the new innovative surgical hemorrhoidectomy described below respects the entire anatomy of the ano - rectum without anal distortion after completion of the intervention . it is practiced without any i - v sedation , it is very economical and practical . it is bloodless , and allows to control the amount of tissue to be excised . it has been used exclusively for hemorrhoids grade 3 and grade 4 as well as for thrombosed , circular , and gangrenous , edematous hemorrhoids . it was used elegantly for rectal mucosal prolapse . the patient leaves the office after the operation on his feet due to lack of i - v sedation . it should be mentioned before the description of this new technique of hemorrhoidectomy that the procedure is preferably performed with an ordinary curved hemostat ( also referred to as crile or forceps ) or with a mosquito depending upon the volume of hemorrhoids . preferably , the curved hemostat has been modified by tailoring the two jaws of the forceps in order to have the same width from proximal to the distal part till the articulation of the forceps . this modification thus allows to have an equal and linear surgical wound after the completion of the operation . before beginning the procedure , every step is explained to the patient in order to obtain his or her consent and confidence . preparation for operation is minimal . patient is asked to have bowel movements before coming to the office . the patient is on fasting . neither laxatives , enema nor antibiotics are used preoperatively or during the procedure . in the operating room , a patient 10 is placed in a jackknife position , ( fig1 ) and the buttocks 12 are retracted with adhesive tape 14 or with the help of an assistant . the operative is cleansed with hibitane solution . the area does not need to be shaved . local anesthesia such as with xylocaine 1 % with or without epinephrine is infiltrated subcutaneously into each hemorrhoidal mass to be removed with no . 30 gauge needle at each side , then the infiltration is extended beneath the mucocutaneous junction and the lining of the lower part of the anal canal ( fig2 ). further amount of local anesthetic solution 5 - 7 ml are placed at the four quadrants of the anus after localizing with the index finger 16 the intersphincteric groove . the needle for this purpose is changed for a no . 25 gauge needle to reach the level of anorectal ring at 3 , 6 , 9 , 12 o &# 39 ; clock , before the infiltration of xylocaine is carried out it is ensured by aspiration that a vessel has not been entered . after a successful anesthesia , the sphincteric relaxation can easily be seen . a gentle two - finger dilatation of the anal sphincter is performed to allow the anal canal to be opened . in one embodiment of the present invention , forceps 18 are placed at the perianal skin outside the mucocutateous junction opposite each primary hemorrhoidal cushion ( left lateral 20 , right anterior 22 , right posterior 24 ) ( fig3 ). a gentle traction is exercised on the forceps and an aversion of the hemorrhoidal complex is obtained . no speculum , no retractor is used . for a mixed internal and external hemorrhoids on the same fine , the modified curved crile 26 ( fig4 ) is applied first , at the base of the internal hemorrhoid 28 ( fig5 ) then with a catgut chromic no . 2 a running suture 30 is passed under the modified crile from the anal canal to the perianal skin , then a knife 32 is applied at the concave aspect 34 of the forceps and an excision of the internal hemorrhoidal mass is performed . then the modified forceps is applied at the base of the external hemorrhoid by encroaching on the first row of sutures that was used to secure the internal hemorrhoid . the knife is applied at the concave aspect of the modified crile for the excision of the external hemorrhoid resulting in a nice homogeneous linear surgical wound . hemostasis is secured before excision so there is no need for electrocautery . a long proximal and distal thread is left in order to control a possible hemorrhage by pulling those threads in opposite direction and placing a figure of eight with the same catgut . this is extremely rare event k the sutures are tightly placed close to each other . the same procedure is applied for the remaining hemorrhoidal complexes . no perianal v - shaped incision is made , no submucosal sphincteric dissection is made . no electrocautery is needed : hemostasis is done before excision of hemorrhoids . after excision of every hemorrhoidal mass , the narrowing of the anal orifice can now be seen , allowing a surgeon to control the amount of tissue to be excised by taking less tissue to avoid an eventual anal stenosis . for circular hemorrhoids 36 , ( fig6 ) the most prominent ones are taken off and remaining secondary hemorrhoids are left in place . after 6 - 8 weeks of observation a band ligation for internal hemorrhoids or remaining rectal mucosal prolapse is done if necessary . interestingly , rarely such intervention is needed may be by securing the main arterio - venous complex during the previous operation a shrinkage of the secondary hemorrhoids are induced . some time , it was possible to apply three times the modified hemostat to excise respectively the rectal mucosal prolapse , the internal hemorrhoid , and the external hemorrhoid located in the same quadrant with excellent and very gratifying outcome for the surgeon . the same technique is used for thrombosed and for gangrenous edematous hemorrhoids . in grade 4 / 4 hemorrhoids ( cauliflower ) the intensity of the disease is such that it could be very difficult to localize even the anal orifice . by excising rectal mucosal prolapse and the internal hemorrhoid , at the beginning , the surgical field could be less cumbersome and the remaining operation easier . those cases are encountered specially in woman at the postpartum period . there is no need to combine other form of therapy such as sclerotherapy , infrared coagulation with this particular method , usually the immediate outcome is satisfactory . some times , rubber band ligation is done only after six weeks of recovery , especially in acute cases with thrombosis and strangulation . trimming of redundant skin is done to prevent tag formation . after completion of the operation , the opening of the anal orifice is such that a finger could be introduced very loosely . a dry gauze is applied externally . the patient may leave the office immediately after the operation on his feet due to lack of i - v sedation and with the usual advices given for these types of surgery . the method of the present invention can be used for almost all kind of hemorrhoids with excellent results without any case of internal sphincter or rectal muscle inclusion . more particularly , the method of the present invention can be used for hemorrhoid grade 3 and 4 , thrombosed hemorrhoids , acute hemorrhoidal diseases specially patients in the post partum period , excision of perianal hematoma , excision of rectal mucosal prolapse , and for other surgical conditions of the anal canal , e . g . fissure , fistula . one late mild hemorrhage after one week , could be avoided by adding a figure of eight suture over the site of oozing bleeder . five cases of anal fissure especially in young patients could be avoided by reducing the amount of tissue excised . in young patients , the perianal skin is very tight . by leaving more tissue , less tension is created on the edges of the wound and the possibility of fissure is reduced . on the contrary , in old patients the perianal skin is very loose . by taking more tissue you may achieve a cosmetic result . fissure is more often encountered after thrombosed hemorrhoid excision . the advantages of the method of the present invention over the existing hemorrhoidectomies ( ferguson closed hemorrhoidectomy and st mark &# 39 ; s open hemorrhoidectomy ) procedure are numerous . more specifically , one skilled in the art may appreciate these advantages : it does not require special skill from one skilled in the art to practice the hemorrhoidectomy of the present invention . anyone knowing how to suture can use the method of the present invention . it can be practiced as an office procedure depending upon the medical condition of the patient . it can be done strictly under local anesthesia with xylocaine 1 % with or without epinephrine . the effective dosage of xylocaine never exceeds 50 ml . it is a bloodless operation except for some bleeding that will occur obviously while suturing . allows to control the amount of tissue to be excised and consequently avoids an eventual anal stenosis or fissure . no i - v sedation is needed . the patient leaves the office on his feet with usual recommendations . respect meticulously , due to technical aspect of procedure , the anatomy of the anus without any kind of distortion or ectropion formation . no single tear of the internal sphincter could be possibly produced because the convex aspect of the modified hemostat is applied on the circular internal sphincter . due to this special technique , an accurate apposition of the wound is realized . it could be practiced in all kind of hemorrhoids , even in acute , incapacitating hemorrhoids consisting of thrombosis , prolapse and strangulation of hemorrhoidal tissue involving one or all three primary complexes . easy to learn and practice ; general practitioner could perform the intervention in remote areas . no long - term complications are observed after six weeks of recovery such as persistent posdefecatory anal pain , fecal urgency or inclusion of rectal muscle as observed following stapled hemorrhoidectomy . ( pph ). table 1 below provides a comparison between st . mark &# 39 ; s open hemorrhoidectomy , ferguson closed hemorrhoidectomy , and the method of the present invention . whitehead hemorrhoidectomy has not been mentioned intentionally because it is not practiced anymore . table 1 thus clearly shows the differences and advantages of the present invention over the prior art techniques . while the invention has been described in connection with specific embodiments thereof , it will be understood that it is capable of further modifications and this application is intended to cover any variations , uses , or adaptations of the invention following , in general , the principles of the invention and including such departures from the present disclosure as come within known or customary practice within the art to which the invention pertains and as may be applied to the essential features hereinbefore set forth , and as follows in the scope of the appended claims .
the present invention relates to a new cosmetic method for removing hemorrhoids . the method comprises sequentially the steps of 1 ) isolating a hemorrhoidal mass from a patient with a curved forceps applied at the perianal skin outside the mucocutaneous junction , and eversion of the internal and external hemorrhoidal mass . 2 ) application of another curved forceps at the base of the internal hemorrhoid , and suturing under the forceps with 20 catgut , then amputation of the internal hemorrhoid with a knife . 3 ) leaving the first forceps in place , application of the second forceps at the base of the external hemorrhoid , suturing as above , amputation of the external hemorrhoid , and removal of the forceps . 4 ) this procedure is repeated for the remaining hemorrhoids .