Simple harmonic scalpel hemorrhoidectomy utilizing local anesthesia combined with intravenous sedation: a safe and rapid alternative to conventional hemorrhoidectomy.

BACKGROUND: Harmonic Scalpel(R) hemorrhoidectomy (HSH) is an established surgical therapy for the treatment of symptomatic grade III and IV hemorrhoids. Hemorrhoid surgery is still being performed as an inpatient procedure with general or regional anesthesia in many centers today. There was a trend toward performing hemorrhoid surgery as an ambulatory procedure using local anesthesia supplemented with intravenous sedation. The aim of the current study was to evaluate the safety and efficacy of HSH performed with combination local anesthesia and intravenous sedation in an ambulatory surgical center. MATERIALS AND METHODS: A retrospective review was performed on the clinical charts of all patients undergoing HSH in an ambulatory surgical center from 2001 to 2005. All hemorrhoidectomies were attempted under propofol/ketamine intravenous sedation and local anesthesia in the prone position. A simple, open technique without routine suture was used. RESULTS: During the study period, 180 patients (70 females) underwent HSM. Mean procedure and total operating room time were 12 and 28 min, respectively. One patient (0.6%) was converted to general endotracheal anesthesia. Ten patients (5.6%) required post anesthesia care unit (PACU) observation. All patients were discharged home after the procedure. Postoperative complications occurred in 19 patients (10.6%). There were no reoperations and the total readmission rate was 3.7%. CONCLUSION: HSH performed with a combination of intravenous sedation and local anesthesia is safe and effective in the ambulatory surgery setting. The combined technique was associated with a rate of complications comparable to published series utilizing conventional hemorrhoidectomy techniques. Added benefits include shorter hospital stay and a potential for cost savings.

Combination propofol/ketamine is a safe and efficient anesthetic approach to anorectal surgery.

PURPOSE: Concerns persist regarding respiratory complications from combination deep intravenous sedation and local anesthesia for prone position anorectal surgery. We examined the safety and efficacy of this approach by using a propofol-based and ketamine-based technique. METHODS: A retrospective review was conducted on all patients undergoing anorectal surgery. Outcomes (perioperative times, specific complications) were compared with respect to operative position and anesthetic approach. Significance was determined using Student's t-test and chi-squared analysis. RESULTS: Surgery was performed on 448 patients during a three-year period. There was no significant difference in the two anesthetic groups with regard to age and gender. There were 19 anesthesia-related adverse events occurring in the study group (Monitored Anesthesia Care Group): nausea and vomiting (n = 8), airway obstruction necessitating conversion to general anesthesia (n = 2), excessive pain (n = 2), urinary retention (n = 5), and hospital readmission (n = 2). These occurred in <5 percent of those receiving the combination technique (19/407). Although there was no difference in total procedural time, there was a significant difference in total time spent in the operating room (P = 0.001) and in the hospital overall (P = 0.002). Of the patients receiving combination technique anesthesia, only 31 (7 percent) required the use of the postanesthesia care unit. All patients receiving general anesthesia (n = 23) required the postanesthesia care unit. CONCLUSIONS: Combination deep intravenous sedation with local anesthesia based on propofol and ketamine is a safe and effective technique for prone-position anorectal surgery. It results in decreased use of the postanesthesia care unit and earlier hospital discharge, reflecting a more efficient use of hospital resources.