Preparation for surgery
Clear instructions will have been provided to you at your pre-assessment appointment about what to bring with you to hospital and what you may eat or drink on the day of your surgery before you come in. There will be a certain amount of paperwork to get through to check you in. You will be visited both by the surgeon and by the anaesthetist who will discuss the surgery and the anaesthetic respectively with you. You will need to sign a consent form to proceed with surgery. This contains all of the information about the way the surgery is being performed and about the risks of the operation. You will be changed into suitable theatre clothing and you are likely to be offered elasticated compression stockings to reduce the risk of deep vein thrombosis (clots in the leg veins).
You will need to have an enema administered to you on the ward prior to your operation. This is for two principal reasons: one to benefit you and one to benefit the surgeon. In order to adequately see your internal piles and rectum, it needs to be cleared of obstacles. Similarly, we need the back passage to be clear when inserting the instruments with which we perform the surgery. After surgery, you will have a delicate wound: passing faeces can be quite painful and if that stool is already formed, bulky and hard, it might be agonising. Pain relief given for post-operative pain may cause an unwanted side-effect of constipation, so keeping the bowels working nicely is important (see below).
You will be taken down to the theatre either walking or in a wheelchair (if your mobility is poor), accompanied by a nurse and a porter who will check you into the theatre. You enter an anaesthetic room which is attached to the theatre where you will meet the anaesthetist and their assistant. In this room you will be prepared for your operation, with safety checks performed and monitoring attached to you. If you are having a general anaesthetic you will be put off to sleep in that room and then awaken in the recovery area of the theatres once it is all over. Once you are under anaesthetic or adequately numb from a spinal anaesthetic, you will be wheeled into the actual operating theatre where your surgeon and the theatre nurses will be awaiting your arrival.
A routine haemorrhoid operation generally takes just 20-30 minutes to perform. A stapled anopexy operation may take a little longer. However, the necessary safety procedures and preparation, together with the time taken for you to come round from the anaesthetic, will likely mean that you are away from your room for up to 2 hours. When you are deemed to be sufficiently awake and your observations are satisfactory, you will return to your bed on the ward and you will be visited by your surgeon. If it has been determined that you will be for a day case, you will be allowed to go home later that day. Otherwise, you will be staying overnight. There is a resident doctor in the building and a nightshift of nursing staff who will look after you through the night, but your surgeon is always available to you if he is needed. You will be visited by your surgeon before you can go home as it is important to reiterate the advice on what to do in the recovery period. An appointment will be made to review you in the outpatient clinic in approximately 4-6 weeks’ time.
Types of surgery
“Haemorrhoidectomy” means “removal” of piles i.e. cutting them out. Historically, this was the only way to deal with them surgically. Today, the removal of piles is still often the best way forward, particularly if they are associated with a lot of floppy nearby skin (known as skin tags) or if they protrude in just a few areas. However, for piles that exists all the way around the full circumference of the anus (“circumferential piles”) an internal operation higher up in the rectum might be a better alternative. This is called a stapled anopexy or a PPH (Procedure for Prolapse and Haemorrhoids). The removal of piles is exactly that: whether this is done with a scalpel, a pair of scissors, with electrocautery or with laser cautery, is irrelevant. Don’t be persuaded by the hype and sales pitch surrounding these forms of surgery – they all essentially do the same thing. I offer haemorrhoidectomy by electrocautery and I offer PPH stapled anopexy.
This requires you to be asleep under general anaesthetic or to be numbed by a spinal anaesthetic. The culprit haemorrhoids are identified and the incisions that are to be made around the piles are marked out with a surgical pen to ensure that sufficient skin remains. At each pile the skin is incised and the anal sphincter muscle fibres are identified to ensure that dissection is in the correct plane and avoids injury to the muscle. As dissection occurs, the electrocautery seals the bleeding capillaries and blood vessels until the pile has been fully released. The main blood vessels feeding the piles are then ligated with a stitch or sealed off, following which the pile is detached and removed.
PPH / Stapled Anopexy:
This requires you to be asleep under general anaesthetic. An operating speculum is inserted into the anal canal and lower rectum to display the full circumference of the interior lining of the back passage. Beneath this inner lining lie the blood vessels that feed the piles nearer the exit. A running stitch, a bit like a purse string, is placed circumferentially beneath these blood vessels. After a circular stapling device is inserted, the purse string stitch is tightened. A specialised surgical instrument that clasps, staples and cuts is inserted into the back passage and this serves to remove a circumferential cuff of blood vessels and inner lining. In doing so, the blood supply to the piles below is cut off, causing them to shrivel up.
PPH instrument inserted and blood supply clamped
After PPH division and stapling of the blood supply
Risks associated with haemorrhoid surgery
All surgery carries with it some element of risk and these risks are part and parcel of surgery: without risk, nothing can be gained. Remember that very few patients suffer complications and the majority of operations and recoveries are uneventful. Some of the risks described below are serious, but these are very rare. The majority of complications are a nuisance rather than a serious health problem.
- Bleeding: All cutting surgery causes some bleeding, but it is called a complication when bleeding occurs that warrants an unplanned return to the operating theatre to stem the bleeding, or when bleeding is so heavy that a blood transfusion is required
- Infection: Infection is almost inevitable in an open wound near the anus, but it is a wound complication if additional treatment or intervention is needed. Infections may rarely occur internally after PPH and these can be very serious.
- Non-healing: Some wounds stubbornly refuse to completely heal over and may need additional interventions (creams or Botox injection)
- Anal stenosis: narrowing of the anal aperture that prevents easy stool passage may occur if too much anal skin or inner lining of the rectum is removed
- Blood clots: Known as DVT (deep vein thrombosis), these rarely occur in day case surgery that doesn’t prevent you from walking
- Incontinence: an extremely rare complication caused by the unintentional removal of anal sphincter muscle, or caused by loss of the ability to sense waste entering the anus
When can you go home?
In order to safely release you back to the community, there are a number of prerequisites or milestones to reach. These include:
1. you must be comfortable at the site of your operation with the painkillers that you may take home with you
2. you must be adequately mobile and steady on your feet, especially if you have stairs to negotiate at home
3. your observation chart must be satisfactory (pulse rate, temperature, Blood Pressure etc)
4. your wound must be satisfactory and we must be happy that you can manage it yourself
5. you must have eaten and kept your food down
6. you must have passed urine since the operation
7. you must have sufficient support at home
As soon as you achieve these milestones you may go home with our blessing, otherwise you would have to discharge yourself against medical advice.
Advice on your recovery at home
All operations by their nature cause a degree of pain. Haemorrhoid surgery that involves cutting out the haemorrhoids (Ligasure haemorrhoidectomy and Milligan-Morgan haemorrhoidectomy) is not pleasant! During the anaesthetic you will be given pain relieving medication and there will also be local anaesthetic injected into the skin at the end of your operation. The local anaesthetic will last approximately 6 to 10 hours by which time you ought to be able to eat and drink and therefore take oral medication to relieve pain. You will be provided with medication that both relieves pain and settles inflammation, notably those that don’t have constipation as a side-effect.
In the first couple of days after surgery most of the pain arises from the raw endings of nerves that are cut. There is a natural inflammatory response to a wound and this results in swelling and warmth in the wound over the ensuing days; it may produce a tightness or dull throbbing pain. Any bruising that is present will exacerbate this. Thereafter, the presence of faeces on the wound causes a low grade “infection” of the nearby skin at the edge of the wounds. To minimise this, you will be given 5 days of metronidazole, an antibiotic.
As the inflammatory process settles and the body becomes accustomed to the presence of a wound, pain should abate. Many patients report that soaking in a bath, especially a soap-free or salty bath, is just as effective as taking pain killers. Try doing this once or twice a day, especially after moving your bowels. Place 1 tablespoon of coarse sea salt in your bath water. It might smart a bit when you get under the water, but it soon feels very soothing. Saline helps to keep the bacterial population on the wound down to a minimum and it promotes healing.
Sitting is said by some patients to be very uncomfortable for them. This is probably not from sitting ON the anus, but rather from the buttocks separating when sitting, which tends to pull the anal skin apart. Inflatable and soft-fill ring cushions might help if you are required to sit for long periods of time and they might give you some help in returning to office-based work sooner.
I recommend that you use regular painkillers in the first week after your surgery, regardless of whether you happen to experience pain at that time, so that should more pain suddenly emerge you require less additional pain relief to get you through that episode. Use the analogy of a car travelling along a flat road that suddenly finds a hill rising up before it: if it has momentum behind it then it doesn’t need much acceleration to quickly get it over the hill, whereas if it is stalled at the bottom of the hill it takes longer and needs more throttle to get it up and over. If you do suffer with unusually severe pain, please contact the hospital or your GP just in case you have developed a complication in the wound. Remember that time heals and that given sufficient time wounds almost always settle completely.
Your wound is not stitched closed because the wound will get infected, an abscess will form and stitches will cut through when the skin stretches during defaecation. Your wound is thus termed an “open” wound and it gradually heals by filling in with a pink tissue called granulation tissue. This is not strong tissue and it will bleed if traumatised, so expect that moving your bowels will set off some bleeding. Vigorous wiping (if you can tolerate it) might do the same.
A dressing is inserted into the anal wound during your operation. This may be an absorbent sponge dressing which turns to jelly as it moistens, or it may be a Vaseline-impregnated gauze. Both will pass when you move your bowels or sometimes even when breaking wind. This dressing does not need to be replaced and your wound does not need to be dressed daily.
Open wounds weep: they produce a bloody exudate initially and then later a yellowy liquid or slime called slough, which may resemble pus. For this reason, wear an absorbent sanitary pad to soak up any discharge or blood that may emerge. This might be necessary for several weeks.
Visiting the loo after haemorrhoid surgery can be awkward. A bidet is ideal, but many patients do not have one at their disposal and even those of us with one have to make do if nature calls when we are out of our own homes. Douching (splashing water), rinsing with a gentle hand-held shower hose or swilling in a bath are all practical alternatives when in your own home. Be careful when wiping with toilet paper: it will be uncomfortable and it may set off bleeding. DO NOT USE WET-WIPES and avoid placing any local anaesthetic creams or haemorrhoid preparations – these will cause complications and delay healing. Once you feel that your wound is becoming more comfortable and once your confidence has returned, you can begin to wipe with a wet flannel and then progress to toilet paper.
The following advice pertains to the typical patient. Any physical activity that you feel encouraged to do and confident to do you are welcome to do. Exercise common sense in what might be a regrettable pastime e.g. cycling, horse riding or long drives on a hard seat. These are sure to hurt and set off bleeding. If you wish to exercise, you may power walk or run from 2 weeks onwards, but I suggest that you take a spare pair of shorts with you initially and that you wear a pad in case this activity sets off a big bleed. Do not lift weights in a gym: straining engorges veins around your anus – it’s not just your face that turns blue!
Given that your wounds are open for several weeks, I would strongly advise you against swimming in a pool for several weeks as these pools contain other people’s body fluids. Swimming in the sea is probably safe from 2 weeks onwards and is probably very good for your healing. Sexual activity between you and a partner is permissible, provided that the anus is used as an exit exclusively and that sexual activity is not too vigorous.
You will be reviewed in the outpatients clinic at which time your wound will be examined and your progress will be assessed. This is typically four to six weeks after your surgery, by which time most of your surgical symptoms will have eased. If you have further problems beyond that appointment you may need to see your GP or be reassessed by your surgeon.
A small minority of patients may have grumbling pain in the anus still and they may need to take painkillers to ease this. If this does not help or your pain is worsening, please ask your GP to put you back in touch with your surgeon who can ensure that no complication has arisen.
Occasionally the wound stubbornly refuses to completely heal. This leaves a superficial ulcer which behaves just like a fissure – see the menu on the left of this page for information on how this problem arises and how it can be treated.
Some patients have a wound that shrinks excessively, causing narrowing of the anus and an unyielding scarred anus that won’t open sufficiently to pass stools. This may need further assistance with dilators to gradually stretch the scar and the anus to an acceptable size.
In patients who have very extensive piles, the surgeon may only have been able to deal with the bulkiest piles. The remaining smaller ones, if troublesome, might require bed-side treatments or further surgery in due course. Have realistic expectations that removing piles can never restore your anatomy to the brilliant state it was in during your younger days.
You may not drive in the 24 hours after your surgery. Check your car insurance policy to see what, if any, restrictions are placed in your contract as regards driving after surgery. Most policies say either 1 week, 2 weeks, or on the advice of your surgeon. There is no medical evidence to show that driving a normal vehicle in normal circumstances will injure your anal wounds or cause complications. It thus relies on common sense - you decide when to drive. It is very important to consider the legal responsibilities of taking control of a vehicle: you must be able to take all reasonable actions expected of a driver in all circumstances i.e. your wounds (or any other consequence of your surgery and anaesthetic) are not a valid reason for failing to drive in a "normal" way. For example, you must be able to slam on the brakes, wrench the steering wheel and swerve to avoid a child that has run across your path.
GETTING IN TOUCH IF YOU NEED HELP
You will be given clear instructions on how to quickly summons help whilst on the ward. If you should need to stay overnight, a Resident Medical Officer (RMO) is resident in the hospital to attend to you in the first instance. This doctor is able to deal with many emergency situations, as are the well qualified resident nursing staff. If necessary, Mr Bradford will be called both for advice and to attend - he is on-call for you at all times until you are discharged and he can be at your bedside within just a few minutes in an emergency.
Once at home you have access to medical advice in several ways:
1. Call the hospital to speak to the nurse on duty and/or the RMO
2. Call your local GP surgery (during hours)
3. Call the Out of Hours GP service (after hours)
4. Call the emergency services (999) or attend your nearest A&E services
As a general rule, unless it is an emergency rather call the hospital in the first instance for advice on who is best placed to attend to your needs. We have a low threshold for having a quick look ourselves if we are concerned that a complication might have arisen: usually it is a false alarm. If either your GP or the hospital staff feel that Mr Bradford needs to be contacted about you, they will track him down. In the event that your problem has arisen some days later, and Mr Bradford is away, you might have to default to the NHS services for assistance.