with strangulated hemorrhoids.

What to expect before the surgery:

• Sigmoidoscopy examination is performed.
  
  
• Those patients over the age of 45 will likely have to receive a colonoscopy or x-ray of their colon. This is to make sure that the bleeding the patient may be experiencing is not due to some other factor.
  
  
• A patient’s history will be taken and discussed. It will be important to determine if the patient suffers from chronic diarrhea and whether the patient has some sort of bowel disease.
  
  
• Two enemas will be needed prior to the surgery. Laxatives and antibiotics, however, will not likely be administered prior to the operation.

The Surgical Procedure

How the surgery will proceed:

• The patient will likely be placed under general anesthesia. In some instances women have been known to receive the procedure under IV sedation and with local anesthesia.
  
  
• The patient is placed in the jackknife position. Normally pillows are placed under the hips and ankles. This position helps encourage the bleeding to flow away from the area that the doctor needs to be able see. The butt cheeks are separated with adhesive tape.
  
  
• Local anesthetic is used. For postoperative relaxation a combination of bupivacaine and adrenaline can be used. Once the local anesthesia relaxes the sphincter muscle a retractor or speculum is inserted and the anal canal is thoroughly examined.
  
  
• Incisions are made by curved double operating scissors, starting along the dentate line and continue along this path around a third or one-half of the anal canal. If the dentate line is difficult to see (because of trauma to the region or a severe prolapse) the incision will be made in the rectal mucosa. Clamps are used to lift the cut edge of the hemorrhoid-bearing rectal mucosa and mucosal prolapse. The hemmorhoidal mass is then cut out. Skin tags from other thrombosed hemorrhoids can also be removed at this time. The procedure is completed around the remaining circumference (hence the "total" in total hemorrhoidectomy).
  
  
• The incisions are then sutured. Here, A retractor is used to stretch the internal sphincter, so the suture goes through the anoderm to the neodentate line. A piece of gel-foam is placed in the rectum and gauze is taped at the anal opening.

Post-Operative Care

What to expect after the operation:

• The patient can expect to remain in the hospital for 1 or 2 days.
• First ice packs are placed in the area, but after about 12 hours warm packs will be substituted.
• The patient’s fluid intake will be limited in the beginning. Once the person is able to go the bathroom fluid and food will likely be allowed.
• Pain medication will likely be first administered by IV and later will be switched to something oral.

When you get home:

• Sitz bath will be recommended. This is both for cleanliness and pain reduction.
• A bulking agent will be given to maintain the diameter if the anal canal.
• The patient must avoid things that could cause diarrhea. Laxatives and mineral oil therefore are not allowed. Medications that prevent diarrhea may be given.
• If bowel movement hasn't occured by the third day, a mild laxative, such as Milk of Magnesia, may be prescribed.
• The patient will be examined by the physician 3 weeks after the surgery. The examination often entails the physician inserting his finger into the rectum to check on health of the area.

Complications

Summary

Total hemorrhoidectomy has largely been replaced as a surgical technique by open and closed hemorrhoidectomies. However, in rare instances of circumferential prolapsing hemorrhoids, this maybe the only viable treatment.

Nevertheless, because of the risks involved in cutting such a large portion of rectal tissue, total hemorrhoidectomy should only be performed by surgeons who have had ample experience and familiarity with the technique.