Case Study

HEMORRHOIDECTOMY

Submitted by: Calunsag, Josie T.

Submitted to: Mr. TJ BONBONER D. AUGUSTIN, RN

 Table of Content

I. Case Scenario
II. Abstract
III. Surgical Approach
-Procedure
-Anatomy and Physiology
-Diagnostic Exam
-Surgical Nursing Considerations
III. Possible Nursing Care Plan
IV. 3 Review of Related Literature
Case Scenario
A 52-year-old man consulted in extreme perianal discomfort that he had experienced
for 48 hours. He had no past history of similar problems and was otherwise
asymptomatic. There was no abnormality on abdominal examination, while on
examination of the perianal area there was a tense, dark blue, grape-sized swelling
that was acutely tender to touch. Rectal examination was difficult to perform
adequately because of pain but no other masses were palpable.

Abstract
Symptomatic hemorrhoid disease is one of the most prevalent ailments associated
with significant impact on quality of life. Management options for hemorrhoid disease
are diverse, ranging from conservative measures to a variety of office and
operating-room procedures. In this review, the authors will discuss the anatomy,
pathophysiology, clinical presentation, and management of hemorrhoid disease.

Keywords: hemorrhoids, rectal bleeding, thrombosis, management

Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis,

accounting for ∼ 3.3 million ambulatory care visits in the United
States.1 Self-reported incidence of hemorrhoids in the United States is 10 million per
year, corresponding to 4.4% of the population. Both genders report peak incidence
from age 45 to 65 years. Notably, Caucasians are affected more frequently than
African Americans, and higher socioeconomic status is associated with increased
prevalence.2 Contributing factors for increased incidence of symptomatic
hemorrhoids include conditions that elevate intra-abdominal pressure such as
pregnancy and straining, or those that weaken supporting tissue.

Despite its prevalence and low morbidity, hemorrhoid disease has a high impact on
quality of life, and can be managed with a multitude of surgical and nonsurgical
treatments. In this review, we will discuss the anatomy, presentation, and
management of symptomatic hemorrhoid disease.

Surgical Approach
Hemorrhoidectomy is surgery to remove hemorrhoids. You will be given general
anesthesia or spinal anesthesia so that you will not feel pain.
Incisions are made in the tissue around the hemorrhoid. The swollen vein inside the
hemorrhoid is tied off to prevent bleeding, and the hemorrhoid is removed. The
surgical area may be sewn closed or left open. Medicated gauze covers the wound.
Surgery can be done with a knife (scalpel), a tool that uses electricity (cautery pencil),
or a laser.
The operation is usually done in a surgery center. You will most likely go home the
same day (outpatient).
There is a procedure that uses a circular stapling device to remove hemorrhoidal
tissue and close the wound. No incision is made. In this procedure, the hemorrhoid is
lifted and then "stapled" back into place in the anal canal. This surgery is called
stapled hemorrhoidopexy. People who have stapled surgery may have less pain after
surgery than people who have the traditional hemorrhoid surgery. But the stapled
surgery is more expensive. And people who have stapled surgery are more likely to
have hemorrhoids come back and need surgery again.
Doppler-guided hemorrhoidectomy is a procedure that uses a scope with a special
probe to locate the hemorrhoidal arteries so that less tissue is removed. Some studies
show that it is less painful but more long term studies are needed to compare it with
other procedures.

Anatomy and Pathophysiology

Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective tissues
that lie along the anal canal in three columns—left lateral, right anterior, and right
posterior positions. Because some do not contain muscular walls, these clusters may
be considered sinusoids instead of arteries or veins. Hemorrhoids are present
universally in healthy individuals as cushions surrounding the anastomoses between
the superior rectal artery and the superior, middle, and inferior rectal veins.
Nonetheless, the term “hemorrhoid” is commonly invoked to characterize the
pathologic process of symptomatic hemorrhoid disease instead of the normal
anatomic structure.

Classification of a hemorrhoid corresponds to its position relative to the dentate line.

External hemorrhoids are located below the dentate line and develop from ectoderm
embryonically. They are covered with anoderm, composed of squamous epithelium,
and are innervated by somatic nerves supplying the perianal skin and thus producing
pain. Vascular outflows of external hemorrhoids are via the inferior rectal veins into
the pudendal vessels and then into the internal iliac veins. In contrast, internal
hemorrhoids lie above the dentate line and are derived from endoderm. They are
covered by columnar epithelium, innervated by visceral nerve fibers and thus cannot
cause pain. Vascular outflows of internal hemorrhoids include the middle and superior
rectal veins, which subsequently drain into the internal iliac vessels.
While no taxonomy of external hemorrhoids is used clinically, internal hemorrhoids
are further stratified by the severity of prolapse. First-degree internal hemorrhoids do
not prolapse out of the canal but are characterized by prominent vascularity.
Second-degree hemorrhoids prolapse outside of the canal during bowel movements or
straining, but reduce spontaneously. Third-degree hemorrhoids prolapse out of the
canal and require manual reduction. Fourth-degree hemorrhoids are irreducible even
with manipulation.4

The exact pathophysiology of symptomatic hemorrhoid disease is poorly understood.

Previous theories of hemorrhoids as anorectal varices are now obsolete—as shown by
Goenka et al, patients with portal hypertension and varices do not have an increased
incidence of hemorrhoids.5Currently, the theory of sliding anal canal lining, which
proposes that hemorrhoids occur when the supporting tissues of the anal cushions
deteriorate, is more widely accepted. Advancing age and activities such as strenuous
lifting, straining with defecation, and prolonged sitting are thought to contribute to
this process. Hemorrhoids are therefore the pathological term to describe the
abnormal downward displacement of the anal cushions causing venous dilatation.6 On
histopathological examination, changes seen in the anal cushions include abnormal
venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and
fibroelastic tissues, and distortion and rupture of the anal subepithelial muscle. In
severe cases, a prominent inflammatory reaction involving the vascular wall and
surrounding connective tissue has been associated with mucosal ulceration, ischemia,
and thrombosis.7

DIAGNOSTIC EXAM
Rectal pain and bleeding should never be blindly attributed to hemorrhoids. A
thorough history and physical examination is required to help identify any possible
alternative diagnosis, and the possibility of a more insidious cause of rectal bleeding
should always be considered. In the colorectal surgeon's office, a detailed anorectal
examination is crucial to diagnosis. Patients may be examined in a prone-jackknife or
left lateral position. External inspection will reveal any thrombosed external
hemorrhoid, which often appears as a firm, purplish nodule that is tender to palpation.
Thrombosed hemorrhoids may also have ulcerations with bloody drainage. Skin tags
maybe signs not only of prior hemorrhoids but also of fissure disease. Digital
examination will exclude distal rectal mass and anorectal abscess or fistula.
Evaluation of sphincter integrity during the digital examination is important to
establish baseline function, and is especially important in patients who report
incontinence as any future surgical intervention may further worsen function. Lastly,
anoscopy and rigid or flexible proctosigmoidoscopy should be performed routinely to
identify internal hemorrhoids or fissures, and to rule out distal rectal masses. Internal
hemorrhoids can be reliably identified in the three above-mentioned columns, and
described based on grade and degree of inflammation.

If uncertainty remains after office examination, a total colonoscopy is often

appropriate to rule out a proximal source of bleeding. Certainly, any patient over the
age of 50 years without an up-to-date colonoscopy requires this to be performed. For
younger patients, the decision for colonoscopy must be based on risk factors, clinical
suspicion, and response to initial therapy.

Position:

In addition to an abdominal examination, the perineal and rectal areas should be

inspected with the patient at rest and while bearing down.7,11 The patient can be in the
lateral decubitus, lithotomy, or prone jackknife position (i.e., patient prone with table
adjusted so that hips are flexed, with head and feet at a lower level). The presence of
external hemorrhoids or prolapse of internal hemorrhoids may be obvious. A digital
rectal examination can detect masses, tenderness, and fluctuance, but internal
hemorrhoids are less likely to be palpable unless they are large or prolapsed.

Anoscopy is an effective way to visualize internal hemorrhoids that look like purplish
bulges through the anoscope. Physicians should avoid use of clock face terms to
describe lesions, because the position of the patient can vary. Instead, the physician
should use terms relative to the patient, such as anterior, posterior, left, or
right.7 Typically, hemorrhoids develop on anatomic planes, or hemorrhoidal columns,
in the left lateral, right anterior, or right posterior aspect of the anus.

What are the Risks & Complications of Hemorrhoidectomy?

Hemorrhoidectomies have a high success rate. Most patients have a satisfactory
recovery following surgery, without any complications or recurrence. However, even
after a successful surgery, there is a 5% chance of recurrence. Complications are
usually rare with hemorrhoidectomy, but nevertheless, can occur. One of the most
painful complications of internal or external hemorrhoids is thrombosis. Other
complications may include the following:
 Anal fistula or fissure
 Severe constipation
 Excessive bleeding
 Excessive fluid discharge from the rectum
 Fever of 38°C or higher
 Inability to urinate or have bowel movements

 Intense pain if bowel movements occur

 Redness and swelling in the rectal area

 Stenosis (narrowing) of the anus
 Recurrence of the hemorrhoid

Nursing Care Plans

Nursing management of hemorrhoids depends on the type and severity of hemorrhoid

and on the patient’s overall condition. Treatment includes measures to ease pain,
combat swelling and congestion, and regulation of the patient’s bowel habits. Patient
care includes preoperative and postoperative support.

Here are three (3) nursing care plans (NCP) and nursing diagnosis for patients with
hemorrhoids:

1. Impaired Tissue Integrity

2. Constipation
3. Acute Pain

Impaired Tissue Integrity

Nursing Diagnosis

 Impaired Skin Integrity

May be related to

 Hemorrhoidal surgery and procedures

 Alteration in activity
 Changes in mobility
 Aging process
 Loss of elasticity of the skin

Possibly evidenced by

 Disruption of skin tissue from incisional sites

 Destruction of skin layers
 Thrombosed hemorrhoids
 Internal prolapsed hemorrhoids
 Pain
 Swelling
 Drainage

Desired Outcomes

ADVERTISEMENTS

 Patient will have intact skin with no signs or symptoms of rectal prolapse
or bleeding.
 Hemorrhoids will be reduced or removed.
 Patient will exhibit no evidence of thrombosed hemorrhoids or rectal bleeding.
 Patient will have normal CBC with no noted anemias.
 Patient will be able to accurately verbalize understanding of causes of
hemorrhoids, methods of preventing the worsening of hemorrhoids, and comfort
measures to employ.
 Swollen hemorrhoids will be reduced in size, with no pain evoked.
 Patient will be able to tolerate procedures to diagnose problem and to treat
hemorrhoids without the presence of any complication.

Nursing
Rationale
Interventions

Provides baseline
information as to the
type of hemorrhoids
Assess patient for (external or internal),
the presence of degree of
hemorrhoids, venous thrombosis,
discomfort or pain presence of
associated with complications,
hemorrhoids, diet, including bleeding,
fluid intake, and and risk factors that
presence preclude patient to
of constipation. hemorrhoids to enable
initiation of care plan
appropriate for the
patient.

Administer topical Reduces swelling,

medication as pain, and/or itching in
ordered. order to make the
patient more
comfortable.

Hemorrhoids are
exquisitely painful and
the patient may not be
able to sit in a chair
and apply pressure to
Provide “donut
delicate tissues.
cushion” for the
patient to sit on if
Donut cushions can
needed.
help remove pressure
from hemorrhoid;
caution on the
occurrence of pressure
areas.

Helps prevent
straining and increases
the pressure that may
cause clotted vessels
Administer stoolsof to rupture or cause
teners as ordered. further hemorrhoids to
develop. Helps relieve
pain by avoiding
passage of hard fecal
material.

Sclerotherapy may be
used if the problem is
detected early, it
involves an injection
of quinineurea
hydrochloride or other
Assist with
agents into sclerosed
procedures for the
vessels, with resultant
treatment of
swelling and dying of
hemorrhoids.
the vessel, with
reabsorption within
the body.

Banding hemorrhoid
may also be
 performed, this
involves the
application of a rubber
band around the base
of each hemorrhoid,
which ultimately
results in the death
and necrosis of
hemorrhoid.

Laser surgery may

also be performed but
symptomatic relief is
not obtained
immediately.

Hemorrhoidectomy is
performed if the
patient has internal
hemorrhoids with
prolapse, or if the
patient has both
internal and external
hemorrhoids. It
relieves symptoms
immediately but can
create scar tissues and
other complications;
should be done as a
last resort.

Instruct patient
and/or family Hemorrhoids are
regarding causes of caused by straining,
hemorrhoids, heavy lifting, obesity,
methods of pregnancy, and any
avoiding activity that distends
hemorrhoids, and rectal veins and causes
treatments that can them to prolapse.
be performed.

Instruct patient Internal hemorrhoids

and/or family are normally
regarding all diagnosed by
 procedures anoscopy or flexible
required. sigmoidoscopy
because the digital
rectal exam cannot
adequately detect
hemorrhoids. Barium
enemas
or colonoscopy may
be required to ensure
that intestinal masses
are not present as well.

Increasing bulk, fiber,

fluids, and eating
Instruct patient
fruits and vegetables
and/or family in
can help by
dietary
maintaining soft stools
management.
to avoid straining at
bowel movements.

Bulk-forming
Instruct patient laxatives help absorb
and/or family water to increase
regarding the use moisture content in the
of bulk producing stool,
agents, such as increases peristalsis,
psyllium husk. and helps promote soft
bowel movements.

Use of rubber donuts

remove pressure
Instruct patient directly placed on the
and/or family in hemorrhoid. Warm
comfort measures sitz baths or
to use with the suppositories
presence of containing anesthetic
hemorrhoids. agentscan help to
alleviate pain
temporarily.

Constipation
Nursing Diagnosis

 Constipation

May be related to

 Low residue diet

 Lack of dietary bulk
 Hemorrhoidal pain
 Medications

Possibly evidenced by

 Passage of hard, formed stool

 Decreased bowel sounds
 Inability to evacuate stool
 Severe, exquisite rectal pain
 Abdominal pain
 Abdominal distention
 Ileus
 Absent bowel sounds
 Frequency of stool is less than normal
 Less than the usual amount of stool
 Palpable mass
 A feeling of rectal fullness
 Flatulence

Desired Outcomes

ADVERTISEMENTS

 Patient will have normal elimination pattern reestablished and maintained.

Nursing
Rationale
Interventions

Assists with the

Determine the
identification of an
patient’s bowel
effective bowel
habits, lifestyle,
regimen and/or
ability to sense an
impairment, and
urge to defecate,
need for assistance.
painful hemorrhoids,
GI function may be
and history of
decreased as a result
constipation.
of decreased
 digestion. Functional
impairment related to
muscular weakness
and immobility may
result in decreased
abdominal peristalsis
and difficulty with
the identification of
the urge to defecate.

Assess patient’s
stool frequency,
Aging, such as
characteristics,
decreased rectal
presence of
compliance, pain,
flatulence,
impairment of rectal
abdominal
sensation can lead to
discomfort or
constipation.
distension, and
straining at stool.

Abnormal sounds,
Auscultate bowel such as high-pitched
sounds of presence tinkles, suggests
and quality. complications like
ileus.

Adequate amounts of
fiber and roughage
provide bulk and
Monitor diet and adequate fluid intake
fluid intake. of at least 2 L per
day is important in
keeping the stool
soft.

Gas, abdominal
distention, or ileus,
Monitor for could be a factor.
complaints of Lack of peristalsis
abdominal pain and from impaired
abdominal digestion can create
distention. bowel distention and
worse to the point of
ileus.
Monitor patient’s
mental status, Undue straining may
syncope, chest pain, have harmful effects
or any transient on arterial circulation
ischemic attacks. that can result in
Notify the physician cardiac, cerebral, or
if these symptoms peripheral ischemia.
occur.

Excessive straining
may produce
hemorrhoids, rectal
Assess for rectal
prolapse, or anal
bleeding.
fissures, with
resultant pain and
bleeding.

Provide bulk, stool

softeners, laxatives, May be used to
suppositories, or stimulation
enemas as evacuation of stool.
warranted.

Provide a high-fiber
Improves peristalsis
diet, whole grain
and promotes
cereals, bread, and
elimination.
fresh fruits.

Analgesics,
anesthetics, anticholi
Monitor medications
nergics, diuretics,
that may predispose
and other drugs are
patient to
some medications
constipation.
that are known to
cause constipation.

Activity promotes
peristalsis and
Instruct patient in
stimulates
activity or exercise
defecation. Exercises
programs within
help to strengthen
limits of the disease
the abdominal
process.
muscles that aid in
defecation.
Acute Pain

Nursing Diagnosis

 Acute Pain

May be related to

 Hemorrhoidal pain
 GI bleeding
 Gastric mucosal irritation
 Inflammation
 Infection
 Constipation
 Spasm
 Surgery

Possibly evidenced by

 Verbalization of pain
 Fever
 Malaise
 Rectal pain
 Elevated WBC
 Surgical wounds
 Drains
 Tachycardia
 Hypertension
 Tachypnea
 Facial grimacing
 Crying
 Moaning
 Rectal bleeding
 Rectal pruritus
 Rectal burning

Desired Outcomes

ADVERTISEMENTS

 Patient will achieve relief from aches and pain

 Patient will report pain is controlled or eliminated

Nursing Interventions Rationale

Assess patient for

complaints of
Caused by
headaches, sore
inflammation or
throat, general
elevated
malaise or body
temperature.
weakness, muscleach
es, and pain.

VS are usually
Assess VS for
increased as result
changes from
of autonomic
baselines
response to pain.

Pharmacologic
therapy to control
Administer
pain and aches by
analgesics as ordered.
inhibiting brainprost
aglandin synthesis.

Provide restful, quiet Reduces stimuli that

environment. may increase pain.

Warmth causes
Provide warm baths
vasodilation and
or heating pad to
decreases
aching muscles.
discomfort.

Provide cool
Promotes comfort
compress to head
and treats headache.
prn.

Provide backrubs Promotes relaxation

prn. and relieves aches.

Encourage gargling
with warm water;
Reduces throat
provide throat
discomfort.
lozenges as
necessary.

Instruct patient or SO Helps patient to

 in deep breathing, focus less on pain,
relaxation and may improve
techniques, guided efficacy of
imagery, massage analgesics by
and other decreasing muscle
nonpharmacologic tension.
aids.

Acetaminophen may
relieve pain and
headache, but
should be used
cautiously in
Instruct patient or SO
patients with liver
regarding use of
dysfunction because
acetaminophen and
of acetaminophen
to avoid the use
metabolism in the
of aspirin.
liver. Aspirin can
potentially cause
hemorrhage and
ulceration, therefore,
must be avoided.

Literature Review on Hemorrhoidectomy

According to G. Orangio, 2017.The surgical hemorrhoidectomy remains the gold
standard for the management of symptomatic grade III and grade IV Hemorrhoids. In
1937, Milligan-Morgan described the surgical hemorrhoidectomy, leaving the wounds
open, the term open hemorrhoidectomy came to symbolize the excisional
hemorrhoidectom.(Milligan et al., Lancet 233:1119–1124, 1937) In 1959 Ferguson et al.,
described the technique of modifying the Milligan-Morgan hemorrhoidectomy by
closing hemorrhoidectomy wounds, the term closed hemorrhoidectomy came to
symbolize the modification of the Milligan-Morgan procedure. (Ferguson and Heaton,
Dis Colon Rectum 2:176–179, 1959) The “closed” hemorrhoidectomy has become the
main technique for hemorrhoidectomy instructed in General Surgery and Colon and
Rectal Surgery residencies in the United States. The principal of the surgical
hemorrhoidectomy is to completely excise all of the haemorrhoidal tissue, in the three
most common quadrants, the right anterior, right posterior and left lateral areas of the
anal canal. The most common complaint for patients is postoperative pain, and the
disability caused by the pain. This postoperative pain is the driving force in the
development or “quest” for the “painless” hemorrhoidectomy. All other procedures
are compared to the excisional hemorrhoidectomy, for postoperative pain, disability,
bleeding, stricture formation and recurrence. There are multiple modalities that are
utilized to diminish post hemorrhoidectomy pain, which I will discuss. There has been
development of new technology for “non-excisional” hemorrhoid procedures with the
promise to decrease post hemorrhoidectomy pain and disability. The two most
commonly used alternatives today is the Procedure for Prolapsed Hemorrhoids (PPH)
more commonly known as the “Stapled Hemorrhoidopexy” and the other is the
Doppler-Guided Hemorrhoidal Artery Ligation, known as Transanal Hemorrhoidal
Dearterialization (THD) with plication of the Hemorrhoids (ligation anopexy or
mucopexy). (Yeo and Tan, World J Gastroenterol 20:16,976–16,983, 2014; Lohsiriwat,
Tech Coloproctol 12:229–239, 2015). The standard tools for the surgical
hemorrhoidectomy are the scalpel, scissors or electrocautery, however efforts to
decrease the amount of intraoperative bleeding, and the associated post-operative pain
and disability have led to the development of alternative energy devices to dissect and
excise the haemorrhoidal tissue. The LigaSureTM a computer-guided bipolar
electrothermy device (BED) and the Harmonic ScalpelTM, which is vibratory energy
(VE)(Mastakov et al., Tech Coloproctol 2:229–239, 2008; Neinhuijs and G.R. Orangio
(*) Department of Surgery, Louisiana State University School of Medicine, New
Orleans, LA, USA e-mail: [email protected]; [email protected] # Springer
International Publishing AG 2017 C. Ratto et al. (eds.), Hemorrhoids, Coloproctology
2, DOI 10.1007/978-3-319-51989-0_26-1 1 de Hingh, Cochrane Database Syst Rev
1:CD 006761, 2009; Chung et al., Dis Colon Rectum 45:784–794, 2002; Armstrong et
al., Dis Colon Rectum 44:558–564, 2001) This chapter will discuss the literature
leading up to the current management of patients with advanced haemorrhoidal
disease and the procedures and the methods utilized to minimize postoperative pain
and disability.

Acciording to Muhammad Ahmad, 2021. To compare the efficacy of harmonic scalpel

versus Milligan Morgan technique in patients undergoing haemorrhoidectomy.
Methodology: The comparative study was conducted at the General Hospital, Lahore,
Pakistan, from March to September 2019, and comprised patients undergoing
haemorrhoidectomy who were randomised into haemorrhoidectomy group A and
open haemorrhoidectomy group B which was exposed to the Milligan Morgan
procedure. Data was collected through a predesigned questionnaire. Data was
analysed using SPSS 25. Results: Of the 60 patients, there were 30(50%) in group A;
17(56.7%) males and 13(43.3%) females with an overall mean age of 44.6±7.6 years.
The remaining 30(50%) patients were in group B; 19(63.3%) males and 11(36.7%)
females with an overall mean age of 43.8±8.2 years. In group A, mean operative time
was 20.8±2.8 minutes, while it was 26.5±2.8 minutes in group B (p=0.001). In group A,
mean convalescence period was 9.7±2.9 days, while it was 13.4±3.7 days in group B
(p=0.001). Group A required less time for complete wound healing compared to group
B (p<0.05). Conclusions: Harmonic scalpel haemorrhoidectomy was found to be an
advantageous method compared to the Milligan Morgan technique in patients
undergoing haemorrhoidectomy.

According to V. Popov, A. Yonkov,etc.,2020. A variety of effective methods for

treatment of hemorrhoids has been proposed. In recent years, there has been an
increasing number of studies comparing transanal hemorrhoidal dearterilization (THD)
and conventional hemorrhoidectomy (CH), but the focus of most studies has been
about the early postoperative results. The data about long-term outcomes is still
limited. We aimed to compare Doppler-guided THD and CH with regard to early and
long-term postoperative results.MethodsThe conducted prospective research included
287 patients who underwent CH (167 cases) or Doppler-guided THD with mycopexy
(120 patients) between November 2010 and December 2015. Information on
hemorrhoidal stage, demographic data, presenting symptoms, complications, duration
of hospital stay, postoperative pain, patients’ satisfaction and follow-up were obtained.
Statistical tests were performed by SPSS 19.0.ResultsThere was no significant
difference between the studied groups according to gender, mean age, preoperative
prolapse, pain and pruritus, hemorrhoidal stage and postoperative complications.
Preoperative bleeding was more frequent in THD group (p = 0,002). The mean visual
analog scale (VAS) pain scores in CH and THD groups on days 1, 2 and 7 were 7.01
vs 5.03, 5.07 vs 2.98, 2.39 vs 0,57 (p = 0,000). Practically, there was no difference in
VAS on day 30 and patients’ satisfaction at the 18th month. Mean hospital stay was
5,13 (CH) and 3,38 days (THD), p = 0,000. The postoperative follow-up was between
18 and 78 months (mean 46 ± 16 months). During this stage, 5 patients (2,99%) in CH
group required surgery for recurrence. In THD group, 3 patients (2,5%), all with
4th-degree hemorrhoids underwent additional procedures (p
0,802).ConclusionsDoppler-guided THD seems to be an efficient and safe option for
treatment of hemorrhoids, related to lower postoperative pain and excellent, similar
long-term outcomes compared to CH. For advanced grades of hemorrhoids,
Doppler-guided THD could be a valuable alternative, but there is a need for patients’
selection.Trial registration(retrospectively registered) researchregistry3090.