Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Surgical Excision of
Internal and/or External Hemorrhoids
Your symptoms and physical exam suggest that you have hemorrhoids. Hemorrhoids are abnormally
swollen veins in the anal canal. Hemorrhoids can usually be treated with conservative measures, including
Sitz baths and stool softeners. When conservative measures fail to resolve the hemorrhoids, alternative
treatments are offered. Hemorrhoids are on ongoing nuisance, but pose no major health threat. Surgery is
considered only when the hemorrhoids remain troublesome.
Description of the Procedure
Surgical excision of hemorrhoids can usually be performed without admission to the hospital. The
hemorrhoid is excised and the wound sutured shut. An anesthetic pad is left in the anal canal.
Alternative Treatments
1. Rubber band ligation – an excellent first treatment modality if the hemorrhoids are small and
internal.
2. Injection sclerotherapy – a high complication rate and high recurrence rate generally discourage
this form of treatment.
3. Cryotherapy – poor results and time-consuming treatment discourage use of this modality.
4. Conservative management – general first-line management of hemorrhoids, which includes the use
of a high fiber diet and Sitz bath. Other treatments are offered if this is unsuccessful.
Benefits of Treatment
Surgical excision offers a safe, convenient and low risk treatment of hemorrhoids. Coupled with the
aggressive use of stool softeners and a high residue diet, this treatment assures a reasonable low recurrence
rate for hemorrhoids.
Risks/Complications of Treatment
1. Recurrence of hemorrhoids – a new hemorrhoid may develop, particularly if diet and bowel habits
are not changed.
2. Pain – a sense of discomfort in the rectum will be experienced for several days following the
operation. Pain medicine helps but will not completely eliminate the pain. This usually resolves
spontaneously.
3. Bleeding – heavy rectal bleeding will happen occasionally after hemorrhoidal surgery, sometimes as
late as one or two weeks after the procedure is performed. This may require an additional procedure
to stop the bleeding.
4. Ulceration – a small ulcer will normally develop following treatment, that resolves spontaneously.
An ulcer may rarely become large and troublesome.
5. Infection – the surgery site may occasionally become infected. Occasionally, this may be severe
enough to require major surgery to correct. On occasion, a patient has died from not seeking early
treatment for an infection following hemorrhoidal surgery. You should notify your surgeon
immediately should you develop increasing pain, fever, or drainage from the anus or rectum
following surgery.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Most people experience pain, and are not able to
resume normal work activities for a week or two after surgery.
(see other side)
Consent for Treatment
I understand my condition to be hemorrhoids. I have read and understand the above explanation of
the procedure being proposed. My surgeon has answered my questions, and I choose to proceed with
surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people with hemorrhoids benefit from surgical excision, I may not. My
condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless, I understand the need for this surgery and grant permission to the surgeon to proceed on
my behalf.
SIGNATURE _____________________________________________________ DATE _________________
03/01 consent