Improved Outcomes in Colon and Rectal Surgery part 19. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | 17 Hemorrhoidal surgery Dan R Metcalf and Anthony J Senagore CHALLENGING CASE A 38-year-old man presents to your office after receiving an urgent hemorrhoidectomy 1 year previously. He had continued pain and bleeding with bowel movements. He feels his anus is too tight and continues to be symptomatic despite attempts at dilatation daily fiber and stool softeners. Examination reveals three healed incisions and anal stenosis. The anus will only admit the tip of your finger with discomfort. CASE MANAGEMENT The patient has anal stenosis due to removal of an excessive amount of anoderm with his surgery. The management of refractory posthemorrhoidectomy stenosis usually requires some type of flap repair. The choice of flap repair selected will depend on the degree of stenosis and the surgeon s experience. The editors have found one or multiple house advancement flaps to be the most common option chosen in our practice. INTRODUCTION Few diseases are more chronicled in human history than symptomatic hemorrhoidal disease. 1 2 Citations of hemorrhoidal disease have been noted in historic texts dating back to Babylonian Egyptian Greek and Hebrew cultures. 1 2 A multitude of treatment regimens have been offered including anal dilation various topical liniments and the often feared red hot poker. 3 4 Although few people have died of hemorrhoidal disease some patients wish they had particularly after therapy and this fact led to the beatification of St. Fiachre the patron saint of gardeners and hemorrhoidal sufferers. 5 This chapter will guide the practitioner to a more humane approach to hemorrhoidal disease with the emphasis on cost-effectiveness and obtaining superior short and long-term outcomes. ANATOMY ETIOLOGY Hemorrhoidal cushions are located within the submucosa of the upper anal canal and are a normal component of the anorectal anatomy. These cushions are composed of blood vessels smooth muscle Treitz s muscle connective tissue and elastic tissue. 6 Figure .
