HEMORRHOIDS IS A COMPLEX DISEASE WITH COMPLEX MANAGEMENT.THIS POWERPOINT AIMS TO RESOLVE THIS COMPLEXITY IN THE MOST CONVENIENT WAY

1. Surgery
Haemorrhoids
Presenter: Dr. Sachin

2. Haemorrhoids ?
Engorgement of the haemorrhoidal venous plexuses
with redundancy of their coverings.

3. Haemorrhoids
haimorrhoides bleeding
haima=blood rhoos=flowing

4. Piles
pila (a ball)
swelling
in anal canal
which may or may not bleed

6. 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

7. above dentate line
Arterial

 superior rectal A.
supply  below dentate line
 inferior rectal A.

8. 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

9. Venous drainage
External haemorrhoidal plexus
 Lies outside muscular coat of
anal canal
 Communicate freely with internal
plexus

10. Potential sites for
Primary Haemorrhoids

11. Anal veins
 Arrange radially around anal margin
 Communicates with internal plexus & IRV
 Straining rupture these vein
 Ruptured vein present
 as subcutaneous perianal hematoma

12. Venous SRV
drainage
MRV
IRV

13. Aetiology
Straining
Constipation
Prolonged lavatory sitting
Trauma
Ageing
Diarrhoea
Lack of fibre rich diet
hereditary

14. Secondary causes
Local anorectal deformity,
hypotonic sphincter
Abdominal ascites
gravid uterus,
Pelvic uterine neoplasm,
ovarian neoplasm,
Pregnancy
Portal hypertension
paraplegia,
Neurological multiple sclerosis

15. 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

16. 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

17. 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.

18.  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.

19. 11 o’clock
3 o’clock
7 o’clock

20. Incidence
 Difficult to evaluate.
 Prevalence ~ 5%.
 Peak of prevalence is between 45 and 65.
 unusual before the age of 20.
 Caucasians > Afro-Caribbeans.

21. Earliest symptom
Bleeding { A splash in the pan }
Discharge
Prolaps H’oids
Haemorrhoids
& Pruritus
Pain
( If complication )
Symptoms

22. Physical Examination
 Left lateral decubitus position
 Any rashes, condylomata, or eczema
 Any abscesses, fissures or fistulae

23. 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

24. Diagnostic Tests
 Physical examination.
 Proctoscopy.
 Flexible sigmoidoscopy
 Evaluation under anaesthesia in acute pain
 Anal manometry
 if h/o soiling & incontinence

25. • Classified according to origin of haemorrhoid.
• Above or below the Pecinate line?
External or Internal

26. External hemorrhoid Internal hemorrhoid
Below dentate line Above dentate line
Varicosities of veins Varicosities of veins
draining draining
inferior rectal artery superior rectal artery
Lined by Lined by
squamous epithelium columnar epithelium
Painful Pain insensitive
Prone to thrombosis if May prolapse outside
vein ruptures anal canal
(Thrombosed pile) (prolapsed hemorrhoid)

27. Gr I Gr II Gr III Gr IV
not prolapse returns spontaneously manually returned remains prolapsed
Grading of hemorrhoids (on history)

28. Complications of hemorrhoids
prolapse
Gripped by Ext. sphincter
Impeded venous return
Gangrene Strangulation Fibrosis
Ulceration Thrombosis
Suppuration
Portal pyaemia

29. Thrombosed
External haemorrhoids

30. Prolapsed
Internal haemorhoids

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

32. Dietary & Lifestyle
modifications
Minimize straining at stool.
and
Prevention of constipation

33. Dietary & Lifestyle
modifications
 Drinking Fluids
 High-fiber diet
 Use of Fiber
supplements
 Stool softeners
 Exercise
 Local hygiene

34. Dietary & Lifestyle
modifications
“you don't defecate in the library
so
you shouldn't read in the bathroom”

35. Dietary & Lifestyle
modifications
 Ifprolapses,
gently push back
into anal canal
 Use moist towelettes or wet toilet paper
instead of dry toilet paper.

36. Topical Treatment
 Include:
 Pads,
 Ointments,
 Creams,
 Gels,
 Lotions
 Suppositories.

37.  Used now a days includes
 Calcium dobesilate .25%
 Anhydrous lignocaine 3%
 Hydrocortisone acetate .25%
 Zinc 5%

38. 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

39. Sitz bath
 Postoperative
 Warm water is used
 Dialatation of blood vessels
 Allow blood to pass through
swollen piles more quickly
 Relaxes muscles so ease anal
sphincter tone

40. 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.

41. Topical medications
Commonaly used is
Combination of
Calcium dobesilate & docusate sodium

42.  Calcium dobesilate:
 Decrease capillary permeablity,
 Decrease platelet aggregation
 Stops bleeding
 Reduce thrombus formation
 Improves mucosal inflammation

43.  Docusate sodium:
 Stimulant laxative,
 makes bowel movement softer and easier
to pass
 Reduces pain or rectal damage caused by
hard stools or straining

44. Office procedures
 Sclerotherapy
 Infra-redCoag
 Band Ligation
 Cryosurgery
 Manual Dilation of anus.
 Sphincterotomy (lateral)
 Bicap electrocoagulation
 haemorrhoidolysis

45. Sclerotherapy(Mitchell)
 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
Injected in submucosa
around pedicle

46. Sclerotherapy
 Causes
 oedema,
 inflammatory reaction
 & intravascular thrombosis.
 Submucosal fibrosis &
scarring
 minimises the extent of
mucosal prolapse
 and potentially shrinks the
haemorrhoid as well.
Injected in submucosa
around pedicle

47. Sclerotherapy
 Quick
 painless
 Follow up after 6 weeks
 2-3 further injections may
be required
 Free from major
complications
Injected in submucosa
around pedicle

48. Sclerotherapy
 Contraindications
 Prolapsed pile
 Infection
 Complications
 retroperitoneal sepsis,
 portal pyemia
 necrotising fascitis
 Prostatitis
 Impotence
 Rectovaginal fistula
Injected in submucosa
around pedicle

49. 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

50. 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

51. Barron’Band Ligation
 Complications:
 anal stenosis
 Inclusion of dentate line
cause pain
 vasovagal shock
 sepsis
occlude base of hemorrhoid
above dentate line

52. cryosurgery
 Freezing of hemorrhoidal tissue
 liquid Nitrogen probe at -160oC for 3 minutes
 Applied for 10-15 minutes
 Over upper part of hemorrhoidal area
 Profusewatery discharge is most common
complication (in first 3 hrs)

53. Cryosurgery
 Painless
 Causes necrosis of hemorrhoidal tissue
 Healing completes in 4-6 wks
 Little efficacy in prolapsed hemorrhoids

54. Infrared photocoagulation
 High intensity infra red light
 3-6 pulses of 1.5 sec each
 appllied to mucosa

55. Infrared photocoagulation
 Coagulate vessels & fix underlying mucosa
 Useful for actively bleeding piles
 Painless and uncomplicated

56. BICAP Electrocoagulation
 Theoretically similar to photocoagulation
 Probe must be left in place for ten minutes.
 Poor patient tolerance minimizes the effect of
this procedure.

57. Lord’s Maximal anal dilatation
 Spasmof int sphincter responsible for many
symptoms of hemorrhoids
 Reserved for large Gr II & Gr III hemorrhoids
 NOT eliminate redundant tissue
 Risk of incontinence

58. Haemorrhoidolysis
 Therapeutic galvanic waves
 Produce chemical reaction
 Shrink and dissolve hemorrhoidal tissue
 Most effective on internal hemorrhoids

59. 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

60. Milligan-Morgan (open)
Haemorrhoidectomy
First described
over 2 centuries ago.

61. Milligan-Morgan (open)
Haemorrhoidectomy

62. Milligan-Morgan (open)
Haemorrhoidectomy

68. Final Operative Aspect in a Haemorrhoidectomy.
Wound left open

69. Ferguson’s (Closed)
Haemorrhoidectomy
 Developed in 1952
 Haemorrhoidal tissue excised.
 Mucosal wound and skin sutured completely
with a continuous absorbable suture.

72. Harmonic Scalpel
 sutureless technique
 shorter operative time
 less post-op pain.
 hospital stay not required.
 Comparative Increased
cost to other techniques.

73. MIPH
Longo introduced the technique in 1995.

74. MIPH
Stappler haemorrhoidopexy

93. 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

94. 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

95. 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

96. A.M.I. (DG) HAL/RAR®
System

97. 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

98. Complications of surgery
 Late complications
 Anal stenosis
 Anal fissure
 Fecal impaction
 Mild incontinence
 Submucous abscess
 Delayed bleeding
 Skin tags
 Recurrence

99. 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

100. Thank you for your patience