|Year : 2018 | Volume
| Issue : 1 | Page : 14-16
Surgery for hemorrhoids: A review
Kum Kum Singh
Department of General Surgery, JLN Medical College, Ajmer, Rajasthan, India
|Date of Web Publication||17-Sep-2018|
Kum Kum Singh
Department of General Surgery, JLN Medical College, Ajmer, Rajasthan
Source of Support: None, Conflict of Interest: None
There are various surgical options available for treatment of heamorrhoids. It essentially depends on the grade of heamorrhoids. Each option has its pros and cons. This article reviews the various surgical options
Keywords: Heamorrhoids, management strategy, surgical options
|How to cite this article:|
Singh KK. Surgery for hemorrhoids: A review. Indian J Colo-Rectal Surg 2018;1:14-6
| Introduction|| |
Hemorrhoids are as old as history itself. The management is mentioned in ancient Greek literature and Sushrutas charaksamhita. The word hemorrhoid is derived from the Greek word hem–blood and rhoos–flowing. Indeed, the main symptom of hemorrhoids is painless bleeding which can cause lot of anxiety to the patient. Pain is seen in complicated piles only. Bleeding occurs in drops and sometimes may be severe enough to cause anemia. A proper workup including digital rectal examination, proctoscopy, and routine investigations is required to manage hemorrhoids. Various modalities are available to treat hemorrhoids depending on grade. The present article discusses the various surgical options available.
Surgery for hemorrhoids
The common indications for surgery include:
- Bleeding piles of any grade
- 3rd and 4th grade piles
- Strangulated and prolapsed piles
- Thrombosed piles.
There are various surgical options available, which indirectly implies that none is perfect with each procedure having its own advantages and disadvantages.
The surgical options available are:
- Milligan and Morgan's open haemorrhoidectomy
- Ferguson closed haemorrhoidectomy
- Stapler haemorrhoidectomy
- Doppler-guided hemorrhoidal artery ligation
- Energy sources (Ligasure and harmonic scalpel)
- Laser ablation
Precautionary Preoperative Principles to be followed before any hemorrhoid surgery:
- If a patient on anticoagulants, then stop them a week before surgery
- To follow universal precautions in HIV patients
- Bleeding hemorrhoids require emergency surgery and not packing and hemostatic agents
- Recurrence to be managed as primary surgery only
- To always keep bridge of tissue to avoid anal stenosis which will require additional surgery.
Milligan and Morgan's open hemorrhoidectomy
One of the most popular procedures widely practiced across the globe till date. It can be performed even in the smallest of, hospitals by trained general surgeons. It does not require any additional expertise.
The procedure involves patient to lie in lithotomy position under anesthesia. At the onset, a gentle anal dilation is done. The pile masses are identified in the three primary positions, i.e., 3, 7, and 11 O' clocks. The pile mass is held with Allis forceps and dissected from mucocutaneous junction to the base of pile mass where it is transfixed and ligated using Vicryl 0 or Silk 0. When ligation of all three pile mass is being done, then it is better do 3 and 7 first and then 11 O' clock to avoid bleeding from hampering the surgical field.
In the closed technique of Fergusson, all steps are the same except that the ligated base of pile is covered with mucosa using catgut or Vicryl 2/0.
Advantages of the closed technique are that it causes less pain and bleeding and sutures are not palpable.
The drawbacks of open haemorrhoidectomy are pain and high complication rates such as bleeding and stenosis.
There have been various randomized controlled trials (RCT) to prove better-wound healing in closed method versus open 2.8 versus 5 weeks.
It is advisable to always leave a bridge of skin between hemorrhoids so as to avoid anal stenosis.
If secondary piles (due to minor cushions) are present, it is advisable not to operate on all at one sitting to avoid anal stenosis.
Complications include severe pain (if anal skin involved in bite) bleeding, urinary retention, and infection.
The procedure is also called as stapled hemorrhoidopexy and procedure for prolapsed hemorrhoids. The principle of this surgery is based on rectal redundancy theory of hemorrhoids. A part of rectal mucosa above dentate line is divided and stapled at the same time, using a circular anal stapler. Care is taken to remain in submucosal plane, at the same time taking care not to injure vagina. Sutures are always taken 3–3.5 cm above dentate line. Taking of sutures too low causes' pain, while taking of sutures too high causes stenosis of rectum.
This procedure not only divides excessive rectal tissue but also causes disruption of blood supply to piles.
It is indicated mainly in 3rd and 4th degree hemorrhoids. Occasionally, large grade 2 hemorrhoids can also be dealt with this procedure.
Complications include injury to vagina, rectal perforation, failure of stapler device, and pain (involvement of dentate line).
The advantage of this procedure is less postoperative pain and bleeding, shorter operating time, absence of external wound, less incidence of urinary retention and early return to work.
Disadvantages include the availability of expertise and stapler, high cost, injury to rectum and high rate of recurrence.
Ligasure and harmonic scalpel
Under anesthesia the pile mass is held with Allis forceps. Dissection is done up to base with either of the energy source, and the pile mass is divided.
It does not cause any postoperative bleeding and pain is also less.
The complication is in the form of excessive fibrosis leading to anal stenosis.
However, its availability in smaller hospitals is an issue.
RCTs have reported less pain, less operating time, shorter hospital stay and less urinary retention in ligasure group when compared to conventional haemorrhoidectomy. However, post bleeding, difficulty in defecating, anal fissure, anal stenosis can occur.
Doppler guided haemorrhoidal artery ligation
The procedure is also known as transanal-hemorrhoidal-dearterialization. It is based on the principle that hemorrhoidal vessels are abnormal with increased diameter and blood flow, and a higher peak velocity. Ligation of these vessels allows pile mass to shrink and relieve all symptoms.
A special instrument is used for this which contains a special proctoscope fitted with an ultrasound sensor at tip to detect blood flow and a lateral window for haemorrhoidal artery ligation using a specialized needle (5/8 curvature). Once the artery is under-run using Vicryl 2/0 the blood flow to pile mass is interrupted and pile mass shrinks. The same can also be seen in the form of tracing on screen.
Its disadvantage is the lack of expertise and availability of instrument everywhere and also a high recurrence rate (8%).
Its advantage is it being a daycare procedure with minimal pain and bleeding and no tissue excision at all.
It was very popular previously but felt into disrepute because of the occurrence of prolonged and excessive postoperative mucous diarrhea following its use.
Nd: Yag laser
Nd Yag Laser is used to cauterize and destroy the pile mass.
It can be performed in a small set up as a daycare procedure.
However, the hindrance to this procedure is its high cost and its availability. The advantage is less pain and bleeding.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Uba AF, Obekpa PO, Ardill W. Open versus closed haemorrhoidectomy. Niger Postgrad Med J 2004;11:79-83. [Full text]
Aly EH. Stapled haemorrhoidopexy: Is it time to move on? Ann R Coll Surg Engl 2015;97:490-3.
Cerato MM, Cerato NL, Passos P, Treigue A, Damin DC. Surgical treatment of hemorrhoids: A critical appraisal of the current options. Arq Bras Cir Dig 2014;27:66-70.
Xu L, Chen H, Lin G, Ge Q. Ligasure versus ferguson hemorrhoidectomy in the treatment of hemorrhoids: A meta-analysis of randomized control trials. Surg Laparosc Endosc Percutan Tech 2015;25:106-10.
Aigner F, Gruber H, Conrad F, Eder J, Wedel T, Zelger B, et al.
Revised morphology and hemodynamics of the anorectal vascular plexus: Impact on the course of hemorrhoidal disease. Int J Colorectal Dis 2009;24:105-13