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.
