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Surgical Therapy For External haemorrhoids Indications: Refractory to office procedures. Large external haemorrhoids. Combined internal and external haemorrhoids with significant prolapse. High complication rates and most postoperative disability. Internal haemorrhoids From superior haemorrhoidal cushion. Overlying mucosa is rectal Innervation is visceral. External haemorrhoids From the inferior haemorrhoidal plexus beneath the dentate line. Somatic pain receptors. Skin tags excess skin from previous pile thombosis Clinical Manifestations — Patients with haemorrhoids usually seek treatment for painless bleeding on tissue paper/ drip into pan. Prolapse. Pain associated with a thrombosed haemorrhoid. Pruritus. Faecal soilage. Complications of haemorrhoidectomy: Urinary retention - in 30 %; treatment involves warm sitz baths and analgesia. Urinary tract infection - in 5 % possible urinary retention related. Delayed haemorrhage (7-16d post-op) -2%. From clot sloughing; treatment involves none/ suture ligation. Faecal impaction -From postop pain and opiates; treat with laxatives. Submucosal abscess in<1 % - severe fasciitis or necrotizing infections are rare. Pain -in 100%. From spasm of the internal sphincter. Treat with perianal topical diltiazem ointment (2 %) tds for 7d or botulinum toxin. Conservative Treatment For Internal Haemorrhoids: For bleeding — Add fibre to diet. For irritation and pruritus — See anal pruritis. For trombosed haemorrhoids — Conservative if internal and excision or analgesia for external until spontaneous resolution occurs. Topical 0.5 % nitroglycerin ointment may provide temporary analgesia by reducing internal anal sphincter spasm. Nifedipine/ botulinum may also be useful. Rubber band ligation — Indication: 1st, 2nd, and selected 3rd degree haemorrhoids. Technique: Very similar to banding oesophageal varices Place 5mm above dentate line Treat 1 column/session to minimize problems with necrosis Complications: 1. Delayed bleeding once band fallen off (after 2-4 days) 2. Ulceration and mucosal sloughing cause bleeding 5-7 days after 3. Localized infection 4. Thrombosis of haemorrhoids distal to band Bipolar, infrared, and laser coagulation — Technique: Coagulating bipolar current Indication: Grade I to II internal haemorrhoids Fewer side effects but more recurrence than band ligation Sclerotherapy — Indication: Grade I and II internal haemorrhoids. Examples include sodium morrhuate, 5 % phenol, and hypertonic saline. Less effective than rubber band ligation. Cryosurgery —High rate of complication and less patient satisfaction. Internal haemorrhoids
Surgical Therapy Indica - tions For Internal Haem - orrhoids: -Failure of medical and nonoperative therapy. -Symptomatic 3rd-degree, 4th-degree, or mixed internal and external haemorrhoids. -Symptomatic haemorrhoids in the presence of a concomitant anorectal condition that requires surgery. Treatment
Haemorrhoids
External haemorrhoids
Associations: -Advancing age. -Diarrhea. -Pregnancy. -Pelvic tumours. -Prolonged sitting. -Straining. -Chronic constipation (never proven). More painful with external than internal. If internal haemorrhoid strangulates can cause gangrene Epidemiology The prevalence of haemorrhoids is 4 %. Males are as likely as females to have them. The peak age of incidence is between 45 and 65. Theory 1 : Weak connective tissue Theory 2: Increased tone of the internal anal sphincter (During defecation, the fecal bolus forces the haemorrhoidal plexus against the internal sphincter, which causes them to enlarge and become symptomatic) Theory 3: Swelling of haemorrhoidal cushions. Non-surgical Treatment
Avoid incision and drainage as not haema - toma and thrombosis will recur and may extend. Non-surgical Treatment for Inter - nal Haemorrhoids These do not usually require minimally invasive or surgical therapy unless thrombosed. Treatment for Thrombosed External Pile: Excise within 72 hours to relieve the pain Manage expectantly if >72 hours Avoid constipation Patient analgesia Ice or sitz baths. Other complications include sphincter damage ( rare), wound dehiscence (which is common but usually of no clinical consequence), and stricture formation (1 %).
Written by Dr Sebastian Zeki
Anatomy Of Haemorrhoids They are derived from a plexus of submucosal dilated veins arising from the superior and inferior haemorrhoidal veins. External haemoorrhoids are below the dentate line, internal are above. All haemorrhoids drain into the internal pudendal veins, and ultimately the IVC. Haemorrhoids aldo have direct communication with the portal system.
External anal sphincter muscle Internal anal sphncter muscle Levator ani muscle Rectal mucosa
Columns of Morgagni Perianal skin Squamous mucosa Dentate (pectinate) line
Internal haemorrrhoid External haemorrhoid
Surgical Techniques For Internal Haemorrhoids: Closed haemorrhoidectomy —the most common technique with a 95% success rate. Open haemorrhoidectomy . Stapled haemorrhoidectomy (stapled haemorrhoidopexy). Lateral internal sphincterotomy — For internal haemorrhoids associated with high
Degree of haemorrhoids 1- No protrusion 2- Protrude but spontaneously reduce 3-Manual reduction needed 4. Permanent protrusion
