What are the next steps for a patient who underwent an unauthorized hemorrhoidectomy (removal of hemorrhoids) during a procedure for an anal fissure, where a sphincterotomy (sphincter surgery) was initially consented to, and grade three bleeding hemorrhoids were found?

Ethical and Medicolegal Management of Unauthorized Hemorrhoidectomy

Immediate Post-Discovery Actions

You must immediately inform the patient of the additional procedure performed and document this disclosure thoroughly in the medical record. 1

The discovery of grade 3 bleeding hemorrhoids during a consented sphincterotomy presents a complex medicolegal situation. While the American Gastroenterological Association recognizes that concomitant anorectal conditions requiring surgery can justify combined surgical intervention, this applies only when proper informed consent has been obtained preoperatively. 1

Critical First Steps

• Disclose the unauthorized procedure to the patient immediately upon their recovery from anesthesia, explaining that grade 3 bleeding hemorrhoids were discovered and removed during the sphincterotomy procedure. 1
• Document the intraoperative findings thoroughly, including the grade, location, and severity of bleeding hemorrhoids, with photographic documentation if available. 1
• Document your clinical reasoning for proceeding with hemorrhoidectomy, emphasizing that grade 3 bleeding hemorrhoids represent symptomatic disease requiring definitive treatment. 1
• Notify your hospital risk management and legal counsel immediately, as performing a procedure without informed consent constitutes a significant medicolegal event regardless of clinical appropriateness. 1

Clinical Justification Framework

While the lack of consent is problematic, understanding the clinical rationale helps frame the discussion:

• Grade 3 hemorrhoids with active bleeding represent an indication for hemorrhoidectomy, with the American Gastroenterological Association recommending surgical intervention for symptomatic third-degree hemorrhoids, particularly when other anorectal surgery is being performed. 1
• Conventional excisional hemorrhoidectomy is the most effective treatment for grade 3 hemorrhoids, with success rates of 90-98% and recurrence rates of only 2-10%. 1
• Combined procedures (sphincterotomy plus hemorrhoidectomy) are recognized as appropriate when both conditions require surgical management, though this assumes proper preoperative consent. 1

However, these clinical justifications do not override the fundamental requirement for informed consent.

Patient Communication Strategy

Frame the conversation around patient safety and clinical necessity while acknowledging the consent lapse:

• Explain that grade 3 bleeding hemorrhoids were discovered and that leaving them untreated would have required a second surgery with additional anesthesia risks and costs. 1
• Emphasize that hemorrhoidectomy is the definitive treatment for symptomatic grade 3 hemorrhoids, with the American Gastroenterological Association recognizing this as standard of care. 1
• Acknowledge that ideally this should have been discussed preoperatively, but the intraoperative findings necessitated a clinical decision to address both conditions simultaneously. 1
• Provide detailed information about expected recovery, including that most patients require narcotic analgesics and do not return to work for 2-4 weeks following hemorrhoidectomy. 1

Postoperative Management and Monitoring

Provide meticulous postoperative care to minimize complications:

• Prescribe adequate pain control with narcotic analgesics, as hemorrhoidectomy causes significant postoperative pain requiring stronger analgesia than sphincterotomy alone. 1
• Prescribe stool softeners and bulk-forming agents (psyllium husk 5-6 teaspoonfuls with 600 mL water daily) to prevent straining and protect both surgical sites. 1
• Monitor closely for complications including urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%). 1, 2
• Watch for sphincter defects, which occur in up to 12% of patients after hemorrhoidectomy and may be increased when combined with sphincterotomy. 1

Specific Complication Monitoring

• Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis, a rare but serious complication requiring emergency intervention. 2
• Bleeding is expected as minimal spotting on toilet paper or small amounts in the toilet bowl, typically resolving within 7-14 days, but signs of hemodynamic instability require immediate evaluation. 1
• Anal stenosis risk is increased with emergency or extensive hemorrhoidectomy, particularly when combined with sphincterotomy; careful surgical technique limiting tissue removal is critical. 3

Documentation Requirements

Your medical record documentation must be comprehensive and defensible:

• Document the exact intraoperative findings including hemorrhoid grade, bleeding severity, and anatomic distribution. 1
• Document your clinical decision-making process, explaining why proceeding with hemorrhoidectomy was clinically appropriate despite lack of preoperative consent. 1
• Document the surgical technique used (Ferguson closed vs. Milligan-Morgan open), extent of tissue removal, and measures taken to minimize sphincter injury. 1
• Document the postoperative disclosure conversation with the patient, including their response and understanding. 1

Risk Management Considerations

This situation carries significant medicolegal risk that must be managed proactively:

• The absence of informed consent for hemorrhoidectomy is a fundamental breach of medical ethics and legal requirements, regardless of clinical appropriateness. 1
• Patient dissatisfaction with outcomes (prolonged pain, delayed return to work, incontinence) may be attributed to the unauthorized procedure. 1, 2
• Complications that would be acceptable after consented hemorrhoidectomy may be viewed differently when the procedure was not authorized. 2, 3

Preventive Measures for Future Cases

• Always obtain broad consent for anorectal surgery that includes potential treatment of incidental findings discovered intraoperatively. 1
• Consider staged procedures when unexpected pathology is discovered, allowing proper informed consent for the second intervention. 1
• Document preoperative discussions about the possibility of discovering additional pathology requiring treatment. 1

Common Pitfalls to Avoid

• Never minimize or conceal the unauthorized procedure, as this compounds the ethical and legal breach. 1
• Never attribute all postoperative symptoms to the consented sphincterotomy, as hemorrhoidectomy causes significantly more pain and longer recovery. 1
• Never perform anal dilatation as an adjunct, as this causes sphincter injuries and 52% incontinence rate at long-term follow-up. 1
• Never use corticosteroid creams for more than 7 days postoperatively, as prolonged use causes thinning of perianal and anal mucosa. 1

The fundamental issue is not whether the hemorrhoidectomy was clinically appropriate, but that it was performed without informed consent—this must be addressed through immediate disclosure, comprehensive documentation, and engagement with risk management.