Haemorrhoid surgery in Niš

Haemorrhoids are cushions of blood vessels that everyone has at the lower end of the bowel, in the anal canal and around the anus. When they become enlarged, bleed or come out (prolapse), this is called haemorrhoidal disease. Haemorrhoid surgery is a procedure in which the surgeon removes or shrinks enlarged haemorrhoids, ties off the blood vessels that supply them or puts them back into place. The procedure is part of proctological surgery.

Haemorrhoids can be internal, inside the anal canal, or external, under the skin around the anus. Internal haemorrhoids are divided into four grades:

• Grade I: they do not come out of the anal canal, but may bleed.
• Grade II: they come out when you open your bowels and go back in on their own.
• Grade III: they come out and can only be pushed back in by hand.
• Grade IV: they are permanently outside and cannot be pushed back in.

The surgeon assesses the grade, number and size of the haemorrhoids during an examination. This determines whether surgery is needed and which method may be suitable.

For milder grades, treatment usually starts without surgery: changes to diet, drinking enough fluids, topical treatment and outpatient procedures such as rubber band ligation and sclerotherapy.

Surgery is most often recommended:

• for grade III and IV haemorrhoids,
• when symptoms, for example bleeding, persist or keep coming back despite treatment without surgery and outpatient procedures,
• when there are both pronounced internal and external haemorrhoids.

Blood in the stools does not always come from haemorrhoids. This is why the surgeon examines the lower end of the bowel before deciding on the procedure. Depending on the findings and your age, the surgeon may also recommend further tests, for example a colonoscopy. The decision on surgery is made by the doctor and the patient together, after an examination.

Severe pain with a hard, painful lump near the anus, a prolapsed haemorrhoid that cannot be pushed back in, or heavy bleeding are reasons to be seen urgently, rather than waiting for a booked appointment. In these cases, contact a doctor without delay or call the emergency medical service on 194.

Several methods are used in haemorrhoid surgery. Each has its own advantages and limitations.

• Conventional haemorrhoidectomy: the surgeon cuts away the enlarged haemorrhoids. It is most often used for grade III and IV haemorrhoids and for pronounced external haemorrhoids. Recovery usually takes longer than after less extensive methods.
• Laser haemorrhoidoplasty: a thin laser probe is inserted into the haemorrhoid and shrinks it from the inside with laser energy, without conventional cutting of tissue. It is most often considered for grade II and III haemorrhoids.
• Dearterialisation (THD or HAL): using a Doppler ultrasound probe, the surgeon locates the arteries that supply the haemorrhoids and ties them off; prolapsed haemorrhoids are lifted and secured with stitches, without cutting away tissue. It is most often considered for grade II and III haemorrhoids.
• Stapled haemorrhoidopexy (Longo procedure): a special circular instrument is used to remove a ring of the lining (mucosa) above the haemorrhoids, and the haemorrhoids are lifted and returned to their natural position. It is most often considered for grade II and III haemorrhoids with marked prolapse. It is not intended for treating external haemorrhoids.

After less extensive methods (laser, dearterialisation, stapled haemorrhoidopexy), pain is usually milder and recovery shorter, but the likelihood of haemorrhoids coming back is usually higher than after a conventional haemorrhoidectomy.

Which method may be suitable depends on the grade, number and size of the haemorrhoids, any associated conditions (for example an anal fissure) and general health. Sometimes methods are combined. At the consultation, the surgeon explains which methods are performed at Maja Hospital and which one suits the patient's findings.

Arrive for admission at the time agreed with the hospital, fasting and with your bowel prepared according to the instructions you have been given. Bring your ID card, your test results and a list of the medicines you take regularly.

The day usually goes as follows:

• admission, settling into your room and checking your results,
• a talk with the anaesthetist, if this has not been done earlier, and signing the consent form for the procedure and the anaesthetic,
• the procedure in the operating theatre, under the anaesthetic chosen by the anaesthetist,
• monitoring after the procedure, until the anaesthetic wears off,
• pain control and checking that you can pass urine, especially after a spinal anaesthetic,
• discharge with a discharge summary, instructions on aftercare, diet and medication, and a follow-up appointment arranged.

Do not drive for at least 24 hours after a general or spinal anaesthetic or after sedation; the anaesthetist will tell you the exact period. You will need someone to accompany you home.

At Maja Hospital, proctology consultations and haemorrhoid surgery are carried out by specialists in general surgery who work in colorectal surgery and proctology: Dr Milica Nestorović, Prim. Dr Dragoslav Miljković and Dr Dragan Mihajlović, MSc. The pre-operative examination is carried out by the surgeon, and the anaesthetic is managed by a specialist in anaesthesiology and resuscitation.

Like any surgical procedure, haemorrhoid surgery carries certain risks. The most common ones are temporary: pain and discomfort when opening your bowels, minor bleeding, swelling and difficulty passing urine in the first few hours after the procedure. Less common risks are heavier bleeding, which can also occur at home, most often between the 7th and 14th day after the procedure, as well as infection, reduced control of wind or stools (usually temporary), narrowing of the anal canal and haemorrhoids coming back. Some methods also have their own rare complications, which the surgeon discusses when suggesting a method.

The surgeon and the anaesthetist discuss the possible risks with the patient before the consent form is signed.