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9.2 External Hemorrhoids
119
Fig. 9.4 Elliptical incision for the thrombosed
hemorrhoid
Fig. 9.3 Ruptured external hemorrhoids
Digital rectal examination and proctoscopy
are very painful in these cases but should be done
to rule out any other associated condition.
9.2.1.4 Management ofThrombosed
External Hemorrhoids
The swelling usually resolves within 5–7days,
and hence it is called 5-days self-limiting disease. The topical application and sitz bath can be
excellent pain relievers [9]. A thrombosed external hemorrhoid that resolves may leave a residual perianal skin tag that requires excision [9].
Surgical intervention remains the treatment of
choice if the thrombosed hemorrhoids do not
respond to conservative management [10, 11].
There are two ways to treat the condition
surgically:
• Clot evacuation with a radial incision
• Complete excision of the thrombosed hemorrhoid [4] (Fig.9.4)
9.2.1.5 Role ofLasers inThrombosed
External Hemorrhoids
An ideal technique for thrombosed external
hemorrhoids remains excision under local anesthesia. However, the raw area hence created
takes time to heal [12]. Clot evacuation followed
by laser can also be done when signicant clot
formation occurs. An incision is given over the
thrombosed hemorrhoid, and the clot is evacuated. This is followed by laser coagulation using
a bare ber which has a hemostatic effect. The
ber is inserted through the incised wound. The
thermal energy seals the blood vessels in that
area or compartment. The only complication
one can encounter is a remnant small skin tag
that can be removed later.
9.2.1.6 Postoperative Care
• Sitz bath twice a day.
• An ointment containing an analgesic and an
anesthetic cream is recommended. A combination of sucralfate, metronidazole, and lignocaine provides excellent relief [7].
Some Interesting Facts from Literature
Thrombosis of the inferior hemorrhoidal
plexus is often seen as a “perianal hematoma.” However, Hamish Thomson, in
1979, stated that “Perianal hematoma” was
a misnomer and preferred the term “clotted
venous saccule” as it was not a true hematoma and was completely sub-anodermal
(sub-pectinate) with no signs of bleeding
[13, 14].
120
9 Lasers inExternal andComplicated Internal Hemorrhoids
9.3 Thrombosed Internal Hemorrhoids
Although internal hemorrhoids are painless, the
presence of pain should raise a suspicion of
thrombosed internal hemorrhoids. The word
thrombosed is formed from “thrombosis,” which
means clotting [15].
9.3.1 Pathophysiology
ofThrombosed Internal
Hemorrhoids
Vascular thrombosis, abnormal venous dilatation, degeneration in the collagen bers and
broelastic tissues, and rupture of the anal subepithelial muscle are part of the pathogenic
occurrences in the anal cushions. Once hemorrhoids develop, increased pressure in the anal
cushions can lead to blood stasis within the vessels, leading to blood clot formation and thrombosis. The blood supply to the anal cushion is
hampered, resulting in ischemia [15]. On histopathology, the hemorrhoidal specimens showed
an intense inammatory response, mucosal
ulceration, and thrombosis [16].
9.3.2 Management ofThrombosed
Internal Hemorrhoids
Thrombosed internal hemorrhoids are treated differently than thrombosed external hemorrhoids.
In the case of thrombosed internal hemorrhoids,
the clot evacuation, followed by nger-guided
hemorrhoidal artery ligation and laser hemorrhoidoplasty, can be done (Fig.9.5). The laser
ber is inserted through the incision where the
clot has been evacuated. In case of thrombosed
internal hemorrhoids, urgent surgical intervention is frequently recommended.
9.4 Strangulated Internal Hemorrhoids
“Strangulation is dened as a condition in
which the blood ow to a portion of the body is
cut off or reduced due to blood vessel compression.” Therefore, strangulated hemorrhoids are
the hemorrhoids whose circulation is impaired
[17].
When the prolapsed internal hemorrhoidal
cushion remains untreated for a long time, its
blood supply is hampered, and it becomes strangulated [18, 19]. These patients may present with
irreducible, prolapsed, gangrenous hemorrhoids
requiring surgical intervention (Fig. 9.6). The
symptoms associated with these hemorrhoids are
pain, swelling, bleeding, and foul-smelling discharge [20].
9.4.1 Pathophysiology
ofStrangulated Hemorrhoids
As the internal anal sphincter lies higher than the
external sphincter, the prolapsed part of internal
hemorrhoid may get trapped between the internal
anal sphincter and the lower portion of the external anal sphincter during straining [21]. This cuts
off the blood supply and obstructs venous return
leading to edema and a painful strangulated hemorrhoid [20]. Subsequently, ulceration may occur
due to necrosis (Table9.1).
Fig. 9.5 Thrombosed internal hemorrhoids showing clot
evacuation
Fig. 9.6 Strangulated hemorrhoids
9.5 Discussion
121
Table 9.1 Events in strangulation of hemorrhoids
Prolapsed Hemorrhoids
Constriction caused by
sphincter spasm
Aggravated by irritation,
constant straining,
concomitant trauma, and
infection
Blocking of return flow
of the blood
Strangulated Hemorrhoids
9.4.2 Management ofStrangulated
Hemorrhoids
The treatment of choice remains surgical excision. During surgery, determining the anatomy
and leaving appropriate mucocutaneous bridges
might be problematic [22]. According to Hansen
et al., pedicles are usually well-dened and
spared, which Smith conrmed by histological
studies [20, 23].
Strangulated, ulcerated, or necrosed hemorrhoids are an absolute contraindication for laser
hemorrhoidoplasty. Hemorrhoidectomy remains
the procedure of choice.
9.5 Discussion
Thrombosed external hemorrhoids can be managed by laxatives, sitz baths, and analgesics. The
majority of patients are treated conservatively.
The hemorrhoidal mass should be excised if the
patient has severe pain and is unwilling to wait.
Cavic etal. carried out a study on the topical
application of 2% nitroglycerine, excision of
hemorrhoid, and incision and evacuation of
thrombus. The maximum pain relief was with the
excision of thrombosed hemorrhoids [25, 26].
Following acute thrombosis and strangulation, the infection should be managed with
antibiotics, followed by surgical intervention.
One should try to reduce strangulated internal
hemorrhoids to prevent necrosis. It is not the
amount of sphincter muscle constriction but
the amount of edema that determines whether
strangulated hemorrhoids can be reduced or
not [17]. The edema can be reduced by injecting hylase into the edematous hemorrhoids. It
acts by increasing tissue permeability.
Irreducible strangulated hemorrhoids should
be taken for immediate excision. According to
some authors [17], if the strangulated prolapsed cushion is extensive and very painful,
it is better to treat it conservatively initially
and then go for surgical intervention.
Eisenhammer stated that when multiple
external hemorrhoids become thrombosed, they
may appear like a “bunch of grapes” [27].
Eisenhammer described any condition that
aggravates pain in the anal region as a “pile
attack,” which can be an internal hemorrhoidal
one.
Some Interesting Facts from Literature
In strangulated hemorrhoids, the procedure
of choice remains hemorrhoidectomy. The
correct treatment option for thrombosed
hemorrhoids was a matter of consideration.
Goligher, in 1961 mentioned a strictly con-
servative approach for treating prolapsed
thrombosed hemorrhoids [24]. “Bed rest,
hot baths, soothing local applications, sed-
atives, antibiotics, and laxatives to secure
easy motions” was the treatment protocol
suggested by him [24]. Surgery was not
recommended due to the risk of infection
spreading due to operative intervention in
the septic area.
In 1984, Goligher changed his stance
and preferred hemorrhoidectomy for
thrombosed internal hemorrhoids advocating portal pyemia as a myth [24].
122
9 Lasers inExternal andComplicated Internal Hemorrhoids
The characteristics of the internal hemor-
rhoidal “pile attacks” are:
1. In nonprolapsed hemorrhoids
• Inammation.
• Thrombosis and its sequelae of ulceration
and necrosis with acute sepsis. There are
no external signs of the disease.
2. In prolapsed hemorrhoids
• Inammation
• Thrombosis and its sequelae
• Superimposed strangulation
Every hemorrhoidal mass is not an indication
of laser surgery. Thrombosed internal hemorrhoids can be taken for laser hemorrhoidoplasty.
The laser can be used only after the evacuation of
the clot. Strangulated hemorrhoids are painful
conditions due to necrosis, and immediate excision of the anal cushion is required. Laser has no
role in strangulated hemorrhoids.
Take-Home Message
Thrombosed external hemorrhoids should be
managed conservatively. Failure to reduce pain
after medical management is an indication of
excision. Lasers in thrombosed internal hemorrhoids can only be considered after clot evacuation. In strangulated hemorrhoids, the treatment
of choice remains excision.
References
1. Lohsiriwat V.Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol.
2012;18(17):2009–17. https://doi.org/10.3748/wjg.
v18.i17.2009.
2. Perry KR. Hemorrhoids. https://www.medscape.
com/answers/775407- 182222/what- is- thepathophysiology- of- hemorrhoids.
3. Lawrence A, McLaren ER.External hemorrhoid. In:
StatPearls. Treasure Island, FL: StatPearls Publishing;
2022.
4. Grosz CR.Surgical treatment of thrombosed external
hemorrhoids. Dis Colon Rectum. 1990;33(3):249–50.
https://doi.org/10.1007/BF02134191.
5. Hemorrhoids. https://teachmesurgery.com/general/
anorectal/haemorrhoids/.
6. Sanchez C, Chinn BT.Hemorrhoids. Clin Colon Rectal Surg. 2011;24(1):5–13.
7. Lorber BW.Thrombosed external hemorrhoid excision technique. https://emedicine.medscape.com/
article/81039- overview.
8. Compartment syndrome from the American Academy of Orthopedic Surgeons. https://orthoinfo.aaos.
org/en/diseases%2D%2Dconditions/compartmentsyndrome/.
9. Nienhuijs SW, de Hingh IH. Pain after conventional versus Ligasure haemorrhoidectomy. A metaanalysis. Int J Surg. 2010;8(4):269–73.
10. Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist’s view. World J Gastroenterol.
2015;21(31):9245–52. https://doi.org/10.3748/wjg.
v21.i31.9245.
11. Corman ML, Corman ML.Colon and rectal surgery.
Philadelphia, PA: Lippincott Williams & Wilkins;
2005.
12. Davis BR, Lee-Kong SA, Migaly J, Feingold DL,
Steele SR. The American Society of Colon and
Rectal Surgeons Clinical Practice guidelines for the
management of hemorrhoids. Dis Colon Rectum.
2018;61(3):284–92.
13. Thomson WH.The nature of hemorrhoids. Br J Surg.
1975;62(7):542–52.
14. Thomson H. The anal cushions—a fresh concept in
diagnosis. Postgrad Med J. 1979;55(644):403–5.
15. Health conditions and disease: thrombosis. Johns
Hopkins Medicine. https://www.hopkinsmedicine.
org/health/conditions- and- diseases/thrombosis.
16. Morgado PJ, Suárez JA, Gómez LG, Morgado PJ.Histoclinical basis for a new classication of hemorrhoidal
disease. Dis Colon Rectum. 1988;31:474–80.
17. Puritt MC. Etiology and treatment of strangulated,
thrombosed, infected, and gangrenous internal hemorrhoids. South Med J. 1939;32(1):68–70.
18. Castillo AH. Thrombosed hemorrhoid: what is it,
causes, diagnosis, treatment, and more. https://www.
osmosis.org/answers/thrombosed- hemorrhoid.
19. Strangulated hemorrhoid. Dictionary, Thesaurus,
Encyclopedia. https://www.thefreedictionary.com/
strangulated+hemorrhoid.
20. Hansen JB, Jorgensen SJ.Radical emergency operation for prolapsed and strangulated hemorrhoids. Acta
Chir Scand. 1975;141(8):810–2.
21. Milligan ETC, Morgan CN, Jones LE, Ofcer
R. Edward Thomas Campbell Milligan 1886–1972.
Dis Colon Rectum. 1985;28:620–8.
References
123
22. Mir SA, Mir I, Tak SA, Wani M. Prole and management of complicated (strangulated) prolapsed
internal hemorrhoids at a tertiary care hospital—a
prospective study. Int J Contemp Med Res. 2019;6(5):
E1–3.
23. Smith M.Early operation for acute hemorrhoids. Br
J Surg. 1967;54(2):141–4. https://doi.org/10.1002/
bjs.1800540214.
24. Cirocco WC.Reprint of: why are hemorrhoids symptomatic? The pathophysiology and etiology of hemorrhoids. Semin Colon Rectal Surg. 2018;29(4):
160–6.
25. Cavcić J, Turcić J, Martinac P, Mestrović T, Mladina
R, Pezerović-Panijan R. Comparison of topically
applied 0.2% glyceryl trinitrate ointment, incision
and excision in the treatment of perianal thrombosis. Dig Liver Dis. 2001;33(4):335–40. https://doi.
org/10.1016/s1590- 8658(01)80088- 8.
26. Mott T, Latimer K, Edwards C. Hemorrhoids: diagnosis and treatment options. Am Fam Physician.
2018;97(3):172–9.
27. Eisenhammer S. An attack of piles: its management in general practice. S Afr Med J. 1949;23(11):
192–7.
Anatomy ofPara-Anal
andPararectal Spaces
“Anatomy is to physiology as geography is to history; it describes the theatre of events.”
Jean Francois Fernel
10
Key Concepts
• Surgical procedures for anal abscesses and stulas are technically demanding.
• As a surgeon, it is essential to know the basic
anatomy of para-anal and pararectal spaces to
perform the procedures precisely.
• Abscesses and stulas are named according to
the space they travel.
• Most abscesses and stulas result from an
acute infection of the anal glands.
10.1 Introduction
Surgical procedures for an abscess and anal stula
are technically demanding. Due to the incidence of
recurrence and incontinence, the short-term and
long-term physiological consequences must be
considered while treating them. Accurate knowledge of anatomy helps a surgeon conduct sphinctersaving surgery precisely. Therefore, for reference, a
detailed description of the anatomy of the para-anal
and pararectal spaces has been explained.
10.2 Anatomy ofPara-Anal
andPararectal Spaces
Anatomically some virtual spaces are formed
between the mucocutaneous lining of the anal
canal and the muscular structure of a sphincter
complex (Fig.10.1a, b). Potential spaces of clinical signicance in the anorectal region are discussed below in detail:
10.2.1 Ischioanal/Ischiorectal Space
The shape and structure of an ischiorectal fossa
depend on levator ani muscle disposition, which
creates its roof and inner wall [1]. The boundary
between the ischiorectal and perianal spaces is
marked by fascia, which starts from the “Conjoined
Longitudinal Muscle” (CLM) and extends to an
ischial tuberosity across the subcutaneous external
anal sphincter [2]. This fascia is called “the transverse septum of the ischiorectal fossa,” also known
as “Milligan septum” [2] (Fig.10.2).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_10
125
126
Ischiorectal space
a
Anococcygeal ligament
Side wall of pelvis
Ischiorectal space
Perianal space
Fig. 10.1 (a, b)
Demonstrating para-anal
and pararectal spaces
Perianal space
b
Supralevator space
Intermuscular septum
10 Anatomy ofPara-Anal andPararectal Spaces
Submucosal space
Intersphincteric
space
Alcock’s canal
Milligan septum
Corrugator cutis ani
Retrorectal space
Retrorectal fascia
Fig. 10.2 Ischioanal/
ischiorectal space
Supralevator space
Levator ani
Deep postanal space
Superficial postanal
space
Levator ani
Rectum
Anal canal
Alcock’s canal
Perianal fat
Intermuscular septum
Corrugator cutis ani
Milligan septum
Intersphincteric
10.2 Anatomy ofPara-Anal andPararectal Spaces
Fig. 10.3 Perianal
space
127
longitudinal muscle
Conjoined
Perianal space
10.2.1.1 Boundaries
Medially: Lower rectum and anal canal area
Laterally: Pelvis sidewalls
Above: Levator ani muscle
Base: Perianal space
Anteriorly: Urogenital diaphragm
Posteriorly: Sacrotuberous ligament and glu-
teus maximus
Supralaterally: Alcock’s canal (internal
pudendal vessels and nerve)
10.2.1.2 Contents
The space is covered by large lobules of avascular fat, inferior rectal vessels, and nerves.
10.2.2 Perianal Space
Morphologically it signies part of the proctodeum.
space
Alcock’s canal
Perianal fat
rhoidal plexus. Finely granular and closely
packed fat lls the perianal space (Fig.10.3).
Surgical Importance of Perianal and
Ischiorectal Spaces
• The fat in the perianal space is tightly
arranged and associated with septa formation due to corrugator cutis ani. Hence, pain
in the perianal abscess is excruciating
because of the tension caused by a swelling.
• Both perianal and ischioanal spaces are
common sites of abscesses.
• Sometimes an abscess in the ischiorectal
region does not involve the overlying skin
as it does not penetrate the Milligan’s
septum.
• The stula which invoves the perianal
space is a intersphincteric one.
10.2.2.1 Boundaries
Above: Intermuscular septum
Medially: Intersphincteric space
Laterally: Continuous with subcutaneous
gluteal fat
10.2.2.2 Contents
The perianal region encloses the subcutaneous
“External anal sphincter” (EAS), the bers of
corrugator cutis ani, and the external hemor-
10.2.3 Intersphincteric Space
An area between the internal and external anal
sphincter (Fig.10.4).
10.2.3.1 Boundaries
Medially: Internal anal sphincter
Laterally: External anal sphincter
Superiorly: Supralevator space
128
Internal anal sphincter
External anal sphincter
Submucosal layer of rectum
10 Anatomy ofPara-Anal andPararectal Spaces
Fig. 10.4 Intersphincteric space
Fig. 10.5 Submucosal
space
Levator ani
Supralevator space
Milligan septum
Peritoneum
Intersphincteric space
Intermuscular septum
Submucosal space
Dentate line
Internal anal sphincter
Inferiorly: Intermuscular and Milligan
septum
10.2.3.2 Contents
Fat and connective tissue
Surgical Importance of Intersphincteric
Space
It is crucial in the genesis of intersphincteric, supralevator, perianal or ischiorectal
abscesses as the anal glands’ ramications
are present here.
10.2.4 Submucosal Space
It is located above the dentate line (Fig.10.5).
10.2.4.1 Boundaries
Laterally: Internal anal sphincter
rectum
10.2.4.2 Contents
Internal hemorrhoidal plexus
10.2.5 Supercial Postanal Space
The interposed region between the skin and the
anococcygeal ligament (Fig.10.6a).
10.2.6 Deep Postanal Space
The region is located midway between the tip
of the coccyx and the subcutaneous external
anal sphincter. It is also called the “Retrosphincteric space of Courtney” and communicates with ischiorectal fossae on either side [3]
(Fig.10.6b).
Above: Continuous with submucosa of the
a
Internal anal sphincte
r
10.2 Anatomy ofPara-Anal andPararectal Spaces
Fig. 10.6 (a) Deep and
supercial postanal
spaces. (b) Deep
postanal space
129
Deep postanal space
Anococcygeal ligament
Superficial postanal space
Perianal skin
10.2.6.1 Boundaries
b
Puborectails
Conjoined
longitudinal muscle
r
10.2.7 Supralevator Space
Deep postanal space
Levator ani
Anococcygeal ligament
Deep external anal sphincte
Superficial external
anal sphincter
Subcutaneous external
anal sphincter
Superiorly: Inferior part of levator ani with musculotendinous insertions of three divisions,
Ileococcygeus, pubococcygeus, and puborecta-
Located between the levator and the peritoneum
(Fig.10.7).
lis, into the sides of coccyx and tip.
Inferiorly: Anococcygeal ligament
Anteriorly: Supercial external anal sphinc-
ter (Posterior surface)
10.2.7.1 Boundaries
Medially: Rectum
Laterally: Obturator fascia
Superiorly: Peritoneum
Inferiorly: Levator ani
Surgical Signicance of Deep Postanal
Space
• It communicates posteriorly to the
ischiorectal fossae and is site of horseshoe abscesses.
Surgical Importance of Supralevator Space
Infection from intersphincteric space has
easy access to adjacent supralevator/perirectal spaces. Supralevator abscess may develop
due to upward extending cryptoglandular
Another space of surgical importance is the
deep anterior anal space described by Hanley [4],
which will be discussed later.
infection from intersphincteric abscess or
downward extension from pelvic infection.
However, these spaces are protected from any
kind of infections with fascial barriers [1].