Piles Surgery

Information for patients: About piles or hemorrhoids. Treatment for piles like injection sclerotherapy(injection for piles), band ligation, hemorrhoid artery ligation, stapled hemorrhoidopexy [MIPH/ PPH], hemorrhoidectomy with electrosurgery, lasers, hormonics or ligasure for piles surgery.

What are piles: Piles or hemorrhoids are anal vascular cushions seen in anal canal as three thick regions composed of blood vessels [plexus of arterioles and veins], smooth muscle fibers [Treitz muscle] and connective tissue. These three thick vascular cushions are found in left lateral, right posteriolateral and right anteriorolateral positions [3, 7 and 11 ‘ clock], which correspond to the terminal branches of right and left superior hemorrhoidal artery. The anal cushions receive blood supply from the terminal branches of superior, middle and inferior hemorrhoidal arteries, which intercommunicate with each other. The corresponding veins i.e. superior, middle and inferior hemorrhoidal veins drain blood from these vascular cushions. 


Hemorrhoids are classified into four grades as follows:

First degree: Veins of anal canal increase in number and size, and they bleed on defecation

Second degree: Hemorrhoids prolapsed outside anal canal but reduce spontaneously

Third degree: Hemorrhoids protrude outside anal canal and require manual reduction

Fourth degree: Irreducible hemorrhoids that remain constantly prolapsed



                     Second degree hemorrhoids



 Clinically, hemorrhoids usually present with bleeding, prolapse, pain (with thrombosis or ulceration), perianal mucous discharge, or pruritis. The complications of hemorrhoids are thrombosis, infection with inflammation, ulceration, and anemia.

Treatment is directed to control constipation, bleeding, prolapse and pain. Dietary measures like high fiber diet, Sitz bath, stool softeners, laxatives and various topical creams are advised for treating hemorrhoids. Ambulatory treatment for hemorrhoid comprises of injection sclerotherapy, rubber band ligation, Cryosurgery, Infrared coagulation and Ultrasonic Doppler guided transanal hemorrhoidal ligation. Surgical treatment comprises of open or closed hemorrhoidectomy and stapled hemorrhoidopexy. 

Injection for piles:  Injection sclerotherapy for piles is most commonly performed painless cure for piles without surgery. About 3 ml of sclerosant is injected in each piles. It causes fibrosis of the piles and fixation of the redundant mucosa. In trained hands the procedure is safe and complications are rare. Injection sclerotherapy has a low cure rate, but is a reasonable option for treatment of first and second degree piles with bleeding. 


Band ligation for hemorrhoids: Major surgery for hemorrhoids like surgical excision (hemorrhoidectomy) or stapled hemorrhoidopexy (PPH procedure) can be often avoided in favour of more precise, often painless and outpatient methods of treatment. Variety of minimally invasive surgical techniques can now be offered to many patients as a feasible alternative to painful or costly major hemorrhoid surgeries. For patients with grade 2 and 3 hemorrhoids, Rubber Band Ligation is currently the most widely used in office procedure in the United States. Rubber band ligation is more helpful when combined with a sclerotherapy injection for prolapse. 

 In this procedure, a rubber band is applied to the base of the hemorrhoid to hamper the blood supply to the hemorrhoidal mass. The hemorrhoid will then shrink and fall off within 2-7 days. Rubber band ligation can be performed in an ambulatory setting. The procedure causes less pain and has a shorter recovery period than surgical hemorrhoidectomy. Its success rate is between 60% and 80%


                                            Hemorrhoid band ligation

hemorrhoid band ligation (YouTube Video)


 



Doppler guided hemorrhoid artery ligation (DG-HAL) combined with transanal rectal mucopexy (TRM) is another painless and effective minimally invasive procedure which can be performed on outpatient basis. Hemorrhoidal Arterial Ligation (H.A.L.) is performed using a modified proctoscope that houses a Doppler transducer and has an opening for taking sutures. Using Doppler ultrasound, the blood vessels supplying the hemorrhoids are identified and ligated with absorbable sutures. This results in shrinking of the hemorrhoidal cushions. TRM is then performed by taking a continuous stitch over the mucosa of the prolapsed hemorrhoid from top to the bottom. The suture is then tightened keeping the knot on the top. The prolapsed hemorrhoids are thus lifted up and are integrated in the tissue scar back to their original position. DG-HAL is a safe and effective treatment in the management of symptomatic grade 2 and 3 hemorrhoids and achieves high patient satisfaction with a success rate of over 90%. 

Hemorrhoid artery ligation can also be performed without the use of doppler. It has been suggested that use of doppler for hemorrhoid artery ligation, does not contributes to the beneficial effects of hemorrhoid artery ligation. In an controlled study comparing hemorrhoid artery ligation with or without doppler, no clincally significant difference was seen between the two groups. After 6 weeks and 6 months in both the non-Doppler and the Doppler group, significant improvement was observed with regard to blood loss, pain, prolapse, and problems with defecation (P < 0.05).

 


Stapled hemorrhoidopexy [ MIPH/ PPH] : is a standard surgical treatment option recommended for treatment of 2, 3 and 4 degree prolapsed hemorrhoids.  A circular stapler is used to excise a circumferential strip of mucosa from the insensitive proximal anal canal. The stapler excises as well as reanastomoses the redundant mucosa. This has the effect of pulling the prolapsed hemorrhoidal cushions back up into their normal anatomical position. There are several advantages of stapled hemorrhoidopexy over conventional open hemorrhoidectomy. The benefits to the patient are less pain, shorter operating time, shorter hospital stay, earlier return to normal activity and has proven safety and efficacy. Some of the adverse effects like severe hemorrhage, rectal perforation, pelvic sepsis, rectal stricture and rectal obstruction,are potentially life threatening, and so the procedure should be carried out by a fully trained colorectal surgeon. (See photogallery for pics)

 

Stapled hemorrhoidopexy for fourth degree hemorrhoid ( Preoperative & Postoperative views)


 

Conventional excisional hemorrhoidectomy (open or closed):  is the surgical excision of all the hemorrhoid tissue. Excision of hemorrhoids can be done by scissors, electrocautery, ligasure, hormonic scalpel or laser. In closed hemorrhoidectomy the mucosal defect is closed with a suture. Hemorrhoidectomy is associated with significant post-operative pain and usually requires 2–3 weeks for recovery. In addition to excessive post-operative pain, symptoms of incontinence and anal stenosis are other complications noted after excisional hemorrhoidectomy. However, there is greater long term benefit in those with grade 3 and 4 hemorrhoids.