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Hemorrhoidal disease is a common occurrence requiring surgical intervention in approximately 10% of cases. The prevalence is unknown because asymptomatic patients are less likely to seek medical help. Some sources estimate the incidence rate of 4.4% for symptomatic patients in the US The age range for most patients experiencing symptomatic hemorrhoidal disease is typically between those from 45 to 65 years. Surgical hemorrhoidectomy is necessary for large third- and fourth-degree hemorrhoids when medical management has failed, when a significant external component is present, or when incarcerated internal hemorrhoids need immediate medical treatment. This activity reviews the evaluation and treatment of hemorrhoidal disease and highlights the role of the interprofessional team in evaluating and treating this condition. Participants in this course explore various aspects of hemorrhoidal disease, including its epidemiology, clinical presentation, and surgical indications. Emphasis is placed on evidence-based practices and guidelines for optimizing patient outcomes. By participating in this course, members of the interprofessional team, including physicians, nurses, and other healthcare professionals, enhance their competence in managing hemorrhoidal disease collaboratively. Through interdisciplinary discussions and case-based learning, team members can improve communication, coordination, and decision-making skills, leading to more effective patient care. Objectives: Apply evidence-based surgical techniques for performing a hemorrhoidectomy, considering risk factors and expected outcomes. Select the equipment, personnel, preparation, and technique for a hemorrhoidectomy. Identify the potential complications of a hemorrhoidectomy. Implement interprofessional team strategies for hemorrhoidectomies to improve patient outcomes. Access free multiple choice questions on this topic.

Hemorrhoidal disease is a common disorder requiring surgical intervention in approximately 10% of cases.[1] The prevalence is unknown because asymptomatic patients are less likely to seek medical help. About 4.4% of individuals in the United States exhibit symptoms, and those between 45 and 65 are most significantly impacted.[2][3][4] Hemorrhoids, found within the anal submucosa, are columns of vascular connective tissue that assist in maintaining continence and bulk to the anal canal. Although the pathophysiology of hemorrhoids is not fully understood, one theory suggests that they may develop due to varicose veins in the anal canal. However, this concept is generally not well established. Many experts firmly believe the root cause of hemorrhoids is the deterioration or degradation of vascular cushions rather than any other potential factor.[5] See Image. Hemorrhoidal and Middle Sacral Veins. The 3 primary hemorrhoidal columns are in the left lateral, right anterolateral, and right posterolateral positions of the anal canal. The hemorrhoids can be internal or external based on their location relative to the dentate line.[3] Internal hemorrhoids can be further graded from I to IV based on the degree of prolapse, guiding the treatment options.[2] Patients presenting with symptomatic internal hemorrhoids complain of painless, bright red bleeding, described as streaks of blood in the stool, anal itching, pain, worrisome grape-like tissue prolapse, or a combination of these symptoms. External hemorrhoids are asymptomatic in most patients except for thrombosed external hemorrhoids, which cause significant pain due to their innervation by somatic nerves.[2][4]

The 3 primary hemorrhoidal columns are in the left lateral, right anterolateral, and right posterolateral positions of the anal canal. The hemorrhoids can be internal or external based on their location relative to the dentate line.[3] Internal hemorrhoids can be further graded from I to IV based on the degree of prolapse, guiding the treatment options.[2] Patients presenting with symptomatic internal hemorrhoids complain of painless, bright red bleeding, described as streaks of blood in the stool, anal itching, pain, worrisome grape-like tissue prolapse, or a combination of these symptoms. External hemorrhoids are asymptomatic in most patients except for thrombosed external hemorrhoids, which cause significant pain due to their innervation by somatic nerves.[2][4] Conducting a comprehensive history and physical examination specific to the disease is important, focusing on assessing the severity and duration of symptoms and identifying any relevant risk factors. Hemorrhoids can be treated with medical and surgical interventions depending on their degree of prolapse and whether they are internal or external. Hemorrhoids can undergo treatment with both medical or surgical interventions depending on the degree of prolapse and their locations.[6] One of the first and foremost conservative recommendations is a high-fiber diet. Garg recommends adding 4 to 5 teaspoons of fiber daily, corresponding to 20 to 25 g of supplemental fiber. For this method to be effective and not cause abdominal cramping, an adequate amount of water (500 mL) must be consumed simultaneously with the fiber supplement to absorb the water and result in soft stools. This intervention has proven to stop progression and help decrease the size of prolapse.[7]

Conducting a comprehensive history and physical examination specific to the disease is important, focusing on assessing the severity and duration of symptoms and identifying any relevant risk factors. Hemorrhoids can be treated with medical and surgical interventions depending on their degree of prolapse and whether they are internal or external. Hemorrhoids can undergo treatment with both medical or surgical interventions depending on the degree of prolapse and their locations.[6] One of the first and foremost conservative recommendations is a high-fiber diet. Garg recommends adding 4 to 5 teaspoons of fiber daily, corresponding to 20 to 25 g of supplemental fiber. For this method to be effective and not cause abdominal cramping, an adequate amount of water (500 mL) must be consumed simultaneously with the fiber supplement to absorb the water and result in soft stools. This intervention has proven to stop progression and help decrease the size of prolapse.[7] Rubber band ligation and infrared coagulation are indicated for grade 1 and 2 hemorrhoids that fail medical management.[8] The reported number of rubber banding sessions is 1, occasionally 2, with a waiting period of 4 weeks between visits.[9] When comparing the 2, long-term success favors rubber banding, whereas infrared coagulation is associated with less pain, likely due to lack of mucopexy during the procedure. The failure rate for rubber band ligation is 4 times less than that seen in infrared coagulation.[2] Surgical excision is the most effective treatment for recurrent, symptomatic grade III or IV hemorrhoids. Surgical procedures primarily include closed, also called Ferguson hemorrhoidectomy, the most common technique in the United States, or the open, also called Milligan-Morgan hemorrhoidectomy, used in the United Kingdom and Europe.[2][4]

Potential complications of hemorrhoidectomies can include the following: The patient should anticipate pain and anal fullness within the first week following hemorrhoidectomy and hemorrhoidopexy. Adequate pain control, as well as the use of stool softeners, are a priority in the postoperative period. Early complications include bleeding and urinary retention. Rare but life-threatening complications that must be recognized early include sepsis, abscess formation, and massive bleeding.[2] Late complications include anal stenosis, skin tags, recurrent hemorrhoids, delayed hemorrhage, and fecal incontinence. Complications following surgical hemorrhoidectomy are uncommon, but post-procedure hemorrhage is the most frequently reported complication, ranging from 1% to 2% in larger series. Acute urinary retention is observed in approximately 1% to 15% of cases and is the primary reason for a delayed discharge. Urinary retention rate increases after spinal anesthesia and procedures involving hemorrhoidal artery ligation. However, the risk can be minimized by reducing the volume of intravenous fluids administered and carefully administering local anesthesia.[12][13]

Hemorrhoids are widespread in society, and while they are easy to diagnose, the treatment is not always satisfactory. The disorder is best addressed by an interprofessional team dedicated to anorectal conditions. All healthcare team members see patients with hemorrhoids in different settings, depending on the acuity and severity of the disease. Understanding the degree of prolapse of internal hemorrhoids helps the healthcare professional choose the adequate treatment and provide appropriate education. Correct diagnosis of an acutely thrombosed external hemorrhoid promptly leads to treatment, increasing overall patient safety and satisfaction. Several vital clinical recommendations are published for practice: Increasing fiber intake is useful as a first-line medical treatment option. Grades 1 to 2 hemorrhoids can successfully be treated in an office setting with rubber band ligation. Excisional hemorrhoidectomy is only indicated for grade 3 or 4, recurrent or symptomatic hemorrhoidal disease.[2] Patient education is vital because hemorrhoids are preventable. The nurse, dietitian, and pharmacist should encourage the patient to avoid constipation, drink ample water, be physically active, add fiber to the diet, and refrain from using too many pain medications (which cause constipation). The overall outcomes following surgery vary from good to poor. Residual pain and recurrence are not uncommon after almost every procedure. Interprofessional team management involving clinicians, nursing, and pharmacy can drive better patient outcomes.

The interprofessional team interventions for hemorrhoidectomy include the following: Ensure the patient has given written consent Educate the patient about the treatment of hemorrhoids Help with patient positioning and prepping during surgery Assist the surgeon with the procedure Explain postoperative care Educate the patient on how to perform sitz baths

Interprofessional team monitoring for patients undergoing hemorrhoidectomy include: Monitor the patient during surgery Monitor the patient in the postoperative period Check for bleeding after surgery Assess the level of pain after surgery