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Normally, do people have anal
 Yes
 Within the normal anal canal exist specialized, highly
vascularized “cushions” forming discrete masses of thick
submucosa containing blood vessels, smooth muscle,
and elastic and connective tissue
 These structures aid in anal continence
When would we call them
 Abnormal
 Cause symptoms
 Downward sliding of anal cushions associated
with gravity
 Straining
 Irregular bowel habits.
How do hemorrhoids come?
 The cause of hemorrhoids remains
How could we diagnose
 History
 Physical examination
 Endoscopy
 Dripping or even squirting of blood in
the toilet bowl
 Chronic occult bleeding leading to anemia
is rare, and other causes of anemia must
be excluded
History (cont’d)
 Prolapse
 below the dentate line area can occur,
especially with straining, and may lead to
mucus and fecal leakage and pruritus
 Pain?
 is not usually associated with uncomplicated
hemorrhoids but more often with fissure,
abscess, or external hemorrhoidal
Hemorrhoids can be divided to?
 External
 Internal
-> painless
•Bright red bleeding
•Prolapse associated
with defecation
•Swell, discomfort,
difficult hygiene
-> Thrombosed
How are Internal hemorrhoid
 Extent of prolapse
A:Thrombosed external
B:First-degree internal
viewed through anoscope
C:Second-degree internal
prolapsed, reduced
D:Third-degree internal
prolapsed, requiring
manual reduction
E:Fourth-degree strangulated
internal and thrombosed
Reference : Sabiston Textbook of Surgery, 18th Edition
 Digital examination -> assess
 internal and external hemorrhoidal disease
 anal canal tone
 exclusion of other lesions, especially low
rectal or anal canal neoplasms
 Virtually all anorectal symptoms are
ascribed to “hemorrhoids” , anorectal
pathologies be considered and excluded
 Definitive examination
 Flexible proctosigmoidoscopy should always
be added to exclude proximal
inflammation or neoplasia
 Colonoscopy or barium enema should be
added if the hemorrhoidal disease is
unimpressive, the history is somewhat
uncharacteristic, or the patient is older
than 40 years or has risk factors for colon
cancer, such as a family history
 Depending on degree of disease, treatment
falls into two main categories: nonsurgical
and hemorrhoidectomy.
First degree
Bleeding; no prolapse
Dietary modifications
Second degree
Prolapse with spontaneous
Rubber band ligation
Bleeding, seepage
Dietary modifications
Third degree
Prolapse requiring digital
Surgical hemorrhoidectomy
Bleeding, seepage
Rubber band ligation
Dietary modifications
Fourth degree
Prolapsed, cannot be reduced
Surgical hemorrhoidectomy
Urgent hemorrhoidectomy
Dietary modifications
Reference : Sabiston Textbook of Surgery, 18th Edition
Dietary modifications
 Dietary modifications are always
appropriate for the management of
hemorrhoids, if not for acute care then for
chronic management, and for prevention of
recurrence after banding and/or surgery.
Nonsurgical Rx
 Simple measures
 better local hygiene
 avoidance of excessive straining
 better dietary habits supplemented by
medication to keep stools soft, formed, and
 Symptoms of bleeding but not prolapse can
be significantly reduced over a period of 30
to 45 days with the use of fiber supplements
Suppositories are good?
 Over-the-counter suppositories and anal
salves, although popular, have never been
tested for efficacy
 In the absence of symptomatic
external hemorrhoids, second- and
some third-degree internal
hemorrhoids can be treated with office
procedures that produce mucosal fixation.
What is the best?
 Sclerotherapy
 Infrared coagulation
 Heater probe
 Bipolar electrocoagulation
What is the best?
 The simplest, most effective, and most
widely applied office procedure is
rubber band ligation
How many sites we can perform
this procedure?
 Only one site should be banded each time
Is there any contraindication?
 Taking
 Antiplatelet
 Blood-thinning medications
 Subacute bacterial endocarditis prophylaxis
 Immunodeficient patientsSubacute bacterial
endocarditis prophylaxis
Any advice for patients?
 Be aware of severe perineal sepsis and
even deaths after rubber band ligation
 Return to the emergency department if
delayed or undue pain, inability to void, or
a fever develops
Surgical Rx
 Hemorrhoidectomy is the best means of
curing hemorrhoidal disease
 Considered when
 patients fail to respond satisfactorily to
repeated attempts at conservative measures
 hemorrhoids are severely prolapsed and
require manual reduction
 hemorrhoids are complicated by
strangulation or associated pathology, such
as ulceration, fissure, fistula
 hemorrhoids are associated with
symptomatic external hemorrhoids or large
anal tags
Surgical Rx (cont’d)
 Simple thrombosed external hemorrhoids
 excision in the office is best performed early
in the course of the disease, during the
period of maximum pain
 To remove complex internal or external
hemorrhoids, an open or closed
hemorrhoidectomy can be performed as an
outpatient procedure
 Three bundles are identified in the right anterior,
right posterior, and left lateral positions
 Be careful, sufficient anoderm is preserved to avoid
the long-term complication of anal stenosis
 Postoperative complications
 Fecal impaction
 Infection
 Urinary retention
 Patients typically recover sufficiently to return to
work within 1 to 2 weeks
 As an alternative to the closed technique, the
surgical wounds can be left open to reduce
postoperative pain, but at the expense of longer
healing times.
Newer technology
 Goal to decrease postoperative pain
 The two main categories
 Ultrasonic or controlled electrical energy such
as the Harmonic Scalpel and Liga-Sure
 Longo’s technique
Stapled hemorrhoidopexy
 Longo's technique, commonly referred to as the stapled
hemorrhoidectomy or stapled hemorrhoidopexy
 Excises a circumferential portion of the lower rectal and
upper anal canal mucosa and submucosa and performs a
reanastomosis with a circular stapling device
 As a result, the prolapsed anal cushions are retracted
into their normal anatomic positions within the anal
canal. In addition, the terminal branches of the inferior
hemorrhoidal artery are disrupted, and blood flow into
the cushions is thereby decreased. The primary
physiologic appeal of this operation is that it leaves the
richly innervated anal canal tissue and perianal skin
intact, thus reducing the pain usually associated with
excisional hemorrhoidectomy
 Initially, stapled hemorrhoidopexy was
performed with a large standard end-to-end
anastomosis (EEA) stapler. Recently, however,
a dedicated stapling device specifically
designed for this operation was introduced into
clinical practice. The stapled hemorrhoidopexy
consists of five steps:
 Reduce the prolapsed tissue
 Gently dilate the anal canal to allow it to accept
the instrument.
 Place a purse-string suture
 Place and fire the stapler
 Control any bleeding from the staple line
 Most important technical consideration is proper
placement of the purse-string suture
 The suture should be at least 3 to 4 cm above the
dentate line; if it is too low, a portion of the
dentate line may be excised, which could lead to a
severe prolonged pain syndrome or to persistent
fecal urgency. In addition, the purse-string suture
must be placed so as to incorporate all of the
redundant tissue circumferentially; failure to do so
may lead to incomplete excision and predispose to
recurrent prolapse
 Finally, extreme care must be exercised in placing
the purse-string suture in women so that the
vagina is not entrapped anteriorly.
Stapled hemorrhoidopexy
 Vs. excisional hemorrhoidectomy
 Significantly less postoperative pain overall
 Less pain with the first bowel movement
 Earlier resumption of normal activities
 has been associated with a number of
serious complications, including
anastomotic dehiscence necessitating
colostomy, rectal perforation, severe pelvic
infection, and acute rectal obstruction and
therefore training before use is strongly