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2 Physiology of Defecation
ab
Fig. 2.2 Puborectalis action and anorectal angle. ( a ) Puborectalis sling forming an angle. ( b ) Puborectalis relaxed for
defecation
9
time. This process relies on rectal innervation to
sense and tolerate the increasing volume of stool
(capacity) and maintains a relatively low and
constant pressure with increase in volume
(compliance). Extremes of either of these
components can lead to fecal incontinence
through decreased accommodation or overfl o w .
Bibliography
Miller R, Bactolo DC, Cervero F, et al. Anorectal sam-
pling: a comparison of normal and incontinent
patients. Br J Surg. 1981;75(1):44–7.
Nicholas RJ, Lindsay I. Disorders of defecation and anal
pain. In: Cormanm ML, editor. Cormans colon and
rectal surgery. 6th ed. Philadelphia: Lippincott
Williams and Wilkins/A Wolters Kluwer Health;
2013.
Parks AG, Porter NH, Hard Castle JD. The syndrome of
descending perineum. Proc R Soc Med. 1966;59:
477–82.
Plam TN, Corman BC, Chu P, et al. Radiological changes
after colonoscopic decompression of acute pseudo
obstruction. Dis Colon Rectum. 1999;42(12):
1585–91.
Womachs NR, Williams NS, Holmfi eld JS, et al. New
methods of dynamic assessment of anorectal functions
in constipation. Br J Surg. 1985;72(12):994–8.
Hemorrhoids
P. Sivalingam , Rama Kant , Vijay Arora ,
and Pravin Padmakumar Gore
3
3.1 Introduction
Hemorrhoids are symptomatic dilated anal cushions.
These cushions consist of thickened submucosa,
sinusoids, elastic and connective tissue, and some
P. Sivalingam (*)
Department of Surgery , Madurai Medical College ,
Madurai , India
Govt. Rajaji Hospital Madurai , Madurai , India
drpsivalingam@yahoo.com
e-mail:
R. Kant
Career Institute of Medical Sciences (CIMS) ,
Bhopal , India
SIPS Superspeciality Institute , Lucknow , India
Piles To Smiles Clinic , Lucknow , India
Department of Surgery , CSM Medical University ,
Lucknow , India
Gandhi Memorial and Associated Hospitals ,
Lucknow , India
ramakantkgmc@gmail.com
e-mail:
V. Arora
Department of Surgery, GRIPMER , New Delhi , India
Department of General and Laparoscopic Surgery ,
Colorectal Clinic, Sir Ganga Ram Hospital ,
New Delhi , India
drarora1@gmail.com
e-mail:
P. P. Gore
Department of Surgery,
Bhatia Hospital , Tardeo , India
Global Hospital , Parel , Mumbai, India
drpravingore@gmail.com
e-mail:
smooth muscle fi bers. The hemorrhoidal disease
should be reserved for those anal cushions which
are abnormal and symptomatic. The word
“hemorrhoid” is derived from the Greek words,
haem (blood) and rhoos (fl owing), meaning
fl owing of blood. The word “pile” means pill or a
ball. So we should call this disease piles when the
patient complains of a swelling and hemorrhoids
when the presenting symptom is bleeding.
Hemorrhoidal disease is one of the commonest ailments that affect mankind. The exact prevalence is diffi cult to estimate as patients hide it and
do not come for consultation. Johanson and
Sonnenberg in 1990 have reported a prevalence
of 4.4 % in the USA with a peak prevalence
between 45 and 65 years in both sexes. The
incidence increases with age, and about 50 % of
people above the age of 50 years have some
degree of hemorrhoids. All age groups including
young children are affected. Men are affected
roughly twice as frequently as women.
The rich plexus of vascular tissue under the
anal canal and lower rectal mucosa is called
corpus cavernosum recti which connects arteries
and veins without intervening capillaries. This
plexus is fed by branches of superior, middle, and
inferior rectal vessels. The hemorrhoidal bleeding is bright red (arterial) in color as it occurs
from presinusoidal arterioles.
The vascular cushions have physiological role
in maintaining anal continence. These cushions
provide complete closure of the anus due to
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_3
11
12
P. Sivalingam et al.
engorgement following coughing, sneezing, etc.
leading to raised intrarectal pressure. These cushions also provide a compressible protective lining
for the underlying anal sphincters. Surgical
removal of these cushions may result in some
degree of incontinence especially in patients with
poor preoperative sphincter tone.
There are three main anal cushions located in
left lateral, right anterior, and right posterior
positions corresponding to branches of superior
rectal vessels with some accessory small masses
between them. These hemorrhoids should be
preferably described as such rather than numbers
on the clock.
3.2 Etiopathogenesis
of Hemorrhoids
The supporting tissue of anal canal or suspensory
ligament of Parks (muscularis submucosae ani or
Treitz muscle arising from internal sphincter or
some elastic tissue) anchor and suspend the anal
canal mucosa to the underlying sphincter (Parks
1954 ). Repeated stretching of anal canal mucosa
causes weakness of this supporting tissue thereby
prolapse. Thomson in 1975 proposed a sliding
theory as a cause of hemorrhoids. Predisposing
factors for prolapse include constipation, diarrhea, prolonged straining, and aging. Erect posture, absence of valves in the hemorrhoidal
sinusoids, and obstruction to venous return also
cause congestion of these vascular cushions
(Johanson and Sonnenberg
increased vascularity and laxity of pelvic fl oor
muscles along with abdominal compression of
major veins predispose to higher incidence of
hemorrhoidal disease especially in late pregnancy. Bleeding occurs due to localized trauma
to prolapsed tissue.
While it was thought to be a purely venous
disease yet it was associated with bright red
bleeding. Now the answer for this paradox has
been found. There are arteriovenous communications interspersed with tissues in anorectal areas,
and these start sliding while straining. Thus,
venous drainage becomes poor while arterial circulation keeps pumping blood normally.
1990 ). In pregnancy,
Endoscopy examinations up to rectosigmoid
region should be preferred in all patients presenting with hemorrhoids as they could be secondary
to carcinoma of mid- or upper rectum.
Portal hypertension causes rectal varices and
bleeding from these varices is profuse and dark,
while bleeding from hemorrhoidal varices is
bright red.
Burkitt in 1975 suggested that low-residue
diet results in venous disease including varicose
veins, deep vein thrombosis, and hemorrhoids
(Burkitt 1975 ).
Hereditary predisposition of hemorrhoidal
disease is not well known though certain families
may be affected in young age. This may be due to
structural weakness of venous walls.
3.3 Classifi cation
of Hemorrhoids
3.3.1 Vascular Hemorrhoids
These are usually seen mainly in young individuals in
which distended veins are the main component, and
bleeding per rectum is the essential presentation.
3.3.2 Mucosal Hemorrhoids
It occurs more often in old persons which are
formed by large thickened mucosa. The main
presenting symptom in this type is a feeling of
some sort of obstruction during the initial act of
defecation and a sense of incomplete evacuation.
3.3.3 Internal Hemorrhoids
It is due to redundant portions of the mucous
membrane of the anal canal above the dentate
line. Depending on the symptoms and the extent
of the prolapse, the internal hemorrhoids are
classifi ed as fi rst degree which bleed; second
degree bleed and prolapse and reduce spontaneously; third degree bleed, prolapse, and require
manual reduction; and fourth degree bleed, get
incarcerated, and cannot be reduced (Thomson
et al. 1992 ). This staging has only limited
3 Hemorrhoids
13
value as it refers to one aspect of the disease,
prolapse. The severity of the disease can be
related as much to the severity of blood loss or
the degree of discomfort. Many old people with
third-degree hemorrhoids have relatively little
problem.
3.3.4 External Hemorrhoids
They occur in the perianal region. They are situated below the dentate line and are covered by the
anoderm. The anal skin tags are the result of previous attack of external hemorrhoids.
3.4 Symptoms
The main symptoms of hemorrhoids are bleeding, protrusion, pain, discharge, and irritation.
3.4.1 Bleeding
Bleeding is the most common symptom. Initially,
there is slight streak of blood on the constipated
motion. Later, a steady drip of blood for a few
minutes is usually seen after passage of stool.
When hemorrhoids prolapse, it becomes congested, and bleeding can occur apart from defecation at any time. The blood is bright red in
color because of arteriovenous communications.
The blood loss may be occasional or severe and
persistent enough to cause anemia. In massive
bleeding, the patient may have an urgent desire
to defecate. The volume of the blood may be considerable, but it stops quickly.
Fig. 3.1 Interno-external hemorrhoids with severe
anemia
3.4.3 Pain
Usually, hemorrhoids are associated with some
discomfort. When thrombosis occurs, pain may
be moderate to severe, depending upon the degree
of engorgement. Sever pain may be due to associated fi ssure, sepsis, strangulation, and ulceration
of pile mass.
3.4.4 Discharge and Irritation
The soiling of the underclothing with mucus
may be noticed when the hemorrhoids are persistent and prolapsed. Mucoid discharge from
the anus occurs in any case with prolapsing
even temporarily. Irritation of the perianal skin
in third- and fourth-degree piles is present in
varying degrees of intensity. But the typical
skin changes that occur in pruritus ani are not
common.
3.4.2 Protrusion
Protrusion of the hemorrhoid occurs initially at
defecation and gets reduced spontaneously after
the act. Later, the protrusion occurs during defecation, and the patient has to push it into the anal
canal after defecation. At this stage, the prolapse
can occur on coughing, sneezing, or passing fl atus. In advanced stage, it is permanently prolapsed with the anal mucosa exposed.
3.4.5 Anemia
Repeated profuse anal bleeding causes iron
defi ciency anemia (Fig. 3.1 ). In case of severe
anemia, one should always suspect another
possible occult cause for bleeding. It is advisable to check the hemoglobin regularly after
the hemorrhoidal disease has been successfully
treated to ensure that there is no other cause for
anemia.
14
Fig. 3.2 Third-degree hemorrhoids Fig. 3.3 Prolapsed thrombosed external hemorrhoids
P. Sivalingam et al.
3.4.6 Painful Mass in the Anal Region
When thrombosis of the prolapsed haemorrhoid
occurs, patient may present with a painful mass
with sudden onset (Fig. 3.2 ). Rise in tissue ten-
sion within and outside the anal canal is responsible for pain and edema. The condition can be
diagnosed by inspection alone. If surgery is not
performed, the natural history of thrombosed
hemorrhoid is one of slow resolution. The edema
and infl ammatory swelling reduce in course of
4–5 days, and complete resolution occurs in
4–6 weeks leaving behind a skin tag.
3.5 Clinical Examination
A detailed history is very important in the diagnosis of hemorrhoids. The color and the character of
the anorectal bleeding and the relief obtained from
reduction of the prolapsed mass into the anal canal
lead to the diagnosis. The presence of hemorrhoid
does not exclude other causes of bleeding. Thirddegree hemorrhoid is a prolapsing mass, the outer
part of which is covered with skin, the inner portion with red or purplish anal mucosa, and the
junction between these two areas being marked by
a linear furrow (Fig. 3.3 ). In long-standing cases,
the lining epithelium often undergoes metaplasia
to a squamous type. When this change has
occurred, the covering epithelium is seen as a pale,
white pannus extending from mucocutaneous
junction over the mucosal surface.
3.5.1 Digital Rectal Examination
Usually, uncomplicated hemorrhoids are not palpable. Large hemorrhoids can be felt as soft elevation of the mucosa of the anal canal just above
the dentate line. Piles are felt when thrombosed.
3.5.2 Endoscopic Examination
Proctoscopy permits accurate diagnosis of the
hemorrhoids as well as the degree of prolapse.
Sigmoidoscopy is essential to exclude any pathology beyond the reach of the proctoscope.
One should always keep in mind other anorectal pathological conditions may present with similar symptoms. They include rectal prolapse
(partial or complete), polyps, and carcinoma.
Colonoscopy or air contrast barium enema is
indicated when no source of bleeding is evident
on anorectal examination, presence of occult
blood in stool, atypical bleeding for hemorrhoids,
and when patient is at high risk for developing
colonic neoplasms.
3.6 Treatment
The treatment of hemorrhoids is based on the
degree of prolapse, severity and nature of
symptoms, expertise of the surgeon, and the
facilities available. The treatment options include
dietary modifi cation, medical treatment, offi ce
3 Hemorrhoids
15
procedures for early and less symptomatic
hemorrhoids, and operative intervention for
third- and fourth-degree hemorrhoids.
3.6.1 Dietary and Lifestyle
Modifi cation
Increased fi ber and water intake reduced straining at stools, and local hygiene is an integral part
in the management of all degrees of hemorrhoids.
Patient should be advised to take diet rich in fi ber
(20–35 g/day). Fiber supplementation (psyllium,
methylcellulose, calcium polycarbophil) has
been shown to improve overall symptoms and
bleeding (Alonso-Coello et al. 2006 ). Fiber sup-
plement is usually recommended for patients
who are noncompliant for taking suffi cient fi ber
in diet. Psyllium with water adds moisture to
stools and thereby reduces constipation.
Lifestyle modifi cations play an important
role to improve symptoms in these patients.
Neglecting the fi rst urge to defecate, spending
prolonged time at toilet, and straining are
common defecation errors which need to be
corrected.
3.6.2 Medical Treatment
In spite of lack of rigorous evidence in the literature, doctors continue to use topical and systemic
agents to relieve symptoms in patients with hemorrhoids. Most effective symptomatic relief can
be obtained by warm (40 °C) sitz baths for not
more than 15 mins or use of ice packs for limited
period. Topical ointments or creams containing
corticosteroid, local anesthetics, antiseptics,
decongestants, etc. have been shown to give
symptomatic relief. Micronized purifi ed fl avonoid fractions act by enhancing venous tone.
Topical glyceryl trinitrate has been reported
effective in strangulated internal hemorrhoids by
decreasing internal sphincter tone (Patti et al.
2006 ). Prolonged use of topical agents should be
avoided as they can cause local allergic effects
and sensitization of skin. Although topical agents
improve the symptoms, it is unlikely they will
eliminate or cause the disease.
Calcium dobesilate can be used locally as well
as systemically in the dose of 500 mg twice a day.
It decreases capillary permeability, platelet aggregation, and blood viscosity. It also increases transportation of lymph. Calcium dobesilate has been
found to be safe, fast acting, and effi cient in treating acute symptoms of hemorrhoidal diseases.
3.6.3 Offi ce Procedures
3.6.3.1 Injection Sclerotherapy
The technique was pioneered by Mitchell of
Clinton, Agbo SP, in 1871 . He kept it secret and
sold to quacks just before his death. These quacks
would roam in the USA and were known as traveling “Piles Doctor.” Eventually, Andrews of
Chicago got the secret from one of the quacks
and gave it to the medical profession in 1879.
Sclerotherapy is indicated for fi rst- and
second- degree hemorrhoids but contraindicated
in thrombosed, prolapsed, ulcerated, infected,
and gangrenous hemorrhoids. The agents used
for sclerotherapy are 50 % phenol in vegetable
oil, quinine, sodium morrhuate, sodium tetradecyl sulfate, and hypertonic saline. 5ml of solution is injected into the interstitial tissue of
submucosa (unlike varicose where sclerosant is
injected into the vein). Total of 12–15 ml of solution can be used. The injection is given with a
Gabriel syringe through proctoscope at the base
of the hemorrhoid mass just below the anorectal
ring (Fig.
matory reactions, fi brosis, scarring, and fi xation
of mucosa to muscularis propria thereby shrinkage and reduction of the pile mass.
the barrel and a ring at the end of the piston for a
secured grip. The needle is straight or slightly
angulated with a shoulder on it about 2 cm from
sharp end of the needle. The solution should fl ow
freely. Resistance means wrong placement of
needle. The amount of fl uid to be given depends
on the laxity of mucosa. Following injection, red
mucosa turns purple. After an hour or so, the fl uid
granulates down and may cause some soreness.
First injection is most effective. Subsequent
injections can be given after 1–2 years if symptoms reappear. Repeat sclerotherapy is diffi cult
3.4 ). The sclerotherapy causes infl am-
The Gabriel syringe has two lateral rings on
16
P. Sivalingam et al.
because of previous fi brosis. Injected area feels
like an indurated mass for 2–3 weeks, after which
it gradually subsides. Complication of sclerotherapy includes pain, hemorrhage, local sepsis,
necrosis, ulceration, portal pyemia, prostatitis,
hematuria, and erectile dysfunction (Guy and
Soew-Choen 2003 ). Pain is due to sclerosant
tracking down or injection given low down on
sensitive area. That is why patient is kept on bed
for few hours with foot end elevated. Bleeding
can be stopped by pressure with proctoscope or
fi nger. Sclerotherapy can be given in patients on
anticoagulation. Senapati and Nicholls ( 1988 )
have shown that fi ber supplementation may be as
effective as injection sclerotherapy.
Fig. 3.4 Injection sclerotherapy
3.6.3.2 Rubber Band Ligation
It is a simple, inexpensive, and one of the most
widely used outpatient procedure for bleeding
and prolapsed fi rst-, second-, and third-degree
internal hemorrhoids. The procedure was fi rst
described in 1963 by Baron. The band results in
ischemic necrosis of the tissue which sloughs in a
weeks’ time leaving an ulcer which heals by
fi brosis resulting in fi xation of tissue to the underlying sphincter. Banding should be avoided in
patients on anticoagulants.
Different types of ligators are available in the
market. The conventional Baron’s hemorrhoidal
ligator consists of 11-mm wide hollow drum
(Fig. 3.5a, b ). The rubber band is placed over
the drum by a loading cone. A second drum
moves over it to push the rubber band into position. The two drums are mounted on a handle
fi tted with a trigger device. The hemorrhoidal
mass is drawn into the hollow drum by a specially designed hollow forceps or Allis forceps.
It must be made sure that the rubber band grips
the pedicle at least 2 cm above the sensitive
area, dentate line to avoid pain. The trigger is
pulled, the outer drum slides over the inner one
and pushes the rubber band to grip the pedicle of
the pile mass. The forceps is released and the
ligator is removed.
In a modifi ed technique, a McGown suction
ligator is used whereby hemorrhoidal mass is
drawn into ligating barrel by suction thereby
avoiding the use of second hand or an assistant.
Being smaller in size, it bands lesser tissue than
other ligators.
ab
Fig. 3.5 ( a , b ) Hemorrhoidal band ligator
3 Hemorrhoids
17
O’Regan invented a disposable syringe like
ligator to simplify the procedure for the patient as
well as surgeon.
Multiple hemorrhoidal masses can be ligated
in a single stage with no signifi cant increase in
morbidity (Poon et al. 1986 ). Some surgeons pre-
fer to do it in multiple sittings after seeing the
response to fi rst ligators. The procedure can be
repeated after 4–8 weeks.
About 60–70 % patients respond to single session of band ligation with signifi cant symptomatic relief, although repeat treatment may be
required at a later date. A meta-analysis of fi rst
trials comparing treatment options for grade I to
III hemorrhoids found better response and better
long-term effi cacy with hemorrhoidectomy than
banding, but there were lesser complications in
those patients who underwent banding treatment.
Compared to injection sclerotherapy, banding
showed better response to similar complication
rate (MacRae and McLeod 1995 ; Shanmugam
et al. 2005 ).
Pain is the most common complication which
occurs in 5–60 % of patients. Cataract blade is
used to cut the rubber band to relieve pain.
Delayed pain in the form of sensation of full
mass may occur after 24–48 h and is due to
edema over the band which extends down to dentate line. It is treated by complete bed rest and
anti-infl ammatory drugs.
Bleeding may be primary or secondary after
5–10 days following banding which is due to
sloughing of the pile mass. Passage of blood with
the fi rst bowel moment is common. Patient needs
complete bed rest and reassurance. Perianal and
pelvic sepsis has been reported (Guy and SoewChoen
2003 ; O’Hara 1980 ) in patient present
with anal pain, fever, diffi cult urination, and defecation. Rarely, liver abscess and necrotizing
infection have been reported (Chau et al. 2007 ).
These patients need hospitalization and treatment
with intravenous fl uids, antibiotics, drainage of
pus, and debridement.
3.6.3.3 Cryotherapy
The principle is based on cellular destruction by
rapid freezing followed by rapid thawing. The
freezing temperature is achieved with nitrous
Fig. 3.6 Infrared coagulation equipment
oxide at −60 to −80 °C, or liquid nitrogen at −60
to −190 °C can treat hemorrhoids by necrosing
the vascular cushion due to thrombosis of microcirculation (Smith et al.
1979 ). The procedure is
time consuming and associated with profuse
foul-smelling discharge and irritation. In addition
to pain and slow healing, the inappropriate use of
cryotherapy can cause necrosis of internal anal
sphincter resulting in anal stenosis and incontinence. Therefore, it is no longer recommended
for treatment of internal hemorrhoids.
3.6.3.4 Infrared Coagulation (IRC)
The infrared radiation is generated by a tungsten
Halogen lamp. A gold-plated refl ector and specially made polymer tubing facilitate the process
(Fig. 3.6 ).
First described by Natti and popularized by
Neiger in
1979 , the infrared light penetrates the
tissue to a level of approximately 3 mm in the
submucosa in the form of heat energy of
100 °C. This heat process is an actual burn, leading to tissue destruction and eventually to scarring. It causes not only the disappearance of
vascular tissue but also the tethering of the hemorrhoids, resulting in no further bleeding or prolapse. It works best for bleeding small fi rst- and
second-degree hemorrhoids. The site of application is similar to the area advised for sclerosing
agent or rubber band application. Three or four
coagulations can be performed at the base of each
haemorrhoid and it takes about 30 s for each
piles. All the three hemorrhoids can be treated in
one session. Repeat application may be needed in
18
P. Sivalingam et al.
some patients after 2 months. There can be some
mucous discharge and a sensation of fullness and
discomfort until complete healing occurs. An
ulcerated area develops over the applied site after
4–5 days which usually heals in 4 weeks’ time.
A meta-analysis of fi ve trials comparing different technique showed similar results 12 months
after treatment for IRC, RBL, and injection
sclerotherapy. However, IRC was associated with
fewer and less severe complications. They suggested that IRC may be an optional alternative
method of treatment.
3.6.3.4.1 Complications
Transient discomfort during application of the
probe is common. If pain persists, it is because the
site chosen is too close to the dentate line.
Bleeding after infrared coagulation may occur in
the 6–8th post-application day and can be managed by bed rest and other conservative methods.
3.6.3.5 Bipolar Diathermy or
Coagulation (BICAP
OR LigaSure)
This technique was designed to produce tissue
destruction, ulceration, and fi brosis by the local
application of heat. This effect is obtained by
bipolar diathermy, an electric current to generate
a coagulation of tissue at the end of cautery tip.
Heat does not penetrate as deeply as monopolar
coagulation. A 2-s pulse is applied to each hemorrhoid in a suitable location in the same manner
as infrared coagulation. It can be repeated as
many times as required. This technique has been
used in fi rst- to third-degree hemorrhoids with
high success rate.
3.6.3.6 Direct Current Therapy
In this technique, direct current is applied through
an anoscope to the apex of the hemorrhoid. It is
not so effective for large pile masses and as such
has not become popular.
3.6.3.7 Anal Dilatation or Stretch
(Lord’s Procedure)
The proponents of this method were of the opinion that stretching improves the venous return
thereby causes reduction in pile masses and some
symptomatic relief. But because of high rates of
incontinence due to sphincter damage, it has
almost been given up.
3.6.4 Surgical Treatment
Any surgical treatment of anorectum should be
undertaken seriously with special care, proper
judgment, and careful execution. The anal canal
deserves as much respect as urethra or common
bile duct. Surgical treatment is indicated for
patients who do not respond to conservative or
offi ce procedures, patients with large external hemorrhoids, grade III to IV interno-external hemorrhoids, thrombosed, strangulated and gangrenous
hemorrhoids, and concomitant conditions like fi stula or fi ssure. Some patients with even lower
grades of disease may show preference for surgical
treatment. If properly executed, recurrence is
uncommon. Though surgery is the most effective
treatment for hemorrhoids especially grade III, it is
indicated only in about 5–10 % of patients.
Numerous surgical options are available. In
conventional procedures, hemorrhoidal tissue is
excised and either left open to heal by secondary
intention (Milligan Morgan hemorrhoidectomy)
or closed primarily (Ferguson’s hemorrhoidectomy). Various modifi cations have come up using
different instruments for excision like electrocautery, bipolar sessions, laser LigaSure, harmonic
scalpel, circular stapler and Doppler-guided hemorrhoidal artery ligator (DGHAL) alone or in
combination with resection (RAR).
3.6.4.1 Open Hemorrhoidectomy:
Milligan Morgan
The choice of anesthesia and patient positioning
are individualized and generally depend on
patient’s condition and surgeon’s preference.
Nowadays, any surgeons perform open hemorrhoidectomy as a day-care procedure.
Open hemorrhoidectomy was the procedure
commonly performed throughout the world up to
1960. Milligan et al. popularized the open technique. Since the procedure was relatively simple,
it was adapted at one time throughout the world.
This technique is popular in the UK and Europe.
3 Hemorrhoids
ab
cd
19
Fig. 3.7 ( a – d ) Steps of open hemorrhoidectomy
The haemorrhoid complex is everted by applying artery forceps to reach the level of the anorectal ring (Fig. 3.7a–d ). A V shaped incision is
made in the anal and perianal skin. The point of
V should lie 1–1.5 cm from the anal verge. As the
dissection proceeds upward, the mucosa is
divided on each side of the hemorrhoidal mass to
converge toward the apex of the pedicle in order
to avoid a broad bulky mucosal pedicle. Care
should be taken not to injure the internal anal
sphincter during dissection. The apex of the pedicle is transfi xed with 1/0 Vicryl suture with
round body needle. While incising the perianal
skin and anal mucosa, leave suffi cient islands of
anoderm between the excised segments to prevent anal stenosis. After completion of the operation, the perianal wound should look like a clover
or three pear-shaped wounds. Open hemorrhoidectomy is an option when the wound cannot be
completely closed or in the presence of gangrene
or circumferential hemorrhoids. Though the
results are excellent, it is more painful in the
postoperative period, takes a little longer time to
heal, and incidence of postoperative stenosis is
relatively high.
3.6.4.2 Closed Hemorrhoidectomy (Ferguson)
Ferguson and Heaton reported closed hemorrhoidectomy technique in 1959. Over the years,
this technique was widely accepted and practiced
and is more popular in the USA. Closed hemorrhoidectomy has three principle objectives: (1) to
remove as much vascular tissue as possible without sacrifi cing anoderm, (2) to minimize postoperative serous discharge by prompt healing, and
(3) to prevent stenosis that may complicate healing of large raw wounds.
After positioning the patient, decision should
be made which hemorrhoid should be removed