Hemorrhoids are a common condition. We are all born with hemorrhoids but only some of us suffer from them occasionally.

Hemorrhoids or piles, as they are commonly known are one of the most common and benign conditions of the colo-rectal region. They are said to be “The penalty for erect posture” and inflict individuals without regards for gender, class, sex or socio-economic status.

In fact it’s estimated that in industrialized countries around 50% of the population aged over 50 suffer, or have suffered,from recurrent hemorrhoid problems. With the advancement of minimally invasive surgery, surgical management of hemorrhoids has grown by leaps and bounds.

Classification

Patho-physiology

The Haemorrhoidal plexus is a physiological structure of large vascular spaces and arteriovenous shunts (corpus cavernosum recti [CCR]), located above the dentate line, 3-5 cm from the anal verge. The CCR is described as an arterio-venous cavernous network without the interposition of a capillary system. The superior rectal artery (SRA) contributes exclusively to the blood supply of the CCR. It is a functional blood supply that fills this cavernous network, forming a gas-tight seal of the anal canal. It, therefore, plays an essential role in the pathogenesis of hemorrhoids.
Additionally, the bright red color and arterious pH of the blood confirms the arterial nature of the bleeding.

Surgical Treatments
Current surgical modalities include: sclerotherapy, band ligation, cryotherapy and infrared coagulation can cause excessive bleed, pain and prolonged hospitalization. Additionally, minimally invasive procedures have developed intensely during the past 10 years; of which Stapler-Hemorrhoidectomy and Transanal Hemorrhoidal Dearterialization (THD) are most common surgical techniques.

Stapler Hemorrhoidectomy
Stapler Hemorrhoidectomy is a new technique involving circular staplers, introduced by A Longo (1998).
The procedure involves simultaneous excision and primary wound closure without dissection using a specialized disposable instrument by the name of HCS33 (33 mm hemorrhoidal circular stapler). This works on the theory, that interruption of the feeding superficial hemorrhoidal arteries above the base of hemorrhoid was adequate for complete treatment of symptoms. This provides rapid wound healing and decreases post-operative pain.



The patients recommended for this surgery are primarily classified as Grade II -IV piles or have prolapsed anal mucosa.

The patients are placed in the Lithotomy position under Spinal anesthesia. The anal verge is held by three atraumatic forceps and everted to facilitate introduction of an anal dilator along with an obturator. After removing the obturator (introducer), the prolapsed mucous membrane falls into its lumen. The anal dilator is then fixed to the surrounding skin. A ‘purse string suture anoscope’ is then introduced through the dilator, the window of which facilitates inclusion of mucous membrane.




Schematic representation of stapler Hemorrhoidectomy being done

A purse string suture with a prolene 2.0, round bodied, 30mm ½ circle needle is taken around the anal circumference, 2cm proximally to the denate line by rotating the anoscope.

The head of the opened circular stapler is introduced proximal to the purse string; and the knot is applied. The suture ends are subsequently pulled out using a threader (flange) and knotted externally. The entire casing of the circular stapler is introduced and moderate traction is applied to the knot to draw the mucous membrane into the casing of HCS33. Instrument is tightened, safety lock released and fired. It is kept in closed position for 20 seconds after firing so that it acts as tamponade and helps in promoting homeostasis. A fiber optic light cable, supplements for additional light in the anal canal.

The tissue is subsequently checked for a complete circumferential doughnut. Finally the stapled line is examined which is over the anorectal ring at least 2 cm from the dentate line.

Anal packing done with betadine and paraffin gauze is removed the next morning, and the patient walks back home.

The staples are titanium micro staples that fall without the patient’s knowledge.

Transanal Hemorrhoidal Dearterialization

THD Surgical approach
Another recently developed mode of surgical management for hemorrhoids of Grade II and above is, Transanal Hemorrhoidal Dearterialization (THD), in which hemorrhoidal arteries are ligated using a Sound Doppler.

Operative Technique
The patient can be placed in Lithotomy, Jack-Knife or Left
Lateral Decubitus position.

A sound Doppler probe is attached to a disposable and specialized proctoscope and introduced into the anal canal.

The probe identifies the artery, which is ligated using an absorbable suture (Vicryl). Absence of sound on the Doppler indicates ligation the selected artery.

Complete ligation of the terminal branches of the superior rectal artery is done circumferentially in the similar manner followed by check of the ligations via Doppler.

THD allows the localization of the terminal branches of the SRA. The particular shape of the instrument permits precise needle rotation and penetration, hence selective ligation of the terminal arterial branches supplying the internal hemorrhoidal plexus.

Following arterial ligation blood inflow to the piles drops without compromising venous outflow. Thus the ratio of the inflow/outflow decreases. This change in ratio results in collapsed piles and hemostasis.

The decreased tension allows for the regeneration of the connective tissue within the cushions, which facilitates the shrinkage of hemorrhoids and induces permanent reduction of the prolapse.

The sutures used to ligate the arteries create a rectal plexus by stitching the rectal mucosa to the layers below and elevating the hemorrhoidal cushions above the dentate line, thus reducing or eliminating the rectal prolapse.

Complications though rare may include
• Bleeding
• Sub-mucosal haematoma
• Sphincter damage
• Anal Stenosis
• Anal fissure
• Thrombosed Piles
• Delayed discharge

Advantages
• Day Care Procedure
• No need of anesthesia (THD)
• Minimal post-op complication
• No post-op pain
• Highly effective
• Rare relapses
• Highly effective
• Negligible tissue trauma

Disadvantages
• Not indicated in presence of analmucous prolapse
• Expensive disposable device
• Moderate complications rate
• Technically good expertise required

In the end, we would like to conclude that Stapler Hemorrhoidectomy and Doppler guided THD are safe and effective procedure for the treatment of II and III degree hemorrhoids with minimal postoperative pain and quick recovery.

back to top