hemorroidectomy

8/15/2019 hemorroidectomy

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4atients may experience mucoid anal discharge or fecal soilage as internal hemorrhoids prolapse through the anal canal. Thisirritation of the perianal s+in can result in significant pruritus.[1]

Complications

Thrombosis and infection

Thrombosis is the most painful complication of internal or external hemorrhoids. The pain is often severe enough to affectroutine daily activities. 'hile it can occur in large, prolapsed hemorrhoids, thrombosis is more common in external hemorrhoids.3f the epithelium overlying the thrombosed hemorrhoid brea+s down and allows invasion of bacteria, it may lead to infection,which is rare.[%]

Anemia

The incidence of hemorrhoidal bleeding that results in anemia is low.

Classification of hemorrhoids

*xternal hemorrhoids originate below the dentate line and are covered by s5uamous epithelium.

3nternal hemorrhoids are located above the dentate line and are covered by transitional or columnar epithelium.

3nternal hemorrhoids can further be divided into 6 categories determined by the extent of prolapse, as follows7

• 8rade 17 emorrhoids bulge into the lumen of the anal canal but do not descend below the dentate line.

• 8rade #7 emorrhoids prolapse below the dentate line with straining but reduce spontaneously. )ee the image below.

8rade # hemorrhoids.

• 8rade %7 emorrhoids prolapse with straining or defecation and have to be reduced manually. )ee the images below.



8rade % hemorrhoids.

8rade % hemorrhoids.

• 8rade 67 emorrhoids are permanently prolapsed and irreducible. )ee the image below.

8rade 6 hemorrhoids.

Although this grading system has limitations, it is beneficial to determine the efficacy of various forms of treatment.



Indications

*xternal hemorrhoids

Thrombosed external hemorrhoids diagnosed within 9# hours of symptom onset may undergo excision of thrombus with

excellent results. /ertain patients with thrombosis longer than 9# hours who still have maximal pain may see some relief, but the

clot is usually beginning to resorb and expectant management is appropriate. :verall, base the management on the severity of

the patient;s symptoms at the time of diagnosis.[1]

3nternal hemorrhoids

or the most part, symptomatic hemorrhoids are a 5uality of life issue. )tart all patients with conservative management as

described below. 3f this fails to improve the patients; symptoms, offer a procedure.

ailed medical management is the primary indication for surgery. The authors usually offer escalating treatments, from least

invasive to most invasive. or bleeding hemorrhoids refractory to dietary modification, rubber band ligation is their preferred

treatment. )clerotherapy and infrared coagulation are also options.

'ith prolapse of tissue, rubber band ligation re5uires multiple applications, so the authors offer hemorrhoid artery ligation (A<!

or stapled hemorrhoidopexy (procedure for prolapse and hemorrhoids [44]!. The authors prefer A< in women, as there is less

dilation of the sphincter complex and no cutting of tissue. They believe that this provides a safe and effective treatment withoutsignificant ris+ to the sphincter complex. 'ith large prolapsing hemorrhoids, they offer 44 or excision. 3n patients with a large

external component, excision is the most effective option.

)ymptomatic hemorrhoids affecting 5uality of life is the general indication for intervention. )ymptoms include pain, bleeding, and

difficulty with hygiene. 3n some cases of patients on antiplatelet or anticoagulation therapy or patients with hemophilia, surgical

intervention is needed to prevent hemorrhage.

Anesthesia

:ffice procedures

The authors use lidocaine 1= with epinephrine for office excision of a clot from a thrombosed hemorrhoid. A standard bilateral

pudendal nerve bloc+ is used followed by in$ecting the perianal s+in and mucosa. The authors do not use anesthetic for

sclerotherapy, rubber band ligation, or infrared coagulation.

:perative procedures

The authors prefer monitored anesthesia care (A/! with local anesthetic. ost procedures are less than #- minutes and they

can achieve moderate sedation until the bloc+ is complete and then lighten the sedation to reduce the ris+ of apnea.8eneral

anesthesia with an endotracheal tube is re5uired in patients at ris+ for apnea. 3f the patient is to be in lithotomy position, a

laryngeal mas+ airway (<A! is preferred.

All patients should receive local anesthesia with lidocaine and bupivacaine with epinephrine before any incision, unless

contraindicated.

2upivacaine liposome

A liposomal form of the local anesthetic bupivacaine (*xparel! was approved by the >) ood and 0rug Administration (0A! in

:ctober #?11. A single dose infiltrated into the surgical site produces postsurgical analgesia for hemorrhoidectomy. A total dose

of #@@ mg (#? m<! diluted with 1? m< of saline (for a total of %? m<! is used once for hemorrhoidectomy. The mixture is divided

into @ ali5uots (- m< each!. 4erform the anal bloc+ by visualiing the anal sphincter as a cloc+ face and slowly infiltrating 1

ali5uot into each of the even numbers.

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Equipment

:ffice e5uipment

The most common office procedures performed are sclerotherapy and rubber band ligation. 3n addition to whatever agent is

re5uired for sclerotherapy, good lighting and anal retractors are re5uired. The authors use 2uieirschmann anoscopes

(irschmann "ectal )pecula! for office procedures. They prefer lighted retractors because they improve visualiation. They do

not anesthetie for office procedures because they are wor+ing above the dentate line.

or rubber band ligation, use a grasping or suction techni5ue. 3f using the grasping techni5ue, the e5uipment needed includes a

c8ivney ligator, grasping forceps, a loading cone, and rubber bands. 3f using a suction ligator, the e5uipment needed include a

suction apparatus, the suction ligator, and rubber bands.

:perating room e5uipment

The standard hemorrhoidectomy tray has basic instruments as well as basic retractors and a 2ovie cautery. )tandard excision

with open or closed techni5ue re5uires no other specialied e5uipment. Again, the authors prefer lighted retractors because they

improve visualiation these are ordered separately.

3f using other techni5ues such as <iga)ure, armonic, T0, and 44, these items and the appropriate supplies are purchased

separately.

Positioning

The patient can be treated in several positions. /hoose the position in which the patient is the most comfortable.

3n the office, the authors use a tilt table and do all office procedures in the prone$ac++nife position. 3n their opinion this affords

the best lighting, is tolerated well by most patients, and allows excellent visualiation of the anal canal. 3f a tilt table is

unavailable, the left lateral position, with the +nee to chest and buttoc+s over the edge of the table is the most effective.

3n the operating room, the authors also prefer the prone $ac++nife position. The authors routinely use this techni5ue with A/

and sedation. 4lace the patient in the prone $ac++nife position and give light sedation. >se a pudendal bloc+ and local analgesia

and then perform the procedure. 3n patients who are obese or have airway issues, either general anesthesia or lithotomy

position may be used. 'hen the authors use lithotomy, they use /andy /ane stirrups as opposed to yellow fins or Allen stirrups,

as they provide better eversion of the perineum.

Technique

edical management

<ifestyle and diet modification are best suited for patients with only minor symptoms and should be attempted before more

aggressive treatment is underta+en. 3n general, topical creams and suppositories are not effective.

Diet modification

Adding bul+ing agents in the form of fiber is the recommended firstline therapy, and a highfiber diet should be encouraged.

owever, compliance is an issue because many people are not motivated to adhere to a longterm, highfiber diet. 3n this case,

doctors may prescribe psyllium seed extract or methylcellulose to facilitate the consumption of fiber in a more convenient way.

Ade5uate hydration must be encouraged as well. This is generally a good initial approach to reduce hemorrhoidal bleeding and

is most ideal for the treatment of grade 1 and some grade # hemorrhoids. [1, #]

:fficebased procedures

Sclerotherapy






The goal of sclerotherapy is to produce submucosal fibrosis so that prolapse is less li+ely to occur. The solutions commonly

in$ected are phenol, 5uinine urea, and sodium morrhuate. The popularity of sclerotherapy has gradually diminished in favor of

the more effective modalities.[1, #]

Rubber band ligation

"ubber band ligation is a 5uic+ and effective office procedure for the treatment of internal hemorrhoids. The principle behind

rubber band ligation is similar to that of sclerotherapy, in that it results in fixation of the mucosa. The band leads to ischemic

necrosis and finally ulceration of the mucosa. The procedure is performed using an anoscope and a rubber band ligator. The

bands should be placed on the rectal mucosa above the hemorrhoidal group. Bo special bowel prep is re5uired and multiplegroups can be banded during one session. The success rate of rubber band ligation is variable in the literature but has been

reported to be as high as 9-=.[1, %] ore than one banding session may be re5uired.

Infrared coagulation

The infrared coagulator uses heat to induce coagulation of an internal hemorrhoid. <i+e sclerotherapy and rubber band ligation,

the goals are to induce fibrosis and scarring of the hemorrhoids, preventing future bleeding and prolapse. [1] This procedure is

more expensive than rubber band ligation and re5uires specialied e5uipment. <i+e rubber band ligation, repeat procedures are

often re5uired.

:perative treatment of hemorrhoidal disease

The classic operative approach, or criterion standard, is excisional hemorrhoidectomy. *xcisional hemorrhoidectomy is broadly

classified as open or closed. The distinction is made by whether the anorectal mucosa is closed with sutures after the excision.

These procedures are indicated for patients who fail to improve after multiple attempts of nonoperative management or office

based procedures and patients who have mar+edly prolapsed hemorrhoidal disease (grade % and 6!. :ther procedures include

stapled hemorrhoidopexy and A<.

All patients are told to ta+e # leets enemas # hours before the procedure.

Excisional hemorrhoidectomy closed techni!ue

4osition the patient in the prone $ac++nife position. Apply adhesive tape to the buttoc+s and to retract it laterally to aid in

exposure. 4erform a bilateral pudendal nerve bloc+ and infiltrate the perianal s+in and mucosa with lidocaine 1= or bupivacaine?.-= with epinephrine. 3nsert a illerguson retractor for inspection of the anal canal and distal rectum. 8rasp the prolapsed

hemorrhoid in a Celly clamp and retract toward the center of the anal canal. The authors prefer the Celly clamp to visualie the

internal anal sphincter and ensure they are not too deep. 4lace a #? chromic suture in a figure eight manner above the pedicle

first as this decreases blood loss. ar+ an elliptical incision with the +nife from the external component of the hemorrhoid group

to the proximal end of the clamp. *xcise the hemorrhoid with scissors or electrocautery.

This techni5ue allows excision without in$ury to the underlying internal sphincter muscle. /omplete the excision with cautery for

hemostasis. inally, close the wound with a running, absorbable #? suture, beginning at the apex of the wound with a loc+ing

stitch. The authors usually use the original stitch from ligating the pedicle. )mall bites of internal sphincter muscle are included in

the closure to decrease dead space. They often close the incision in an inverted Tshape to ensure no stenosis of the anal canal

)ee the image below.



)urgical excision of hemorrhoids.

Excisional hemorrhoidectomy open techni!ue

4lace the patient in the lithotomy or prone position and prep and drape the area. 3n$ect local anesthesia as described above.

4lace a lighted illerguson retractor. 8rasp the component of hemorrhoidal tissue that is covered by s+in with a Celly clamp.

4ull the hemorrhoid downward, prolapsing the hemorrhoid tissue completely out of the anus, ma+ing visible the rectal mucosa

superior to the hemorrhoid. >se a #? chromic suture to ligate the vascular pedicle as described above.

*xcise the hemorrhoid from the underlying sphincter muscle proximally to its apex. <eave the wound open and apply a

nonadherent dressing.

The patient is advised to change the outer gaue daily as needed. The pac+ing may be removed in #6 hours. )tool softeners

can be used to ensure a more comfortable first bowel movement. Bonnarcotic analgesics can be used to alleviate pain. 4ain is

usually mild during the initial days following the procedure but is exacerbated by bowel movements. )itting in a warm bath

immediately after having a bowel movement may decrease pain.

The patient should be seen for a postoperative visit 6@ wee+s after the procedure at this point they can tolerate a rectalexamination, which is necessary to ensure that there is no stenosis. 3f stenosis is present, the daily use of an anal dilator is

recommended.

Alternati"e energy de"ices

"ecently, the <iga)ure (/oviden!, a bipolar cauteriing device, and the armonic )calpel (*thicon!, an ultrasonic energy device,

have gained popularity. These techni5ues use bipolar diathermy and ultrasound energy, respectively, to completely coagulate

the vessels while limiting thermal spread and excess tissue in$ury. The ris+ of infection and postoperative pain may be reduced

when compared with the standard techni5ues.

"andomied trials have shown that the <iga)ure techni5ue is faster and generally produces less blood loss and pain when

compared with the conventional hemorrhoidectomy. 3nformation on longterm followup is not yet available.[#]

Stapled hemorrhoidopexy

0uring stapled hemorrhoidopexy, remove a ring of mucosa and submucosa approximately 6- cm from the dentate line using a

specific 44 circular stapler. D4exyD the distal mucosa to the proximal mucosa with the stapling device. The procedure also

interrupts the arterial blood supply to the hemorrhoids, allowing involution of the hemorrhoidal plexus. The early experience with

this techni5ue found it to be safe and effective. )ince all the wor+ is done above the dentate line, there is less pain than with

conventional excision. )tudies have shown significant reduction in postoperative pain, a 5uic+er recovery and earlier return to

wor+, and few complications. <ongterm studies suggest that recurrence may be higher relative to conventional

hemorrhoidectomy.[1, %, #] )ee the images below.



)ource7 "oswell , 2ello , emingway 0. /ircumferential

mucosectomy (stapled hemorrhoidectomy!7 randomied, controlled trial. The <ancet, Eol. %--, ar 6, #???99F9G1.

)ource7 eter B, 0emartines B, andschin A*. )tapled vs.

excision hemorrhoidectomy, longterm results of a prospective randomied trial. Archives of )urgery. #??#.

Stapled hemorrhoidopexy techni!ue

The preparation of the patient is the same as conventional hemorrhoidectomy. 4osition the patient either in the prone $ac++nife

or lithotomy position. 8eneral anesthesia is typically used, although the procedure may also be done with A/ and local

anesthesia as described above. 3n$ect local anesthesia as described. *vert the anoderm slightly and insert a circular anal dilator

and anoscope, which reduces the prolapse. "emove the dilator and the mucosa that was prolapsed falls into the lumen of the

anoscope, which is transparent to facilitate easy visualiation of the dentate line.

4lace an anal retractor and place a #? 4rolene purse string suture in the mucosal layer at least 6- cm proximal to the dentate

line. Assess the complete purse string via digital examination. eel the mucosa circumferentially as the string is pulled. Bo

suture should be felt. :pen the dedicated %%mm hemorrhoidal circular stapler fully and introduce it into the anal canal proximal

to the purse string, which is then tied. 4ull the threads through the holes on the sides of the stapler and +not or hold with forceps.

/lose the stapler while holding traction on the sutures and gently pull outward.

:nce the stapler is completely closed, wait one minute for hemostasis and vessel compression. 3f this procedure is being

performed on a woman, a vaginal examination should be performed before firing the stapler to ma+e sure there is no vaginal

entrapment in the device. After firing and removing the stapler, use the retractor to examine the staple line, and if there is any

bleeding or gaps, place sutures at this time.[%, #] 0o not pac+. 4lace dry gaue on the anal verge and +eep it in place with mesh

underwear. )ee the images below.






44 stapled hemorrhoidectomy7 anatomy of the anal canal.

44 stapled hemorrhoidectomy7 prolapsed internal hemorrhoids.



44 stapled hemorrhoidectomy7 pursestring suture placed 6- cm

above dentate line.

44 stapled hemorrhoidectomy7 retracting and operating

anoscopes.

44 stapled hemorrhoidectomy7 placing pursestring suture.



44 stapled hemorrhoidectomy7 schematic of circumferentially

excised mucosa.

44 stapled hemorrhoidectomy7 schematic of approximated

mucosa.



44 stapled hemorrhoidectomy7 completed procedure.

44 device through purse string suture.



44 stapled hemorrhoidectomy7 A! stapler inserted through purse string and 2! excised mucosa and

stapler.

44 stapled hemorrhoidectomy7 completed procedure.

Stapled hemorrhoidopexy postoperati"e management

Advise the patient to change the outer gaue daily as needed. )tool softeners can be used to ensure a more comfortable first

bowel movement. 4ain is usually most severe in the first 9# hours after the procedure and can be alleviated with nonnarcotic

analgesics. 4ain is not exacerbated by bowel movements.

)ee the patient for a postoperative visit 6@ wee+s after the procedure, as at this point they can tolerate a rectal examination.

#emorrhoid artery ligation

*xcision of anal tissue by any means re5uires a good deal of prudence. The anal sphincter is at ris+ for being damaged if the

depth of the excision is too great. A techni5ue recently introduced is +nown as 0opplerguided hemorrhoid artery ligation (A<!.

Two platforms are currently available in the >nited )tates, transanal hemorrhoidal dearterialiation (T0! and one from the

Agency for edical 3nnovations (A3!. The authors have been using T0 for the past 6 years. The procedure involves 0oppler



guided ligation of the arteries supplying the hemorrhoidal cushions, thereby decreasing the pressure within the plexus

hemorrhoidalis. A hemorrhoidopexy can then be performed if there is redundant mucosa. )ince the introduction of endorectal

0opplerguided T0 in 1FF- by orinaga, several reviews of this therapy have been completed. This techni5ue has evolved

over the past decade, and it is being recognied as both a safe and effective means to treat symptomatic grade #6

hemorrhoids.

#emorrhoid artery ligation techni!ue

4lace patients either in the prone $ac++nife or lithotomy position. 4atient preference and comorbidities dictate the anesthetic

plan. 8ive local anesthetic to all patients. The +it includes a lighted anal retractor with 0oppler, needles, and a needle driver.4lace the T0 device into the anal canal. >se the 0oppler probe to identify pulsatile arterial segments. <oad the provided

absorbable suture to the appropriate mar+s on the needle driver and then use the suture to ligate the artery with # bites until the

0oppler signal is obliterated. 3f there is redundant hemorrhoidal tissue, remove the 0oppler slide and perform a

hemorrhoidopexy using the same suture running distally. Bever come closer than 1 centimeter from the dentate line. [6]

0uplicate the procedure circumferentially until all signals are obliterated. )ix to seven separate bites are commonly re5uired. 0o

not pac+ or place gaue. 4atients are discharged the same day. )ee the images below.

emorrhoid artery ligation device from T0 America.



T0 America slide7 The needle is premeasured to ligate the

hemorrhoidal arteries.

#emorrhoid artery ligation postoperati"e management

)tool softeners can be used to ensure a more comfortable first bowel movement. 4ain is usually most severe in the first 9#

hours after the procedure and can be alleviated by nonnarcotic analgesics. 4ain is not exacerbated by bowel movements.

)ee the patient for a followup visit 6@ wee+s after the procedure.

Pearls

:verview

'hen dealing with patients with hemorrhoids, isolating the predominant symptom is extremely important. 4atients may have

external tags and complain of bleeding, so a simple rubber band ligation may suffice. Always tailor the therapy to the specific

symptoms, as hemorrhoids are a 5uality of life issue.

:ffice procedures

4atient comfort is the +ey to success. Bothing is worse for a patient than undergoing a procedure of the anorectum. <idocaine

ointment is good to use for a rectal examination and allows some local analgesia. 4lacing the anoscopes slowly and allowing the

anorectal inhibitory reflex to initiate allows for easier placement. Always have all the e5uipment ready and have bac+up

materials (second rubber band ligator! ready. After the procedure, allow the patients a few minutes to rest. 2eware of a

vasovagal response. 4atients who get nauseated or have excessive sweating during the procedure are at ris+ for a syncopal

episode.

:perations

3n$ecting local anesthetic with epinephrine decreases bleeding. Always remember to aspirate first so that epinephrine is not

in$ected into a blood vessel. 'hen in$ecting the mucosa, elevate it off the internal sphincter with the in$ection to help ensure the

sphincter is not clamped during an excisional hemorrhoidectomy.

0uring a stapled hemorrhoidopexy, evert the anal canal with 6 sil+ sutures prior to placing the dilator. 3t brings the dentate line

closer to the anal verge, decreasing the possibility of incorporating anoderm into the staple line. 3f a large amount of redundant

mucosa is present, place a small sponge into the anal canal before inserting the anoscope, as it will allow better visualiation of

the operative field.



0uring A< procedures, ma+e sure the hemorrhoidopexy is not too close to the dentate line leaving at least a 1centimeter

margin will help decrease postoperative discomfort.

:fficebased procedures

)clerotherapy, rubber band ligation and infrared coagulation have similar morbidities. 4otential complications include pain,

urinary retention, bleeding, and local sepsis. /omplications are generally due to poor placement of in$ections, rubber bands, and

the coagulator.

2leeding, which is usually limited, may also occur as the mucosa sloughs off and an ulcer forms. This may especially be true in

patients continuing antiplatelet medications after treatment. 4erianal sepsis after rubber band ligation has been reported. This

dreaded complication is exceedingly rare in patients that are not immunocompromised.

Acute postoperative complications

Pain

4ain is an important factor in a patientHs decision whether or not to undergo hemorrhoidectomy. owever, postoperative pain is

very dependent on the individual patient. Therefore, it is natural for surgeons to want to use a procedure that produces as little

pain as possible.[%] Bewer techni5ues li+e 44 and A< have been shown to cause significantly less pain when compared with

the conventional techni5ues.

$rinary retention

>rinary retention can occur in up to 1-= of patients posthemorrhoidectomy.[%] any factors are thought to contribute to urinary

retention following hemorrhoidectomy, with pain being a ma$or contributor. 4erioperative restriction of fluid inta+e has been

shown to reduce the need for catheteriation. 3n general, most patients have no further issues after 1 catheteriation. en with

enlarged prostates may re5uire an indwelling oley catheter for up to 9# hours.

Bleeding

2leeding is often minor and can be stopped with external pressure. 3f the location of the bleeding is uncertain, or if the patient

becomes hemodynamically unstable with undetected bleeding, he or she should be examined in the operating roomunder general anesthesia. After the rectum is irrigated with sterile saline, the bleeding site should be ligated under direct vision.

/hronic complications

Poor %ound healing

An anal fissure or ulceration, although rare, may develop if one of the hemorrhoidectomy sites fails to heal properly. 3f it

develops, supplemental fiber, nitroglycerin ointment, and diltiaem creams may be used to aid healing.[%] )tools should be +ept

soft. ealing generally occurs without further intervention.

Abscess or fistula

Anorectal sepsis formation is rarely reported following hemorrhoid procedures. 3n these cases, the wound should be examined

under anesthesia and reopened to promote continued drainage.

Incontinence

ran+ incontinence is rare, although some patients experience lea+age and soiling from the anus that usually resolves by @

wee+s to # months. [%] There are not enough data to meaningfully comment on the incidence after stapled hemorrhoidopexy or

A<.

Anal stenosis






This complication is uncommon and can be prevented in most cases by leaving significant mucosal bridges between excision

sites. >sing a closed techni5ue with a retractor in place ensures ade5uate room in the anal canal.

3f any narrowing of the anal canal is observed during the first postoperative visit, encourage the patient to use an anal dilator

along with diet modification. Anoplasty may be considered if the anus cannot be easily dilated and medical treatment has failed.[%

Postoperative Care after Hemorrhoidectomy, HemorrhoidectomyComplications

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Postoperative Care after Hemorrhoidectomy

After surgery, the patient is taken to the postanesthesia care unit (PACU). Patients are closely monitored by the

nursing sta and remain there until they are stable. !he amount of time spent in the PACU depends on the

patient"s progress and the type of anesthesia received. #eneral anesthesia must $ear o and the patient must

be a$ake and coherent before they leave the PACU.

%utpatients are transferred to another room to &nish their recovery, and inpatients are taken to their hospital

room. !he intravenous line remains in until clear li'uids are taken and tolerated. !his can be almost immediately

follo$ing surgery, especially if local anesthesia $as used. ometimes general anesthesia induces nausea, $hich

may delay taking oral uids. %nce clear li'uids are tolerated, the diet progresses to solid foods.

pinal anesthesia usually $ears o $ithin a fe$ hours. *uring the &rst hour follo$ing surgery, patients lie at on

their back to decrease the risk for an anesthesia+induced headache, $hich can be painful and prolonged. efore

being discharged, the patient must regain full sensation in the lo$er part of the body.

ecause of s$elling and the dressing, some patients have temporary di-culty urinating. f there is urgency, but

the urine $ill not o$, a catheter is used to empty the bladder. %utpatients may need to stay overnight, if they

are unable to urinate. Patients must be able to urinate on their o$n before being discharged.

/ven though the anesthesia has $orn o, most patients remain groggy for the rest of the day. Patients must

arrange for a family member or friend to be $ith them if they are being discharged the same day as the surgery

Patients e0perience pain and discomfort during the immediate postoperative period (i.e., about 12 days). Pain

medication is prescribed and should be taken as directed. ometimes relief can be achieved $ith an over+the+

counter preparation such as !ylenol3. f a pack $as inserted into the rectum follo$ing surgery, the physician

usually removes it in a day or t$o.

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hemorroidectomy

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