Hemorrhoidectomy

Anesthesia Implications

Position: Supine, Lithotomy, Prone, Jack-Knife, arms at side on armboards
Time: 30-60 min (short)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

Positioning – Supine with lithotomy is the most common. Some surgeons will prefer to have the patient prone. In the case of prone, an endotracheal tube would be indicated. Jackknife is also suggested as a possible position.

Intraop pain preparation – excision of a hemorrhoid is extremely stimulating. Make sure to have the patient deep enough before the surgeon begins cutting. Once the drapes are up, this is a good cue to give additional fentanyl.

Postoperative pain preparation – patient will be in extreme pain postoperatively if the surgeon does not give an perianal block. Ask ahead of time. If the anal block is applied, immediate postoperative pain should be minimal.

From the Pros – We routinely do these under spinal MAC with pt in jacknife. The spinal is low dose (I usually use 0.3-0.6 mls of the hyperbaric bupi in the spinal kit.) If I’m feeling fancy I’ll put 10-15mcgs of Fentanyl intrathecally as well. I then give a small dose of precedex & ketamine with a low dose propofol infusion. Pts do great.

Prone Position (general considerations): Maintain cervical neutrality. Keep IV’s out of the antecubital space. The patients arms are typically flexed, which will kink the IV. Eye protection should be used as the prone position heightens the risk of corneal abrasion and/or traction on the globe (which can result in blindness). Check the patients eyes/ears/nose regularly throughout the case to ensure they are free of pressure. Positioning of the leads is typically high on the posterior and posterolateral back (somewhere free of pressure and out of surgical borders). Keep your connections and tubing where you’ll have fast access.