- Hemorrhoids Treatment & Management
- Surgical Treatment: Evidence-Based and Problem-Oriented.
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- Surgical Management of Hemorrhoids
Because it's highly sensitive near the cuts and you might need stitches, the area can be tender and painful afterward.
Recovery most often takes about 2 weeks, but it can take as long as 3 to 6 weeks to feel like you're back to normal. PPH is also called a stapled hemorrhoidectomy. The doctor will use a stapler-like device to reposition the hemorrhoids and cut off their blood supply. Without blood, they'll eventually shrivel and die. This procedure moves the hemorrhoid to where there are fewer nerve endings, so it hurts less than a traditional hemorrhoidectomy.
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You'll also recover faster and have less bleeding and itching. And there are generally fewer complications. Pain is the most common complaint, especially when you're pooping. You can take over-the-counter pain relievers, such as acetaminophen, aspirin , or ibuprofen, if your doctor says it's OK. Soaking in a warm bath may help, too. If your anal sphincter gets damaged during surgery, you could have accidental bowel or gas leaks, a condition called fecal incontinence. Continued After Hemorrhoid Surgery Pain is the most common complaint, especially when you're pooping.
Stool softeners can make it easier to poop. Exact incidence in developing countries is unknown, but the disease is being more frequently encountered, perhaps due to westernized life style. Report of first recorded treatment for hemorrhoids comes from the Egyptian papyrus dated BC: Smear a strip of fine linen there -with and place in the anus, that he recovers immediately. Hippocrates in BC wrote of hemorrhoids treatment similar to today's rubber band ligation procedure thus: A Roman physician named Celcus 25 BC - AD 14 described the ligation and excision surgeries, as well as possible complications.
Galen AD 13I - also promoted the use of severing the connection of the arteries to veins in order to reduce pain and avoid spreading gangrene. The Indian Susruta Samhita , an ancient Sanskrit text dated between the fourth and fifth century AD , described treatment procedures comparable to those in the Hippocratic treatise, but with advancement in surgical procedures and emphasis on wound cleanliness. During the 19 th century, another mode of treatment for hemorrhoids, called anal stretching or rectal bouginage, became popular. In , Fredrick Salmon, the founder of St. The diathermy hemorrhoidectomy by Alexander Williams, rubber band ligation by Barron, and the stapled hemorrhoidectomy by Longo were three additional developments in the late 20 th century.
Hemorrhoids are cushion sinusoids thought to function as part of the continence mechanism and aid in complete closure of the anal canal at rest. Secondary cushions may be present. Bleeding and thrombosis of the pre-sinusoidal arterioles may occur in association with prolapse. Proposed etiological factors include constipation, prolonged straining, pregnancy, obesity, ageing, hereditary, derangement of the internal anal sphincter, weak blood vessels and absent valves in the portal vein. The erect posture of humans is also a predisposing factor. Despite several studies, the pathogenesis of hemorrhoids still remains unclear.
Hemorrhoids can either be external or internal [ Figure 1 ]. The external variety is covered by skin below the dentate line, while the internal variety lies proximal to the dentate line. Combination of the two varieties constitutes interoexternal hemorrhoids. Internal hemorrhoids are further classified into the following grades:. Grade I — Hemorrhoids bleed and may protrude into, but do not prolapse out of, the anal canal.
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Grade IV — Hemorrhoids cannot be reduced. They are permanently prolapsed [ Figure 2 ]. There is no similar classification for external hemorrhoids; they are considered to be swellings of the skin and endoderm around the anus. The main complaints are bleeding during or after defecation, pain, prolapse, itching and peri-anal soiling. Diagnosis is made by examining the anus and anal canal, and it is important to exclude more serious causes of bleeding, like rectal cancer.
Differential diagnosis of hemorrhoids includes anal skin tags, fibrous anal polyp, peri-anal hematoma, rectal prolapse, anal fissure, dermatitis and rectal tumor. Prevention is the best treatment for hemorrhoids.
Hemorrhoids Treatment & Management
The disease once established tends to get worse over time. Medical application of creams and suppositories can relieve irritation and pain but rarely provide long-term benefit. The mainstay of treatment therefore is surgical. But unfortunately, operative hemorrhoidectomy is usually associated with significant postoperative complications, including pain, bleeding and anal stricture, which can result in protracted period of convalescence. Recent advances in instrumental technology have led to the development of the bipolar electro-thermal devices — ultrasonic scalpel, circular stapler and the ligasure vessel-sealing systems.
Some of the surgical options for treating hemorrhoids include the following:. Rubber band ligation, sclerotherapy, infrared photocoagulation, cryotherapy, manual anal dilatation, LASER hemorrhoidectomy, the harmonic ultrasonic scalpel hemorrhoidectomy, Doppler-guided hemorrhoidal artery ligation, and the new atomizing technique that uses the atomizer wand to excise and vaporize hemorrhoids.
Most nonoperative procedures are reserved for first- and second-degree hemorrhoids and are usually carried out on outpatient basis. Operative hemorrhoidectomies are reserved mainly for third- and fourth-degree hemorrhoids. Bleeding from first-, second- and some selected third-degree hemorrhoids can be treated by rubber band ligation.
By this method, mucosa cm above the dentate line is grasped and pulled into a rubber band applier the Barron gun. After firing the gun, the rubber strangulates the underlying tissue causing scarring and preventing further bleeding and prolapse. Generally, only one or two quadrants are banded per visit.
No anesthesia is required. Results are superior to those of injection sclerotherapy. A recent meta-analysis of hemorrhoidal treatment concluded that rubber band ligation was the initial mode of therapy for first- to third-degree hemorrhoids. Mitchell of Illinois, USA first used carbolic acid for injecting hemorrhoids in The objective is to cause thrombosis of the vessels and promote fibrosis, which retracts the prolapse. Where possible, the Gabriel's syringe should be used.
It is specially adapted to pass through the proctoscope. Disposable syringes have however now replaced the Gabriel's syringe. Not more than 3 injections at 6-week intervals should be given in one phase of treatment. Complications are few, though infection and fibrosis have been reported.
Surgical Treatment: Evidence-Based and Problem-Oriented.
Infrared photocoagulation is an effective outpatient treatment for first- and second-degree hemorrhoids. Exposure is for 1 second at each site. Results are similar to those of banding and sclerotherapy, but the procedure is less painful. This procedure is indicated for first-, second- and some selected third-degree hemorrhoids. The cryoprobe of liquid nitrogen is applied to the hemorrhoid for about 3 minutes to produce liquefaction of frozen tissue, over the ensuing weeks.
This procedure indicated mostly for second- and third-degree hemorrhoids was advocated by Lord in It aims to dilate the anal sphincter to accept 4 fingers of each hand and to maintain sphincter laxity by regular use of a dilator. It is now largely abandoned due to the frequently occurring complication of incontinence, especially when combined with open hemorrhoidectomy. LASER therapy may be used alone or in combination with other modalities.
The harmonic scalpel uses ultrasonic energy, which allows for both cutting and coagulation of hemorrhoidal tissue at precise points of application, resulting in minimal lateral thermal damage. The vibrating blade at 55, Hz couples with protein and denatures it to form a coagulum that seals bleeding vessels. It is an outpatient procedure reserved for first- and second-degree hemorrhoids. It however has longer operating time and more pain when compared to the ligasure hemorrhoidectomy.
The atomizer wand is an innovative wave form of electrical current wherein a specialized electrical probe excises or vaporizes one or more cell layers at a time, reducing the hemorrhoids to minute particles of fine mist or spray, which are immediately vacuumed away. Results are similar to those of LASER hemorrhoidectomy except that there is less bleeding using the atomizer and that the atomizer costs less.
Patient does not require hospital stay. Presently, atomizing hemorrhoids is offered exclusively in Arizona, USA. This is also a new technique first described by the Japanese surgeon Kazumasa Morinaga in , who identified the hemorrhoidal arteries by means of a Doppler ultrasound technique. It is a day care procedure suitable for first-, second- and some selected third-degree hemorrhoids, and the patient goes home after sedation wears off. There is little or no bleeding postoperatively. Bowel preparation before operation minimizes fecal contamination and keeps the colon quiet for the first few days of the operative period.
This method is now obsolete but has the advantage in not having any form of dissection of tissue planes. The hemorrhoid is grasped in-between the insulated blades of Smith's pile clamp. The greater part of the hemorrhoid mass is then cut away with scissors, leaving only a stump, which is burned with heated copper cautery to arrest bleeding.
The electric cautery or diathermy knives are unsatisfactory substitutes because they are ineffective in arresting hemorrhage and because the coagulating current may penetrate tissues too deeply. The operation is reserved for second- to fourth-degree hemorrhoids and it is done under general anesthesia. This is the most commonly used technique and is widely considered to be the most effective surgical technique for treating hemorrhoids. Adotey and Jebbin in PortHarcourt, Nigeria, showed that open hemorrhoidectomy was the predominant surgical method for treating hemorrhoids.
It is the procedure of choice for third- and fourth-degree hemorrhoids [ Figure 3 ]. This method was developed in the United Kingdom by Drs. The dissection is carried cranially to the pedicle, which is ligated with strong catgut and the distal part excised [ Figure 4 ]. Other hemorrhoids are similarly treated, leaving a skin bridge in-between to avoid stenosis. The wound is left open and a hemostatic gauze pad left in the anal canal [ Figure 5 ]. The procedure is done under general or epidural anesthesia.
Postoperative pain and acute urine retention are common complications. Developed in the United States by Drs. Ferguson and Heaton in , this is a modification of Milligan-Morgan method described above. Here the incisions are totally or partially closed with absorbable running suture, following surgical excision of the hemorrhoids [ Figure 6 ]. The Ferguson method has no advantage in terms of wound healing because of the high rate of suture breakage at bowel movement.
This procedure was developed in the s by Parks, who published results and details of the technique in It is indicated for second- to fourth-degree hemorrhoids. A Parks retractor is inserted. A point just below the dentate line at the hemorrhoid is grasped with a hemostat. A —mL saline containing 1: Scissors are used to excise a small diamond of anal epithelium around the hemostat.
The incision is continued cranially for 2. This dissection is continued into the rectum, where the resulting broad base of tissue is suture-ligated and divided. The mucosal flaps are then allowed to flop back into position. No suture or any intra-anal dressing is used.
Surgical Management of Hemorrhoids
The same procedure is carried out on the other hemorrhoids. Parks hemorrhoidectomy is done under general or epidural anesthesia. It is safe and associated with low rates of complications and recurrence. A recent study by Yang et al. This procedure, also known as total or circumferential hemorrhoidectomy, was first described by Dr. Walter Whitehead in The procedure entails circumferential removal of the hemorrhoid, hemorrhoid-bearing.
Incisions are made by curved double-operating scissors just proximal to the dentate line and continued along this path around the anal canal in stages. Clamps are used to lift the cut edge of the hemorrhoid rectal -bearing mucosa and mucosal prolapse. The hemorrhoidal masses are then suture-ligated and excised, followed by closure of the incisions by suture. Here, a retractor is used to stretch the internal sphincter, so that the suture goes through the endoderm to the neo-dentate line.
A hemostatic sponge is left in the anal canal. The procedure is reserved only for circumferential hemorrhoids, and it is done under general or epidural anesthesia. Recent works by Maria et al. It was first described in by Longo for prolapsing second- to fourth-degree hemorrhoids. A circular anal dilator is introduced into the anal canal. The prolapsed mucous membrane falls into the lumen after removing the dilator. A purse-string suture anoscope is then introduced through the dilator, to make a submucosal purse-string suture around the entire anal canal circumference [ Figure 7 ].
The circular stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string suture, which is then tied with a closing knot [ Figure 8 ]. The entire casing of the stapler is then pushed into the anal canal, tightened and fired to staple the prolapse.