Download - Hemorrhoids-
Presenter: Dr. Sachin
Surgery
Haemorrhoids
Haemorrhoids ?
Engorgement of the haemorrhoidal venous plexuses with redundancy of their coverings.
Haemorrhoids
haimorrhoides
haima=blood rhoos=flowing
bleeding
in anal canal
which may or may not bleed
Piles
pila (a ball)
swelling
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
above dentate line superior rectal A.
below dentate line inferior rectal A.
Arterial supply
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
Venous drainage
External haemorrhoidal plexus Lies outside muscular coat of
anal canal Communicate freely with internal
plexus
Potential sites for Primary Haemorrhoids
Anal veins
Arrange radially around anal margin Communicates with internal plexus & IRV Straining rupture these vein Ruptured vein present
as subcutaneous perianal hematoma
SRV
MRV
IRV
Venous drainage
Aetiology
Straining
Constipation
Prolonged lavatory sitting
Trauma
Ageing
Diarrhoea
Lack of fibre rich diet
hereditary
Secondary causes
Local
Abdominal
Pelvic
Neurological
Pregnancy
Portal hypertension
anorectal deformity,hypotonic sphincter
ascites
gravid uterus,uterine neoplasm,ovarian neoplasm,
paraplegia,multiple sclerosis
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
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
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.
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.
11 o’clock
7 o’clock
3 o’clock
Incidence
Difficult to evaluate.
Prevalence ~ 5%.
Peak of prevalence is between 45 and 65.
unusual before the age of 20.
Caucasians > Afro-Caribbeans.
Symptoms
Prolaps
Pain
Discharge & Pruritus
Bleeding
HaemorrhoidsProlaps
Pain
Discharge & Pruritus
Bleeding
H’oids
Earliest symptom{ A splash in the pan }
( If complication )
Physical Examination
Left lateral decubitus position
Any rashes, condylomata, or eczema
Any abscesses, fissures or fistulae
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
Diagnostic Tests
Physical examination. Proctoscopy. Flexible sigmoidoscopy Evaluation under anaesthesia in acute pain Anal manometry
if h/o soiling & incontinence
• Classified according to origin of haemorrhoid.
• Above or below the Pecinate line?
External or Internal
External hemorrhoid Internal hemorrhoid
Below dentate line Above dentate line
Varicosities of veins draining
inferior rectal artery
Varicosities of veins draining
superior rectal artery
Lined by
squamous epithelium
Lined by
columnar epithelium
Painful Pain insensitive
Prone to thrombosis if vein ruptures
(Thrombosed pile)
May prolapse outside anal canal
(prolapsed hemorrhoid)
Gr I Gr II Gr III Gr IV not prolapse returns spontaneously manually returned remains prolapsed
Grading of hemorrhoids (on history)
Complications of hemorrhoids
Portal pyaemia
Suppuration
Fibrosis
Ulceration
Gangrene
Thrombosis
Strangulation
Gripped by Ext. sphincter
Impeded venous return
prolapse
Thrombosed External haemorrhoids
Prolapsed Internal haemorhoids
TREATMENT
Conservative Dietary and lifestyle modification. Non operative/office procedures. Operative hemorrhoidectomy Minimal invasive procedures
Dietary & Lifestyle modifications
Minimize straining at stool. and
Prevention of constipation
Dietary & Lifestyle modifications
Drinking Fluids High-fiber diet Use of Fiber
supplements Stool softeners Exercise Local hygiene
Dietary & Lifestyle modifications
“you don't defecate in the library so
you shouldn't read in the bathroom”
Dietary & Lifestyle modifications
If prolapses, gently push back into anal canal
Use moist towelettes or wet toilet paper instead of dry toilet paper.
Topical Treatment
Include: Pads, Ointments, Creams, Gels, Lotions Suppositories.
Used now a days includes Calcium dobesilate .25%
Anhydrous lignocaine 3%
Hydrocortisone acetate .25%
Zinc 5%
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
Sitz bath Post operative Warm water is used
Dialatation of blood vessels Allow blood to pass through
swollen piles more quickly Relaxes muscles so ease anal
sphincter tone
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.
Topical medications
Commonaly used is
Combination of
Calcium dobesilate & docusate sodium
Calcium dobesilate:Decrease capillary permeablity,
Decrease platelet aggregation
Stops bleeding
Reduce thrombus formation
Improves mucosal inflammation
Docusate sodium:
Stimulant laxative,
makes bowel movement softer and easier to pass
Reduces pain or rectal damage caused by hard stools or straining
Office procedures
Sclerotherapy Infra-red Coag Band Ligation Cryosurgery Manual Dilation of anus. Sphincterotomy (lateral) Bicap electrocoagulation haemorrhoidolysis
Sclerotherapy(Mitchell)
Injected in submucosa around pedicle
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
Sclerotherapy
Injected in submucosa around pedicle
Causes oedema, inflammatory reaction & intravascular thrombosis.
Submucosal fibrosis & scarring minimises the extent of
mucosal prolapse and potentially shrinks the
haemorrhoid as well.
Sclerotherapy
Injected in submucosa around pedicle
Quick painless Follow up after 6 weeks 2-3 further injections may
be required Free from major
complications
Sclerotherapy
Injected in submucosa around pedicle
Contraindications Prolapsed pile Infection
Complications retroperitoneal sepsis, portal pyemia necrotising fascitis Prostatitis Impotence Rectovaginal fistula
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
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
Barron’Band Ligation
Complications: anal stenosis Inclusion of dentate line
cause pain vasovagal shock sepsis
occlude base of hemorrhoid above dentate line
cryosurgery
Freezing of hemorrhoidal tissue liquid Nitrogen probe at -160oC for 3 minutes
Applied for 10-15 minutes Over upper part of hemorrhoidal area
Profuse watery discharge is most common complication (in first 3 hrs)
Cryosurgery
Painless
Causes necrosis of hemorrhoidal tissue
Healing completes in 4-6 wks
Little efficacy in prolapsed hemorrhoids
Infrared photocoagulation
High intensity infra red light 3-6 pulses of 1.5 sec each appllied to mucosa
Infrared photocoagulation
Coagulate vessels & fix underlying mucosa Useful for actively bleeding piles Painless and uncomplicated
BICAP Electrocoagulation
Theoretically similar to photocoagulation
Probe must be left in place for ten minutes.
Poor patient tolerance minimizes the effect of this procedure.
Lord’s Maximal anal dilatation
Spasm of int sphincter responsible for many symptoms of hemorrhoids
Reserved for large Gr II & Gr III hemorrhoids
NOT eliminate redundant tissue
Risk of incontinence
Haemorrhoidolysis
Therapeutic galvanic waves
Produce chemical reaction
Shrink and dissolve hemorrhoidal tissue
Most effective on internal hemorrhoids
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
Milligan-Morgan (open) Haemorrhoidectomy
First described over 2 centuries ago.
Milligan-Morgan (open) Haemorrhoidectomy
Milligan-Morgan (open) Haemorrhoidectomy
Wound left open
Final Operative Aspect in a Haemorrhoidectomy.
Ferguson’s (Closed) Haemorrhoidectomy
Developed in 1952
Haemorrhoidal tissue excised. Mucosal wound and skin sutured completely
with a continuous absorbable suture.
Harmonic Scalpel sutureless technique
shorter operative time
less post-op pain.
hospital stay not required.
Comparative Increased cost to other techniques.
MIPH
Longo introduced the technique in 1995.
MIPH
Stappler haemorrhoidopexy
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
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
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
A.M.I. (DG) HAL/RAR® System
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
Complications of surgery
Late complications Anal stenosis Anal fissure Fecal impaction Mild incontinence Submucous abscess Delayed bleeding Skin tags Recurrence
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
Thank you for your patience