Procedure Excision of haemorrhoids
Time 20 min
Pain ++/+++
Position Supine, lithotomy, head down
Blood loss Not significant
Practical technique GA, SV LMA and/or caudal
Spinal (“saddle block”)
  • Assess suitability for LMA + lithotomy + head down position. Consider ETT if the patient is obese.
  • Opioid analgesia—short but intensely painful stimulus. Fentanyl and/or alfentanil is a good option.
  • Ensure sufficient depth of anaesthesia—beware laryngospasm/airway difficulties if the depth of anaesthesia is insufficient.
  • Caudal anaesthesia is useful for postoperative analgesia (bupivacaine 0.25% 20 ml), but beware the risk of urinary retention. Infiltration by the surgeon during the procedure is probably as effective.
  • Potential for bradycardia/asystole as surgery starts. Have atropine available.
  • Best to avoid the PR route of drug administration.
Special considerations
  • Beware spinal followed by an immediate head down tilt.
  • Anal stretch is an intense stimulus. Before the surgeon performs this manoeuvre deepen the anaesthetic, e.g. increase volatile and give a bolus of alfentanil (500 µg). The anal stretch can also produce an increase in vagal tone. Be prepared for this.
  • If the patient has a murmur remember to give SBE prophylaxis.
  • A sacral only spinal block (“saddle block”) using heavy bupivacaine is a useful alternative with little effect on cardiovascular dynamics.
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