CO2 Laser surgery:

Unless the hospital you have been referred to has a laser and surgeons who are well trained to use it appropriately this is probably not going to be an option. Lasers have to be used precisely by competent medical personnel and these are costly to install.

The procedure can be performed as a day case patient on grade 3- 4 haemorrhoids. As long as you are fit and healthy and have support at home who can look after you when you go home for at least the following 24 hours. You will be likely to have a general anaesthetic unless it is not suitable in which case you will have a local.

It works by cauterising the tissue at the base of the haemorrhoid which seals the nerves and the blood supply the haemorrhoid can then be removed. 

The haemorrhoids laser treatment procedure 

• The doctor who is performing the procedure will talk to you explain what they are going to do, and will ask for your written permission to perform the procedure.
• This procedure is performed on grade 2-4 haemorrhoids
• If you are happy that you understand both what procedure you are going to have done and have been told of the risks involved with the procedure then you can sign the relevant document.
• The doctor will have discussed with you prior to the day which form of anaesthetic you will be having this will be either local, Spinal, or a General Anaesthetic. Usually this will be performed with a local anaesthetic
• You will be asked to take your clothes off, put on a gown on and  placed in the correct position for the procedure
• You will be positioned either on a couch with stirrups for your feet to go in or on your side on a couch with your knees drawn up to your chest it will depend on the location of the haemorrhoid. ( it will seem all a bit undignified but you will have either a sheet or blanket covering you until the procedure begins
• You will be screened off from the surgeon for your privacy and asked to put on special goggles to protect your eyes, the room will be dark and windows covered
• The procedure will take approximately 15 – 30 minutes
• The haemorrhoids treated with the laser will be operating in a  bloodless field due to the laser, therefore post operatively you should experience either very little or no bleeding

Post procedure pain

You will experience some degree of pain lasting at least 2 weeks especially when passing stools therefore it is very important to maintain a soft stool. This means taking regular pain relief, drinking plenty of fluids and eating food enriched with fibre and possibly the use of a stool softening laxative.

Special precautions

• Ensure you have adequate pain relief available to you.
• Make sure you have someone available to help you should you need it for at least the next twelve hours
• Make sure you are able to urinate easily after the procedure(go for a wee)
• Do not use aspirin for pain relief post procedure as it may encourage bleeding
• Drink plenty of fluids
• Try and do some gentle exercise
• Eat plenty of fibre rich foods so you do not become constipated
• Do not do any heavy lifting for at least four weeks

Healing / recovery time

This is comparative to other treatments and will be 2- 4 weeks

Complications and risks

• You may experience problems passing urine (going for a wee) after the procedure
• You may experience pain during the procedure
• You may experience perianal itching or a burning sensation
• There is a risk of infection although this is uncommon
• Your haemorrhoids may return
• You may have severe bleeding
• Possible short term incontinence

Research comparing a relatively small group of patients was undertaken comparing laser post op recovery time with conventional haemorrhoidectomy.  The findings were such that there were no significant differences between the two operations in the immediate results, regarding post-operative pain, complications or healing time.

Less common Haemorrhoid treatments include Cryosurgery

This is a procedure where haemorrhoid tissue is frozen and eventually sloughs off, it are not popular as a form of treatment due to pain and the watery discharge. The major disadvantage to cryosurgery is the post-operative pain associated it seems to be not as effective as other treatments and people do not tend to want to have repeated treatments due to the pain.

Diathermy – bi-polar

This is used to cause coagulation (burning) of the tissue of the haemorrhoid causing the tissue to fall away. This leaves the tissue underneath fibrosed, like a scar which is hoped will keep the cushions of the anal canal from forming another haemorrhoid. One of the main draw backs of this form of surgery is the burning sensation which local anaesthetic did not completely eliminate during the procedure and post-operative pain. Post operative bleeding was another of the complications.

Radiofrequency Coagulation

This is another form of coagulation (burning) which seals the skin surface causing scaring. Research showed that with early stage 1-2 haemorrhoid treatment this was effective and although patients still experienced pain immediately post operatively the majority of people returned to their activities of daily living quite rapidly. It should be noted that grade 1-2 haemorrhoids do not require the same level of intervention as 3-4 and to date more research is needed with regard to this. However the outlook is distinctly promising with reduced pain, complications and return to work.   

Surgical intervention Haemorrhoidectomy

This operation is the ultimate step when all other avenues have been explored or the situation has arisen where you have thrombosed or are suffering from a strangulated grade 3-4 haemorrhoid which needs treatment.  
Your doctor will have explained the operation to you and any tests that you need will have been organised and completed at the pre-assessment clinic which you will attend prior to going into hospital.

You will be given instructions regarding not eating and drinking anything before the operation. You will also be given detailed instructions about your bowel preparation; this will include a strong laxative which empties your bowels prior to the operation. You may not want to do this, but it is an extremely important aspect of your bowel preparation if the bowel is not clear the surgeon may not proceed.
You will have been advised by the anaesthetist which anaesthetic is appropriate for you this can be either

Regional block – spinal or epidural - numb from waist down

General anaesthetic - a state of unconsciousness whereby you feel no pain or distress

The Haemorrhoidectomy operation
The doctor who is performing the procedure will explain what they are going to do, and will ask for your written consent to perform the procedure. This procedure is performed on grade 3-4 haemorrhoids

1. If you understand both what procedure you are going to have performed and have been told of the risks involved with the procedure then you sign the consent form
2. You will be asked to remove your clothes and put on a gown
3. Prior to going to theatre you will have discussed which anaesthetic is suitable for you with the anaesthetist.
4. You will be escorted to the theatre where you will then have either a general or spinal anaesthetic
5. You will be positioned either on the operating table with stirrups for your feet called the lithotomy position. Or on your front with your bottom raised it will depend on the location of the haemorrhoids. ( it will seem all a bit undignified but you will have either a sheet or blanket covering you until the procedure begins
6. You will have sterile drapes put over you to maintain a sterile field for the surgeon
7. An antiseptic/bacterial solution will be painted around the perineal area to eliminate germs from the skin surface
8. An instrument called a proctoscope will be gently placed in your anus so the doctor will be able to have a good view the haemorrhoid. This will have a light attached so the surgeon may see easily.
9. Local anaesthetic and a blood vessel constrictor will be injected around the haemorrhoids to be treated this will give pain relief to the area as well as reducing the blood flow.
10. The surgeon will then excise (cut away) from the base of the haemorrhoid carefully sealing bleeding vessels with cautery (burn) from the diathermy.
11. Sutures(stitches) are used to tie off larger blood vessels and the haemorrhoid is removed.
12. once the operation is completed non adhesive dressing will be placed around the anus, with dressing gauze and a large sanitary pad this will be taped in position
13. You will be placed on your side after the procedure to cause your buttocks to press together helping with the pressure which reduces bleeding.
14. When you are in recovery the wound site will be inspected frequently to check on bleeding a small amount is expected but larger quantities may require a surgical assessment.
15. 24 hours after the operation the dressings will be removed and you will be encouraged to take a bath.
16. Normal bowel habits should be resumed as soon as possible, and you will be encouraged to eat finer rich foods and drink plenty of fluids. The first bowel movement is often dreaded due to pain however it is important that you open your bowels regularly to prevent constipation.

 Post-operative pain
This is a painful procedure, and it can continue to be uncomfortable and painful for up to 2 weeks after the operation. You will be given regular pain relief medicines to alleviate the pain. You will be given pain relief medication to take when you get home it is important this is taken regularly to maintain a therapeutic pain level. If you do not take pain relief regularly you will be more uncomfortable.

Special precautions 

• Ensure you have adequate pain relief available to you; if you are uncomfortable ask the nursing staff for additional pain relief.
• Make sure you have someone available to help you at home for the next 24 hours when you are discharged form hospital
• Make sure you are able to urinate easily after the procedure(go for a wee)
• Maintain a good  fluid intake
• Take any stool softener or laxatives you have been prescribed
• Try and do some gentle exercise, do not lie in bed or on the couch all the time
• Eat plenty of fibre rich foods so you do not become constipated it will make it very painful
• Do not do any heavy lifting for at least two weeks
• Maintain a good personal hygiene regime and wash after each bowel movement

Healing / recovery time after Haemorrhoidectomy

Most people will takes two weeks off work for recovery but may not be able to return to work for a month depending on the type of work you do. The initial healing takes approximately two weeks until you feel more comfortable but full health can take up to 6 weeks. You may be able to discuss reduced hours with your employer so you are able to resume work gradually.

Complications and risks following Haemorrhoidectomy

• Pain you may find that having your bowels open may continue to cause you pain
• Bleeding – a post-operative bleed can sometimes take place unexpectedly days after the operation  if this occurs you should consult your doctor
• Infection - the internal bowel surface may become infected, you will experience a foul smelling discharge with pus if this occurs.
• Return of the piles – the operation may not be effective
• Faecal (stool/ poo) incontinence – this can happen in the short term do not be alarmed it will  usually will resolve over a short period of time, if not you will need to consult your doctor
• Inability to pass urine (wee) – this is something that might happen immediately post operatively and would be rectified at the hospital
• Anal Fistula / Fissure (a narrow track from inside the bowel to the skin surface)
• Narrowing of the lumen of the bowel (the internal scaring of the bowel has caused it to become smaller)