Presenter: Dr. Sachin

Surgery

Haemorrhoids

Haemorrhoids ?

Engorgement of the haemorrhoidal venous plexuses with redundancy of their coverings.

Haemorrhoids

haimorrhoides

haima=blood rhoos=flowing

bleeding

in anal canal

which may or may not bleed

Piles

pila (a ball)

swelling

Anal sphincters Internal

Involuntary Circular muscle layer Upper ¾ of anal canal Upto to white line of hilton

External Voluntary Striated muscle layer Inferior rectal nerve &

sacral nerve Three parts:

Subcut., superficial, deep

above dentate line superior rectal A.

below dentate line inferior rectal A.

Arterial supply

Venous drainage

Internal haemorrhoidal plexus in submucosa drain in superior rectal vein Communicate with external

plexus Site of communication between

portal and systemic veins Veins at 3,7 and 11 o’clock

position are large Potential site for primary

haemorrhoid

Venous drainage

External haemorrhoidal plexus Lies outside muscular coat of

anal canal Communicate freely with internal

plexus

Potential sites for Primary Haemorrhoids

Anal veins

Arrange radially around anal margin Communicates with internal plexus & IRV Straining rupture these vein Ruptured vein present

as subcutaneous perianal hematoma

SRV

MRV

IRV

Venous drainage

Aetiology

Straining

Constipation

Prolonged lavatory sitting

Trauma

Ageing

Diarrhoea

Lack of fibre rich diet

hereditary

Secondary causes

Local

Abdominal

Pelvic

Neurological

Pregnancy

Portal hypertension

anorectal deformity,hypotonic sphincter

ascites

gravid uterus,uterine neoplasm,ovarian neoplasm,

paraplegia,multiple sclerosis

Pathogenesis

Various theories are :

1. Portal hypertension and varicose veins

2. Upright posture of human beings

3. Hyperplasia of corpus cavernosum recti

4. Erosion and weakening of wall of veins due to infection secondary to trauma

5. Hard faecal matter obstructing venous return

6. Raised anal canal resting pressure

CURRENT VIEW

Shearing forces acting on anus Caudal displacement of anal cushions and

mucosal trauma Fragmentation of supporting structures Loss of elasticity of anal cushions Loss of retraction of cushions

Anal Cushions

Haemorrhoidal venous plexuses together with

some arteriovenous anastomoses surrounded by

smooth muscle, elastic and fibrous tissue

in the subepithelial space both above & below the

pecinate line.

Shield anal canal and sphincter during evacuation.

Complete the closure of the anal canal.

Contribute 15% of the anal canal’s pressure.

Congest during Valsalva manoeuvre or increased intra-abdominal pressure.

Increase in the size is the starting point of haemorrhoids.

11 o’clock

7 o’clock

3 o’clock

Incidence

Difficult to evaluate.

Prevalence ~ 5%.

Peak of prevalence is between 45 and 65.

unusual before the age of 20.

Caucasians > Afro-Caribbeans.

Symptoms

Prolaps

Pain

Discharge & Pruritus

Bleeding

HaemorrhoidsProlaps

Pain

Discharge & Pruritus

Bleeding

H’oids

Earliest symptom{ A splash in the pan }

( If complication )

Physical Examination

Left lateral decubitus position

Any rashes, condylomata, or eczema

Any abscesses, fissures or fistulae

Digital Rectal Examination The resting tone of the anal canal

voluntary contraction of the puborectalis and external anal sphincter.

mass / any area of tenderness.

Int. hemorrhoids are generally not palpable

Appear as bulging mucosa on Anoscopy

Diagnostic Tests

Physical examination. Proctoscopy. Flexible sigmoidoscopy Evaluation under anaesthesia in acute pain Anal manometry

if h/o soiling & incontinence

• Classified according to origin of haemorrhoid.

• Above or below the Pecinate line?

External or Internal

External hemorrhoid Internal hemorrhoid

Below dentate line Above dentate line

Varicosities of veins draining

inferior rectal artery

Varicosities of veins draining

superior rectal artery

Lined by

squamous epithelium

Lined by

columnar epithelium

Painful Pain insensitive

Prone to thrombosis if vein ruptures

(Thrombosed pile)

May prolapse outside anal canal

(prolapsed hemorrhoid)

Gr I Gr II Gr III Gr IV not prolapse returns spontaneously manually returned remains prolapsed

Grading of hemorrhoids (on history)

Complications of hemorrhoids

Portal pyaemia

Suppuration

Fibrosis

Ulceration

Gangrene

Thrombosis

Strangulation

Gripped by Ext. sphincter

Impeded venous return

prolapse

Thrombosed External haemorrhoids

Prolapsed Internal haemorhoids

TREATMENT

Conservative Dietary and lifestyle modification. Non operative/office procedures. Operative hemorrhoidectomy Minimal invasive procedures

Dietary & Lifestyle modifications

Minimize straining at stool. and

Prevention of constipation

Dietary & Lifestyle modifications

Drinking Fluids High-fiber diet Use of Fiber

supplements Stool softeners Exercise Local hygiene

Dietary & Lifestyle modifications

“you don't defecate in the library so

you shouldn't read in the bathroom”

Dietary & Lifestyle modifications

If prolapses, gently push back into anal canal

Use moist towelettes or wet toilet paper instead of dry toilet paper.

Topical Treatment

Include: Pads, Ointments, Creams, Gels, Lotions Suppositories.

Used now a days includes Calcium dobesilate .25%

Anhydrous lignocaine 3%

Hydrocortisone acetate .25%

Zinc 5%

Sitz bath Sitz mean to sit Used in treatment of

Gr. IV hemorrhoids Duration:15-20 minutes Cold water is used

Draw heat out of sore piles Reduce blood flow in them Reduce pressure inside

swollen piles

Sitz bath Post operative Warm water is used

Dialatation of blood vessels Allow blood to pass through

swollen piles more quickly Relaxes muscles so ease anal

sphincter tone

Oral Medications

Oral vasotopic drugs. Most common - purified flavonoid fraction. Actions:

Increases vascular tone Increases lymphatic drainage Anti-inflammatory effects. Several recent studies have shown it to be

effective.

Topical medications

Commonaly used is

Combination of

Calcium dobesilate & docusate sodium

Calcium dobesilate:Decrease capillary permeablity,

Decrease platelet aggregation

Stops bleeding

Reduce thrombus formation

Improves mucosal inflammation

Docusate sodium:

Stimulant laxative,

makes bowel movement softer and easier to pass

Reduces pain or rectal damage caused by hard stools or straining

Office procedures

Sclerotherapy Infra-red Coag Band Ligation Cryosurgery Manual Dilation of anus. Sphincterotomy (lateral) Bicap electrocoagulation haemorrhoidolysis

Sclerotherapy(Mitchell)

Injected in submucosa around pedicle

For Gr I to II haemorrhoids. phenol, vegetable oil,

quinine, and urea hydrochloride.

Albright solution: 5% phenol

in almond or arachis oil with 140 mg of menthol to make 30 ml

Sclerotherapy

Injected in submucosa around pedicle

Causes oedema, inflammatory reaction & intravascular thrombosis.

Submucosal fibrosis & scarring minimises the extent of

mucosal prolapse and potentially shrinks the

haemorrhoid as well.

Sclerotherapy

Injected in submucosa around pedicle

Quick painless Follow up after 6 weeks 2-3 further injections may

be required Free from major

complications

Sclerotherapy

Injected in submucosa around pedicle

Contraindications Prolapsed pile Infection

Complications retroperitoneal sepsis, portal pyemia necrotising fascitis Prostatitis Impotence Rectovaginal fistula

Barron’Band Ligation

Large Gr I & Gr II witout external component

2 bands Not >2 hemorrhoids at a

time Follow up after 1 month Success rate:50-100%

occlude base of hemorrhoid above dentate line

Barron’Band Ligation

Band causes ischemic necrosis ulceration and scarring

Fix connective tissue to rectal wall

necrosis in 24-48 hrs & slough off in 7 days

May cause pain for 24-48 hrs and secondary hemorrhage

occlude base of hemorrhoid above dentate line

Barron’Band Ligation

Complications: anal stenosis Inclusion of dentate line

cause pain vasovagal shock sepsis

occlude base of hemorrhoid above dentate line

cryosurgery

Freezing of hemorrhoidal tissue liquid Nitrogen probe at -160oC for 3 minutes

Applied for 10-15 minutes Over upper part of hemorrhoidal area

Profuse watery discharge is most common complication (in first 3 hrs)

Cryosurgery

Painless

Causes necrosis of hemorrhoidal tissue

Healing completes in 4-6 wks

Little efficacy in prolapsed hemorrhoids

Infrared photocoagulation

High intensity infra red light 3-6 pulses of 1.5 sec each appllied to mucosa

Infrared photocoagulation

Coagulate vessels & fix underlying mucosa Useful for actively bleeding piles Painless and uncomplicated

BICAP Electrocoagulation

Theoretically similar to photocoagulation

Probe must be left in place for ten minutes.

Poor patient tolerance minimizes the effect of this procedure.

Lord’s Maximal anal dilatation

Spasm of int sphincter responsible for many symptoms of hemorrhoids

Reserved for large Gr II & Gr III hemorrhoids

NOT eliminate redundant tissue

Risk of incontinence

Haemorrhoidolysis

Therapeutic galvanic waves

Produce chemical reaction

Shrink and dissolve hemorrhoidal tissue

Most effective on internal hemorrhoids

Indications of surgery Mainly driven by impact of symptoms on

quality of life 3rd and 4th degree piles 2nd degree not cured by conservative means Fibrosed hemorrhoid Interno-external hemorrhoid Bleeding sufficient to cause anemia Soiling Ulceration,thrombosis,gangrene

Milligan-Morgan (open) Haemorrhoidectomy

First described over 2 centuries ago.

Milligan-Morgan (open) Haemorrhoidectomy

Milligan-Morgan (open) Haemorrhoidectomy

Wound left open

Final Operative Aspect in a Haemorrhoidectomy.

Ferguson’s (Closed) Haemorrhoidectomy

Developed in 1952

Haemorrhoidal tissue excised. Mucosal wound and skin sutured completely

with a continuous absorbable suture.

Harmonic Scalpel sutureless technique

shorter operative time

less post-op pain.

hospital stay not required.

Comparative Increased cost to other techniques.

MIPH

Longo introduced the technique in 1995.

MIPH

Stappler haemorrhoidopexy

Advantages Lesser pain Quick return to normal activity Lesser mean hospital stay

Risks Higher chances of recurrence and prolapse May be unsuccessful in large hemorrhoids Pelvis sepsis and sphincter dysfunction

Laser surgery of hemorrhoid

Pile mass excised or vaporised using laser beam

Allow precision and accuracy Rapid and unimpaired healing Lesser bleeding and pain as laser seal off

tiny blood vessels and nerves Can be combined with other modalities

HAL-RAR Hemorrhoidectomy

HAL - Doppler guided haemorrhoidal artery ligation RAR - Recto anal repair proctoplasty (mucopexy) Combine two methods Artery ligated 3-4 cm proximal to dentate line Reducing blood flow to inner hemorrhoidal plexus Mucopexy combined for grade 3-4 hemorrhoid

A.M.I. (DG) HAL/RAR® System

Complications of surgery

Early complications Post operative pain lasting 2-3 weeks Wound infection rarely Post op bleeding Swelling of skin bridges Short term incontinence Difficult urination

Complications of surgery

Late complications Anal stenosis Anal fissure Fecal impaction Mild incontinence Submucous abscess Delayed bleeding Skin tags Recurrence

Prevention

Eat high fiber diet Drink Plenty of Liquids Fiber Supplements Exercise Avoid long periods of standing or sitting Don’t Strain Go as soon as you feel the urge

Thank you for your patience