Barron was the first to describe hemorrhoidal banding with rubber bands in 1963.Since this original description, there have been a number of reports that have documented the efficacy banding offers for the management of the majority of patients with bleeding stage II and III internal hemorrhoids.The procedure is generally well tolerated without the need for prescription analgesia if the band is placed above the level of the dentate line. The technique is demonstrated in the picture below . It is important to ask the patient if he or she experiences any pain during placement of the bander, before deployment of the band. Discomfort immediately after band placement may be reduced by the injection of a local anesthetic agent, but this does not appear to be a long-lasting benefit. Banding is associated with the rare but frequently fatal complication of postbanding sepsis, which is heralded by the symptoms of increasing rectal pain, fever, and inability to void.It is essential to treat these symptoms early and aggressively with early antibiotic treatment coupled with surgical drainage
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Options for hemorrhoidectomy include the techniques of Milligan-Morgan hemorrhoidectomy, closed Ferguson hemorrhoidectomy, Whitehead hemorrhoidectomy, and the stapled hemorrhoidectomy. The procedures are usually performed in the operating room after minimal preoperative preparation of the bowel. Lasers have no role to play in excisional hemorrhoidectomy, and in fact they cause delayed healing, increased pain, and increased cost.Anesthetic management is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective. The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention.
The Milligan-Morgan hemorrhoidectomy, which is widely practiced in Europe, was originally described in 1937, and its efficacy has been subsequently documented in many series.This technique includes resection of the entire enlarged internal hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.[33] The distal anoderm and external skin is left open to minimize the risk of infection in the wounds. This technique is safe and effective. However, the fact that the external wounds are left open can be a cause of considerable discomfort and prolonged morbidity.
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The hemorrhoidal cushions appear predictably in the right anterior, right posterior, and left lateral positions, although there may be intervening secondary hemorrhoidal complexes that blur this classic anatomy. The blood supply is similarly constant, derived from the superior rectal artery, a branch of the inferior mesenteric; from the middle rectal arteries arising from the internal iliac arteries; and from the inferior rectal arteries arising from the pudendal arteries. The venous drainage transitions from the portal venous system above the level of the dentate line to the systemic venous system below this level.
The vascular cushions form the termination of the vascular supply within the anal canal and contribute to the maintenance of anal continence.[6] hemorrhoids occurs as the result of abnormalities within the connective tissue of these cushions, producing bleeding with or without prolapse of the hemorrhoidal tissue.[7] This can occur as the result of excessive straining and chronic constipation.[8] A clear understanding of the pathophysiology is important when considering therapeutic interventions. At the earlier stages of disease progression, when the major manifestation is transudation of blood through thin-walled damaged veins or arterioles, ablation of the vessels should be adequate. Conversely, in late stages of the disease, when there is significant disruption of the mucosal suspensory ligament, fixation of the mucosa to the underlying muscular wall is required for effective therapy.Internal anal sphincter dysfunction may play a role; a number of investigators have demonstrated increased internal anal sphincter tone in patients with hemorrhoids. In reality, a combination of all of these factors is probably important for the ultimate development of large prolapsing internal hemorrhoids.
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The decision to excise the hemorrhoidal plexi requires acceptance by the physician and patient that medical and non-excisional options have either failed or are not appropriate. The usual clinical symptoms that lead to excision are frequent prolapsing of the internal hemorrhoids that results in discomfort and anal seepage. Alternatively, the thickened and prolapsing internal/external hemorrhoidal complexes may make anal hygiene difficult for the patient and may make excision preferable. The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids. It is apparent, however, that hemorrhoidectomy can be performed using standard closed hemorrhoidectomy techniques without undue complications. Specifically, the risk of stenosis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites. In the case of limited external hemorrhoidal thromboses, surgical excision is warranted for more rapid pain relief and avoidance of a residual skin tag.External thromboses are usually easily managed in an office setting with local anesthesia
A, Thrombosed external hemorrhoid in the right lateral quadrant. B, Allis clamp applied to apex of thrombosis and elliptical incision made. C, Thrombosis dissected free of sphincter. D, Appearance of wound after thrombectomy.
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Regardless of the excisional technique used for the treatment of advanced hemorrhoids, the key to effective patient management is avoiding postoperative complications. Pain is the most frequent complication and the most feared sequela of the procedure from the patient’s perspective. A variety of analgesic regimens have been recommended, usually consisting of a combination of oral and parenteral narcotics.The use of local infiltration of bupivicaine into the wounds and perianal skin has been variably successful in long-term pain reduction.Conversely, ketorolac has demonstrated considerable efficacy in the management of posthemorrhoidectomy pain.The use of alternative administration routes for narcotics by either patch or subcutaneous pump has been successful in controlling pain, but the management of these routes of administration can be risky in the outpatient setting because of the risk of narcotic-induced respiratory depression. The most appropriate regimen after outpatient hemorrhoidectomy appears to be the intraoperative use of ketorolac, sufficient doses of oral narcotic analgesics for home administration, and supplementation of the narcotics with oral nonsteroidal medication.
Urinary retention is a frequent postoperative problem after hemorrhoidectomy, ranging in incidence from 1 to 52%. A variety of strategies have been used to treat the problem, including parasympathomimetics, alpha-adrenergic-blocking agents, and sitz baths.The best approach, however, seems to be prevention that includes limiting perioperative fluid administration to 250 ml, an anesthetic approach that avoids the use of spinal anesthesia, the avoidance of anal packing, and an aggressive oral analgesic regimen.
