Benign anorectal disorders

Benign Anorectal
Disorders
123
A Guide to Diagnosis
and Management
Nisar Ahmad Chowdri
Fazl Q.Parray
Editors

Nisar Ahmad Chowdri • Fazl Q.Parray
Editors
Benign Anorectal
Disorders
A Guide to Diagnosis
and Management

ISBN 978-81-322-2588-1 ISBN 978-81-322-2589-8 (eBook)
DOI 10.1007/978-81-322-2589-8
Library of Congress Control Number: 2015953053
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Editors
Nisar Ahmad Chowdri
Colorectal surgery
Sher-i-Kashmir Inst of Medical Sciences
Srinagar
Jammu and Kashmir
India
Fazl Q. Parray
Colorectal Surgery
Sher-i-Kashmir Inst of Medical Sciences
Srinagar
Jammu and Kashmir
India

v
My first reaction to a request from Professor Nisar Chowdri to write a foreword
for his book entitled Benign Anorectal Disorders was of sheer delight because
someone with his background and reputation was undertaking a project
necessary in institutions in India. Colorectal surgery is making such dynamic
strides that any contribution to update various techniques is laudatory.
The Benign Anorectal Disorders book has encompassed all of the anorec-
tal disorders from surgical anatomy and physiology to the common disorders
including a chapter on benign tumors of anorectum. Professor Chowdri has
solicited a galaxy of contributing authors who are recognized giants in the
field of colorectal surgery across India. The various chapters, particularly the
one on hemorrhoids, anal fissure, and the perianal sepsis fistula, are compre-
hensive with the updated material right up to the latest publications.
Unfortunately, it becomes necessary in a textbook such as this to include the
procedures that are outdated and are of historical significance only. However,
an attempt has been made by the authors to separate the wheat from the chaff
and given appropriate prominence to the necessary interventions.
The book will address the needs of surgical residents, general surgeons,
and colorectal surgeons. Realizing that much of the anorectal surgery in dif-
ferent parts of the country is performed by general surgeons, this book will be
particularly useful for the specialists.
I am honored to present this foreword to introduce the monumental task
that Professor Chowdri from Kashmir Institute of Medical Sciences in
Srinagar has undertaken and has done it admirably.
Indru T. Khubchandani, MD, MS, FRCS, FACS, FASCRS, FICS (Hon)
Prof. Honoris Causa (Bolivia); Prof. Surgery (University of
Complutensis, Madrid)
Adjunct Professor of Surgery; Hahnemann Medical School, Philadelphia, PA
President; International Society of University Colon & Rectal Surgeons
Foreword for Benign Anorectal Disorders

vii
It gives me immense pleasure and satisfaction on completion of editing this
book Benign Anorectal Disorders: Approach to Diagnosis and Management, a
dream in my life. When I took this project, I was not aware of the difficulties,
but thanks to the almighty, with whose grace I have been able to complete this
book which took me more than a year, much beyond my expectations.
Benign anorectal disorders are of great concern not only to the patient but
also pose a great challenge to surgeons. This is because of the fact that symp-
toms associated with anorectal diseases are not only distressing but also
alarming to the patient. Any surgical intervention in this part of the gastroin-
testinal tract may be associated with lifelong disabilities like incontinence.
The complex anatomy of this region makes surgery all the more difficult.
Though many books have been published on colorectal diseases, benign
anorectal disorders are not available in a book format. This book on benign
anorectal diseases is the first of its kind in the world literature. The experi-
enced colorectal surgeons of national and international fame from all over
India have worked hard to prepare various chapters for the book. I am highly
obliged and thankful to all for their contribution. I have tried my best to make
sure that all issues pertaining to diagnosis and management of these disorders
are addressed so that decision making is simple for the readers. All the efforts
have been made to write each and every topic up to date and interesting for
the readers.
Mr Naren Aggarwal, Executive Editor, Clinical Medicine, Springer, has
been kind enough to give me the opportunity to write this book. I am highly
indebted to him for his proficient guidance from time to time.
Our thanks are due to Mr Javid Hussain for his experienced skills to com-
pute this book. My family and friends have been a source of great encourage-
ment for me, and probably without their encouragement, love, and affection,
it would have not been possible to take this project to completion.
I pray and hope that this book on benign anorectal disorders will be useful
not only for the colorectal surgeons but also for residents, postgraduate stu-
dents, and surgeons in general.
Srinagar, India Nisar Ahmad Chowdri,
MS,FAIS,FICS,FACRSI,FMAS,FACS
Preface 1

ix
The quality of life and surgical results have improved in the hands of dedi-
cated colorectal specialists in the last two decades. With the increase in scope
of this surgical subspecialty, more and more surgeons are getting attracted
toward it and trying hard for specialized training in this branch of surgery.
There is a lot of literature and text focusing on colorectal malignancies avail-
able, but it is difficult to find a book in the market which really deals with
benign colorectal diseases in detail. Therefore, it was thought worthwhile to
publish a book on benign colorectal diseases which can be of help to all post-
graduates, fellows of colorectal surgery, postdoctoral students, and all clini-
cians practicing colorectal surgery. We tried our level best to get the book
chapters authored by the masters in the field. We are thankful to all the great
contributors who made this dream come true through their valuable contribu-
tion. We have also tried to keep the language very simple and hope that read-
ers will find this book quite interesting and helpful in taking exams and their
clinical practice. It is expected to further their knowledge and skill in the field
of colorectal surgery.
Srinagar, India Fazl Q. Parray,
MS, FICS, FACRSI, FMAS, FACS
Preface 2

xi
Contents
1 Surgical Anatomy of Anal Canal and Rectum. . . . . . . . . . . . . . 1
Ashfaq Hassan and Abdullah Al Mamun
2 Physiology of Defecation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Rauf A. Wani and Natasha Thakur
3 Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
P. Sivalingam, Rama Kant, Vijay Arora,
and Pravin Padmakumar Gore
4 Anal Fissure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Benjamin Perakath and Niranjan Agarwal
5 Perianal Sepsis and Fistula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Parvez Sheikh and Prasang Bajaj
6 Pilonidal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
P.N. Joshi and Shekhar Suradkar
7 Rectovaginal Fistulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Fazl Q. Parray
8 Anorectal Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Satish B. Dharap
9 Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
P.N. Joshi, Ashok Kumar, and Kiran Shah
10 Complete Rectal Prolapse in Adults . . . . . . . . . . . . . . . . . . . . . . 131
Ajay K. Khanna
11 Pelvic Floor Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Brij B. Agarwal and P. Sivalingam
12 Perianal Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Iffat Hassan and Parvaiz Anwar Rather
13 Benign Ulcers of the Anorectum . . . . . . . . . . . . . . . . . . . . . . . . . 177
Ahmad Abdul Hai and Niharika Roy
14 Benign Strictures of Anorectum . . . . . . . . . . . . . . . . . . . . . . . . . 195
P.N. Joshi and C. Kale
15 Benign Tumors of the Anorectum . . . . . . . . . . . . . . . . . . . . . . . . 205
Rajshekar Mohan

1© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_1
Surgical Anatomy of Anal Canal
and Rectum
Ashfaq Hassan and Abdullah Al Mamun
1.1 Rectum
Rectum is a fixed terminal portion of the large
intestine that serves as a reservoir. It is about
10–14 cm in length, and it is located between the
sigmoid colon above and the anal canal below. It
begins at the level of S3 vertebra and ends by
becoming continuous with the anus which corre-
sponds to the apex of the prostate or lower end of
the vagina and is 2–3 cm in front of and a little
below the tip of the coccyx. The proximal part of
the rectum joins the sigmoid colon at the recto-
sigmoid junction which is at about 15 cm from
the anal verge, and the distal part joins the anal
canal at the anorectal junction. The cardinal fea-
tures of large intestine like the taenia, appendices
epiploicae, sacculations, and well-defined mes-
entery are absent in the rectum (Corman 2005;
Chapuis et al. 2002). The lower part of the rectum
is dilated and is called rectal ampulla. Though the
word rectum means straight, the rectum is not
straight. It is curved both anteroposteriorly and
from side to side. The lateral curves are three in
number. The upper and the lower lateral curves
are convex to the right. The middle lateral curve
is convex to the left. Endoluminally, these folds
are known as valves of Houston. The clinical sig-
nificance of these folds is that they must be suc-
cessfully negotiated during successful
proctosigmoidoscopic examination (Corman
2005; Nivatvongs and Gordon 1992; Neugut and
Pita 1988), and it is safer to take biopsies from
these folds which are easily accessible and have
no muscle. There is also minimal risk of perfora-
tion at these folds.
TherectumderivesitssupportfromWaldeyer’s
fascia, lateral ligaments of rectum, rectovesical
fascia of Denonvilliers, pelvic peritoneum, and
perineal body. These supports may get weakened
in prolapse of rectum. The rectum is a distensible
organ and in view of assumption of erect posture,
needs additional supports for maintaining its
position which is provided by the levator ani
muscle that forms an effective support like a
basin for the rectum.
The anorectal ring is an important landmark
and the prime source of maintaining rectal conti-
nence. Damage to this ring results in rectal
incontinence. The anorectal ring is formed by
puborectalis, deep external sphincter, and inter-
nal sphincter (Coller 1987). It can be felt per rec-
tal examination. The ring is more marked
posteriorly due to a larger number of muscle
fibers.
A. Hassan, MBBS, MS
Department of Anatomy, Sheri Kashmir
Institute of Medical Sciences Medical College,
Srinagar, Jammu and Kashmir, India
e-mail: ashhassan@rediffmail.com
A. Al Mamun, FCPS(Surgery), MRCS(Edin)
Department of Surgery,
Shaheed Suhrawardy Medical
College Hospital, Dhaka, Bangladesh
e-mail: mamun1973@gmail.com
1

2
1.1.1 Relations
The relations of rectum are important to know
because of the fact that per rectal examinations, it
can give vital information regarding surrounding
structures. They provide key to the local spread of
rectal cancers and are important in operative
removal of rectum. In males, anteriorly one can
palpate the prostate gland, the seminal vesicles,
and the base of the urinary bladder, and in females,
it is related to the uterus, cervix, and posterior vag-
inal wall. In females, the perineal body and cervix
are felt anteriorly. A layer of specialized fascia
(Denonvilliers) separates the rectum from anterior
structures (prostate, seminal vesicles, or vagina).
The upper two-thirds of the rectum is covered by
the peritoneum and relates to coils of small intes-
tine which lie in the cul-de-sac of the pouch of
Douglas between the rectum and the bladder in
males or uterus in females. Laterally, only the
upper third is covered by the peritoneum. The
lower third of the rectum is entirely extraperito-
neal. In both sexes, the coccyx and sacrum can be
felt posteriorly. These are separated by extraperi-
toneal connective tissue containing the rectal ves-
sels, lymphatic, and lower sacral nerves, emerging
from the anterior sacral foramina. These nerves
may get infiltrated by the cancers spreading poste-
riorly from the rectum, resulting in severe sciatic
pain (Ellis 2002). Laterally, the rectum is sup-
ported by the levator ani. The rectum ends antero-
inferiorly about 2–3 cm from tip of coccyx from
where it turns back sharply and enters the levator
to become the anal canal. The lateral rectal sheath
or ligaments are formed by condensation of pelvic
fascia laterally. These are triangular in shape with
the apex toward the lateral rectal wall. Branches of
middle rectal vessels pass through these ligaments
only in 20–25 % of cases. These stalks also con-
tain branches from pelvic nerves. Posteriorly, pre-
sacral fascia condensation of endopelvic fascia
separates the rectum and mesorectum from the
sacrum and coccyx. Presacral veins, middle sacral
artery, and nerves can be injured with life-
threatening bleeding if the surgeon dissects out-
side this fascia during surgery. The thick
anteroinferior fascial extension of presacral fascia
toward fascia propria of rectum at S4 level above
the anorectal angle is known as Waldeyer’s fascia.
The mesorectal fat or mesorectum is thicker and
posteriorly is enclosed in fascia propria and con-
tains inferior hemorrhoidal vessels and lymphat-
ics. This is the site of metastasis from rectal
cancers. Inclusion of this mesorectum in resection
specimen of rectal cancers (mesorectal excision)
has reduced the rate of recurrence significantly.
Ureters after crossing the pelvic brim in front
of bifurcation of common iliac artery lie between
the peritoneum and internal iliac artery. In
females, these are closely related to the neck of
the uterus and upper vagina.
1.2 Anal Canal
The anal canal represents the distal most part of the
gastrointestinal tract located in the perineum in the
anal triangle between the right and left ischial fos-
sae. The length of anal canal varies depending on
its definition. The surgical or functional anal canal
is approximately 4 cm, extending from the top of
levator ani or anorectal angle to the intersphincteric
groove (the sulcus between internal and external
sphincters) or anal verge (Fig. 1.1). The anatomic
or embryologic anal canal is only 2 cm, extending
from the anal verge to dentate line. The anal verge
or anocutaneous line of Hilton represents the lower
most edge of the anal canal and is about 1–2 cm
from dentate line. Anal verge and dentate line
(more precise) are taken as reference levels for
measurement during proctosigmoidoscopy. Anal
orifice or anus on the other hand is a cutaneous slit
at the lower part of anal canal.
It is angulated at junction with the rectum
because the pull of the sling-like action of puborec-
talis muscle forms anorectal angle (Fig. 1.2). It lies
2–3 cm in front of and slightly below the tip of the
coccyx, which is opposite the apex of the prostate
in males. The anal canal is attached posteriorly to
the coccyx by the anococcygeal ligament. The
anus is surrounded laterally and posteriorly by
loose adipose tissue within the ischioanal fossae, a
potential pathway for the spread of perianal sepsis
from one side to the other. Inferior rectal vessels
and nerves cross it to reach the anal canal.
Anteriorly, the perineal body separates the anal
A. Hassan and A. Al Mamun

3
canal from the membranous urethra and penile
bulb in males or from the lower vagina in females.
The anal complex has two sphincters: internal
and the external. The internal anal sphincter is a
smooth muscle, involuntary in nature, and is
formed by the condensation of circular muscle of
the rectum, while the external anal sphincter is
voluntary in nature and is formed by the striated
skeletal muscle (Felt-Bersma et al. 1989). The
external sphincter has subcutaneous, superficial,
and deep parts (Fig. 1.1). It covers the entire
length of internal sphincter tube. It ends little
below it as subcutaneous portion. The inter-
sphincteric groove between lower edges of inter-
nal and external sphincter can be palpated more
so when anus is stretched. This groove is used to
enter the intersphincteric space in surgical proce-
dures like internal sphincterotomy for anal fissure
and ligation of intersphincteric tract (LIFT) for
fistulae in ano. Endosonographically external and
internal anal sphincters measure 6–8 and 2–3 mm,
respectively. Internal sphincter appears uniformly
hypoechogenic, while external anal sphincter and
puborectalis are predominantly hyperechogenic.
The external and internal sphincters and puborec-
talis are important muscles to maintain automatic
continence and prevent fecal leakage at the time
of threatened incontinence. The conjoined longi-
tudinal muscle is formed by continuation of lon-
gitudinal layer of rectum along with some fibers
of levator ani at the level of anorectal angle. It
Anorectal ring
Surgical
anal canal
Dentate line
Anatomical or
embryological
anal canal
Anal verge
Anal crypt
External anal sphincter
Column of morgagni
Internal anal sphincter
Fig.1.1 Anatomy of anorectum
Fig.1.2 Anorectal angle
1 Surgical Anatomy of Anal Canal and Rectum

4
continues down between the internal and external
sphincters binding them together and traverses
the subcutaneous part of external sphincter as a
corrugator cutis ani to get inserted into perianal
skin. This muscle is supposed to act as skeletal
support that attaches the anorectum to the pelvis.
The levator ani consisting of iliococcygeus, pubo-
coccygeus, and puborectalis forms the pelvic
floor and is important for gross fecal continence.
External and internal sphincters control gas and
liquid contents. Puborectalis is a U-shaped sling
which slings the anorectal angle to pubis and
forms anorectal angle.
1.2.1 Inner Lining
The partition line between upper endodermal and
lower ectodermal part (proctodeum) of anal canal
is called dentate or pectinate line. Failure of
breakdown of separating membrane between the
two parts results in an imperforate anus. The
upper part is lined by columnar cells, while the
lower part is lined by squamous epithelium which
is thin, pale, and smooth devoid of hair and
glands. Above the dentate line, it is innervated by
sympathetic and parasympathetic system, while
the distal part is innervated by somatic nerves,
and any inflammatory process or procedure in
this part of anal canal is painful. The blood sup-
ply and venous drainage above the dentate line
come from and go to superior and middle hemor-
rhoidal vessels and drain to the portal system,
while the part below the dentate line drains into
systemic circulation through inferior hemor-
rhoidal vessels, thereby making this area site for
portosystemic shunts and cavernoma. Lymphatic
above and below dentate line also drains to dif-
ferent groups of lymph nodes (inferior mesen-
teric and groin). Anal valves are located at dentate
line. These valves are remnants of proctodeal
membrane. Above each valve, there is an opening
of anal glands known as anal crypts or sinus.
Anal glands are 3–12 in number located in the
submucosa, internal sphincter, or intersphincteric
space. More than one gland may open into the
same crypt. Half of the crypts have no communi-
cation with the glands. Obstruction of ducts of
these glands causes stasis, infection, perianal
sepsis, and fistula formation.
There are 8–14 longitudinal folds known as
columns of Morgagni. These are present cranially
on the dentate line. Anal papillae are present at
the lower end of these columns. A strip of
0.5–1 cm of mucosa consisting of several layers
of cuboidal cells above the dentate line in the area
of column of Morgagni has a deep purple color
because of internal hemorrhoidal plexus and is
known as anal transition zone. Above this zone,
epithelium changes to single layer of columnar
cells (pink color). Just below the dentate line, the
anal canal is lined by modified squamous epithe-
lium which is thus as pale in color. This white
color makes the reference point for taking a purse
string suture in stapled hemorrhoidopexy.
1.3 Blood Supply of Anal Canal
and Rectum
The arterial supply of the rectum comes from
superior, middle, and inferior rectal arteries and
the median sacral artery. The superior and infe-
rior rectal arteries are the main source of blood
supply to anorectum.
The superior rectal or superior hemorrhoidal
artery is the most important source of blood sup-
ply to the rectum. It is the continuation of the
inferior mesenteric artery which is the artery of
hind gut. The vessel subdivides opposite the third
sacral vertebrae into two branches, the right and
the left. The superior rectal artery lies just poste-
rior to the right of the sigmoid colon, coming in
close contact with posterior aspect of gut at the
rectosigmoid junction.
The middle rectal or middle hemorrhoidal
arteries are a source of blood supply only to the
superficial layers of the lower part of the rectum.
The middle rectal vessels arise usually from ante-
rior division of internal iliac artery and anasto-
mose with the adjacent arteries. In some cases, it
may arise from inferior gluteal arteries. It may be
absent in 40–80 % of cases (Didio et al 1986;
Lawson 1974).
The median sacral artery is a small vessel aris-
ing from the distal part of aorta near its termination.

5
It supplies the rectum in the region of anorectal
junction.
The inferior rectal or hemorrhoidal artery arises
from pudendal artery which is a distal branch of
internal iliac artery. This artery is encountered dur-
ing perineal dissection of abdominoperineal resec-
tion for low rectal cancer. Profuse intramural
anastomotic network in the anorectum maintains
its blood supply even if both superior and inferior
rectal arteries are ligated.
The veins from the rectum drain by virtue of
the superior and middle rectal veins. The superior
rectal vein starts from the internal rectal venous
plexus which ultimately forms three to five veins
which unite to form this vein. The superior rectal
vein continues upward as the inferior mesenteric
vein to end in the splenic vein.
The middle and inferior rectal veins drain the
anal canal and lower rectum and open into the
internal iliac vein and subsequently the inferior
vena cava. Dilatation of subcutaneous venous
plexus situated below the dentate line and one
present above the dentate line gives rise to exter-
nal and internal hemorrhoids.
The venous drainage is particularly important
to understand the spread of rectal cancer. These
tumors may spread to the liver via the portal
venous system or to other organs via inferior
vena cava.
1.4 Lymphatics of Anal Canal
and Rectum
Lymphatics from the upper two-thirds of rectum
pass along the superior rectal vessels to the infe-
rior mesenteric nodes after going through the
pararectal and sigmoid nodes. From the lower
third of the rectum, lymph passes not only in the
cephalad direction to inferior mesenteric nodes
but also along the middle rectal vessels to the
internal iliac nodes. The carcinoma of rectum
spreads cephalad by virtue of the lymphatics to
the local lymph nodes of the rectum and predom-
inantly to pararectal and subsequently to inferior
mesenteric nodes. Laterally, the lymphatics along
middle rectal and inferior rectal vessels drain into
the internal iliac group of lymph nodes. Lymph
from the anal canal above the dentate line drains
to inferior mesenteric and internal iliac nodes,
and lymph from the anal canal below the dentate
line drains into inguinal nodes though less fre-
quently it may go along inferior hemorrhoidal
artery. In females, lymphatic spread also goes to
genital organs like the uterus, cervix, vagina,
broad ligament, and ovaries. The lymphatics are
an important source of dissemination of cancers
from the rectum.
1.5 Nerve Supply of Anal Canal
and Rectum
Sympathetic and parasympathetic innervation of
anorectum comes from L1 to L3 (superior hypo-
gastric plexus around root of inferior mesenteric
artery) and S2 to S4 (nervi erigentes forming pel-
vic plexus), respectively. The right and left hypo-
gastric nerves carry sympathetic fibers to pelvic
plexus (inferior hypogastric plexus) from where
these are distributed along with parasympathetic
fibers to prostate, urethra, ejaculatory ducts, vas
deferens, seminal vesicles, and corpora caver-
nosa. Sympathetic inflow inhibits vasoconstric-
tion, while parasympathetic causes vasodilatation
of corpora resulting in erection of penis. These
nerves may be injured in various pelvic proce-
dures including those of anorectal cancers at vari-
ous levels, i.e., root of inferior mesenteric artery,
sacral promontory or presacral region (pull on
hypogastric nerves leading to retrograde ejacula-
tion and bladder dysfunction), lateral rectal stalks
close to middle rectal arteries (injuring nervi eri-
gentes leading to erectile dysfunction), or near
seminal vesicles and prostate (injuring sympa-
thetic and parasympathetic components leading
to both erectile and bladder dysfunction).
Permanent sexual dysfunction occurs in 100 % of
patients following radical abdominoperineal
resections (APR) (Marcio et al. 2009). Permanent
bladder dysfunction can occur in 7–59 %,
impotence in 15–45 %, and ejaculatory dysfunc-
tion in 32–42 % patients after APR. However,
sexual and bladder complications may not be so
evident in females.
1 Surgical Anatomy of Anal Canal and Rectum

6
External anal sphincter is a voluntary muscle
and is innervated by inferior rectal and perineal
branches of pudendal nerve (S2, S3, and S4).
Sensations from anal canal are carried by inferior
rectal branches of the pudendal nerve. Due to
crossover of ﬁbers at spinal cord sphincter, func-
tion of anal canal is still preserved following uni-
lateral division of pudendal nerve.
1.6 Anorectal Spaces
These are potential spaces around the anorectum
which a surgeon should know to understand the
genesis, diagnosis, and treatment of perianal sep-
sis (Fig. 1.3). The two ischiorectal spaces on
either side of rectum communicate with each
other through deep postanal space of Courtney
and explain the formation of horseshoe abscess.
The lower part of ischiorectal fossa surrounding
the lower part of anal canal contains the subcuta-
neous part of external sphincter, lowest portion of
internal sphincter, and external hemorrhoidal
plexus. It is separated from the ischiorectal fossa
by a thin fascia. The intersphincteric space is
important for genesis of perianal abscess as anal
glands; a source of cryptoglandular infection is
located in this region. The presacral or retrorectal
space is a site for embryogenic remnants and
tumors. The cryptoglandular infection can spread
even to supralevator space above the levators.
Submucous space present above the dentate line
contains internal hemorrhoidal plexus.
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Felt-Bersma RJ, Strijers RL, Janssen JJ, et al. The external
anal sphincter. Dis Colon Rectum. 1989;32:112.
Lawson JO. Pelvic anatomy II. Anal canal and associated
sphincters. Ann R Coll Surg Engl. 1974;54:288.
Marcio J, Jorge N, Habr Gamma A, et al. Anatomy and
embryology of the colon, rectum and anus. In: Beck
DE, editor. The ASCRS manual of colon and rectal
surgery. New York: Springer; 2009.
Neugut AI, Pita S. Role of sigmoidoscopy in screening for
colorectal cancer: a critical review. Gastroenterology.
1988;95:492.
Nivatvongs S, Gordon PH. Surgical anatomy. In: Gordon
PH, Nivatvongs S, editors. Principle and practice of
surgery for Colon, Rectum and anus. St Louis: Quality
Medical Publishing; 1992. p. 3.
Supralevator space
Ischioanal space
Intershincteric space
Perianal space
Peritoneum
Internal
sphincter muscle
Deep external
sphincter muscle
Puborectalis muscle
Levator ani muscle
Transverse septum
Fig.1.3 Perianal spaces

Physiology of Defecation
Rauf A. Wani and Natasha Thakur
2.1 Normal Defecation
Defecation is a reflex provoked through a sacral
arc by distention of the rectum. In infancy, the
evacuation of the rectum occurs reflexly. The
development of the control over defecation reflex
is associated with the growth of inhibition over it.
The cerebral cortex cannot only inhibit the reflex
but can also initiate it when suitable circum-
stances are available for voiding. Thus, conti-
nence is an acquired capacity to suppress the
natural urge to defecate. When this capacity is
impaired, incontinence occurs.
For maintenance of continence, both the rec-
tum and anus play a responsible role. The process
begins with movement of gas, liquid, or solid
contents into the rectum. Distension of the rec-
tum leads to stimulation of pressure receptors
located on the puborectalis muscle and in the
pelvic floor muscles, which in turn stimulates the
rectoanal inhibitory reflex (Fig. 2.1). The internal
anal sphincter relaxes, allowing sampling of
contents (Miller et al. 1981). If defecation is to be
deferred, voluntary contraction of the external
anal sphincter and levator ani muscles occurs,
and the rectum accommodates with relaxation
after an initial increase in pressure. This volun-
tary contraction of the external sphincter can
exercise control for 45–60s. When the anal canal
is deemed to have solid contents and a decision to
defecate is made, the glottis closes, pelvic floor
muscles contract, and diaphragm and abdominal
wall muscles contract, all increasing abdominal
pressure (Womachs et al. 1985). The puborectalis
muscle relaxes, resulting in straightening of the
anorectal angle and slight descent of pelvic floor.
The external anal sphincter relaxes, and anal
canal contents are evacuated. Upon normal com-
plete evacuation, the pelvic floor rises and sphinc-
ters contract once more in a “closing reflex”
(Plam et al. 1999). The mucosal lining of the
lower rectum and that of anus can distinguish
between the flatus and fluid and solid stool. The
cutaneous lining of the anal canal forms a very
sensitive zone which can detect even a minute
quantity of flatus or feces. Any operative proce-
dure in which this segment is sacrificed will lead
to sensory incontinence.
The internal sphincter, the external sphincter,
and the levator ani constitute the motor compo-
nents. The internal sphincter unconsciously
maintains continence by its sustained contrac-
tion. Any damage to the internal sphincter will
R.A. Wani, MS, MRCS (*)
Department of Colorectal Surgery,
Sheri Kashmir Institute of Medical Sciences,
Srinagar, Jammu & Kashmir, India
e-mail: raufw64@hotmail.com
N. Thakur
Department of General and Minimal Invasive Surgery,
Sherikashmir Institute of Medical Sciences Medical
College, Srinagar, Jammu & Kashmir, India
e-mail: doc_nats259@yahoo.co.in
2

8
result into the partial loss of control. The
puborectalis part of the levator ani gets its attach-
ment to the upper part of the external anal sphinc-
ter (Nicholas and Lindsay 2013). This constitutes
the puborectalis sling. It gives strength to the
sphincters and prevents retraction of their cut
edges when they are divided during anal opera-
tions. If puborectalis sling is also divided, large
gaping occurs, resulting in anal incontinence.
2.1.1 Mechanical Factors
of Continence and Defecation
The puborectalis arises from the pubic bone and
passes horizontally and posteriorly around the
anorectum as the most medial portion of the leva-
tor ani muscle. This forms a U-shaped sling
around the anorectum near its anatomic junction
with the anus, pulling the rectum anteriorly and
giving rise to the so-called anorectal angle
(Fig. 2.2). Parks postulated a mechanism by
which this takes place (Parks et al. 1966). The
intra-abdominal pressure increases with sneez-
ing, coughing, or straining. This force is trans-
mitted across the anterior wall of the rectum at
the anorectal angle. The underlying mucosa is
opposed against the upper anal canal, creating a
ﬂap valve mechanism that prevents stool from
passing to the lower anal canal, thereby preserv-
ing continence. This is now disputed as many
multiparous women have this angle obliterated
and are still fully continent.
2.1.2 Reservoir
The rectum must be able to function as a
temporary storage site for liquid and solid stools.
With the passage of the fecal stream into the
rectum, the pliable rectal walls distend and delay
the defecation sequence until an appropriate
Cerebral
cortex
Glottis diaphragm
abdominal muscle
Increased intra
abdominal pressure
Voluntary motor nerve
to external sphincter
Pudendal nerve
(Reflex action)
External anal
sphincter
(skeletal musle)
Sensory nerve
fibers
Pelvic splanchnic
nerves (parasymp.div.)
Stretch receptors
in wall
Involuntary motor Nn
(leading to contraction
& relaxation of bowl
muscles for defecation)
Internal anal
sphincter
Fig.2.1 Reﬂex mechanisms
involved in defecation process
R.A. Wani and N. Thakur

9
time. This process relies on rectal innervation to
sense and tolerate the increasing volume of stool
(capacity) and maintains a relatively low and
constant pressure with increase in volume
(compliance). Extremes of either of these
components can lead to fecal incontinence
through decreased accommodation or overﬂow.
Bibliography
Miller R, Bactolo DC, Cervero F, et al. Anorectal sam-
pling: a comparison of normal and incontinent
patients. Br J Surg. 1981;75(1):44–7.
Nicholas RJ, Lindsay I. Disorders of defecation and anal
pain. In: Cormanm ML, editor. Cormans colon and
rectal surgery. 6th ed. Philadelphia: Lippincott
Williams and Wilkins/A Wolters Kluwer Health;
2013.
Parks AG, Porter NH, Hard Castle JD. The syndrome of
descending perineum. Proc R Soc Med. 1966;59:
477–82.
Plam TN, Corman BC, Chu P, et al. Radiological changes
after colonoscopic decompression of acute pseudo
obstruction. Dis Colon Rectum. 1999;42(12):
1585–91.
Womachs NR, Williams NS, Holmﬁeld JS, et al. New
methods of dynamic assessment of anorectal functions
in constipation. Br J Surg. 1985;72(12):994–8.
a b
Fig. 2.2 Puborectalis action and anorectal angle. (a) Puborectalis sling forming an angle. (b) Puborectalis relaxed for
defecation
2 Physiology of Defecation

Hemorrhoids
P. Sivalingam, Rama Kant, Vijay Arora,
and Pravin Padmakumar Gore
3.1 Introduction
Hemorrhoids are symptomatic dilated anal cushions.
These cushions consist of thickened submucosa,
sinusoids, elastic and connective tissue, and some
smooth muscle fibers. The hemorrhoidal disease
should be reserved for those anal cushions which
are abnormal and symptomatic. The word
“hemorrhoid” is derived from the Greek words,
haem (blood) and rhoos (flowing), meaning
flowing of blood. The word “pile” means pill or a
ball. So we should call this disease piles when the
patient complains of a swelling and hemorrhoids
when the presenting symptom is bleeding.
Hemorrhoidal disease is one of the common-
est ailments that affect mankind. The exact preva-
lence is difficult to estimate as patients hide it and
do not come for consultation. Johanson and
Sonnenberg in 1990 have reported a prevalence
of 4.4 % in the USA with a peak prevalence
between 45 and 65 years in both sexes. The
incidence increases with age, and about 50 % of
people above the age of 50 years have some
degree of hemorrhoids. All age groups including
young children are affected. Men are affected
roughly twice as frequently as women.
The rich plexus of vascular tissue under the
anal canal and lower rectal mucosa is called
corpus cavernosum recti which connects arteries
and veins without intervening capillaries. This
plexus is fed by branches of superior, middle, and
inferior rectal vessels. The hemorrhoidal bleed-
ing is bright red (arterial) in color as it occurs
from presinusoidal arterioles.
The vascular cushions have physiological role
in maintaining anal continence. These cushions
provide complete closure of the anus due to
P. Sivalingam (*)
Department of Surgery, Madurai Medical College,
Madurai, India
Govt. Rajaji Hospital Madurai, Madurai, India
e-mail: drpsivalingam@yahoo.com
R. Kant
Career Institute of Medical Sciences (CIMS),
Bhopal, India
SIPS Superspeciality Institute, Lucknow, India
Piles To Smiles Clinic, Lucknow, India
Department of Surgery, CSM Medical University,
Lucknow, India
Gandhi Memorial and Associated Hospitals,
Lucknow, India
e-mail: ramakantkgmc@gmail.com
V. Arora
Department of Surgery, GRIPMER, New Delhi, India
Department of General and Laparoscopic Surgery,
Colorectal Clinic, Sir Ganga Ram Hospital,
New Delhi, India
e-mail: drarora1@gmail.com
P.P. Gore
Department of Surgery,
Bhatia Hospital, Tardeo, India
Global Hospital, Parel, Mumbai, India
e-mail: drpravingore@gmail.com
3

12
engorgement following coughing, sneezing, etc.
leading to raised intrarectal pressure. These cush-
ions also provide a compressible protective lining
for the underlying anal sphincters. Surgical
removal of these cushions may result in some
degree of incontinence especially in patients with
poor preoperative sphincter tone.
There are three main anal cushions located in
left lateral, right anterior, and right posterior
positions corresponding to branches of superior
rectal vessels with some accessory small masses
between them. These hemorrhoids should be
preferably described as such rather than numbers
on the clock.
3.2 Etiopathogenesis
of Hemorrhoids
The supporting tissue of anal canal or suspensory
ligament of Parks (muscularis submucosae ani or
Treitz muscle arising from internal sphincter or
some elastic tissue) anchor and suspend the anal
canal mucosa to the underlying sphincter (Parks
1954). Repeated stretching of anal canal mucosa
causes weakness of this supporting tissue thereby
prolapse. Thomson in 1975 proposed a sliding
theory as a cause of hemorrhoids. Predisposing
factors for prolapse include constipation, diar-
rhea, prolonged straining, and aging. Erect pos-
ture, absence of valves in the hemorrhoidal
sinusoids, and obstruction to venous return also
cause congestion of these vascular cushions
(Johanson and Sonnenberg 1990). In pregnancy,
increased vascularity and laxity of pelvic floor
muscles along with abdominal compression of
major veins predispose to higher incidence of
hemorrhoidal disease especially in late preg-
nancy. Bleeding occurs due to localized trauma
to prolapsed tissue.
While it was thought to be a purely venous
disease yet it was associated with bright red
bleeding. Now the answer for this paradox has
been found. There are arteriovenous communica-
tions interspersed with tissues in anorectal areas,
and these start sliding while straining. Thus,
venous drainage becomes poor while arterial cir-
culation keeps pumping blood normally.
Endoscopy examinations up to rectosigmoid
region should be preferred in all patients present-
ing with hemorrhoids as they could be secondary
to carcinoma of mid- or upper rectum.
Portal hypertension causes rectal varices and
bleeding from these varices is profuse and dark,
while bleeding from hemorrhoidal varices is
bright red.
Burkitt in 1975 suggested that low-residue
diet results in venous disease including varicose
veins, deep vein thrombosis, and hemorrhoids
(Burkitt 1975).
Hereditary predisposition of hemorrhoidal
disease is not well known though certain families
may be affected in young age. This may be due to
structural weakness of venous walls.
3.3 Classification
of Hemorrhoids
3.3.1 Vascular Hemorrhoids
These are usually seen mainly in young individuals in
which distended veins are the main component, and
bleeding per rectum is the essential presentation.
3.3.2 Mucosal Hemorrhoids
It occurs more often in old persons which are
formed by large thickened mucosa. The main
presenting symptom in this type is a feeling of
some sort of obstruction during the initial act of
defecation and a sense of incomplete evacuation.
3.3.3 Internal Hemorrhoids
It is due to redundant portions of the mucous
membrane of the anal canal above the dentate
line. Depending on the symptoms and the extent
of the prolapse, the internal hemorrhoids are
classified as first degree which bleed; second
degree bleed and prolapse and reduce spontane-
ously; third degree bleed, prolapse, and require
manual reduction; and fourth degree bleed, get
incarcerated, and cannot be reduced (Thomson
et al. 1992). This staging has only limited
P. Sivalingam et al.

13
value as it refers to one aspect of the disease,
prolapse. The severity of the disease can be
related as much to the severity of blood loss or
the degree of discomfort. Many old people with
third-degree hemorrhoids have relatively little
problem.
3.3.4 External Hemorrhoids
They occur in the perianal region. They are situ-
ated below the dentate line and are covered by the
anoderm. The anal skin tags are the result of pre-
vious attack of external hemorrhoids.
3.4 Symptoms
The main symptoms of hemorrhoids are bleed-
ing, protrusion, pain, discharge, and irritation.
3.4.1 Bleeding
Bleeding is the most common symptom. Initially,
there is slight streak of blood on the constipated
motion. Later, a steady drip of blood for a few
minutes is usually seen after passage of stool.
When hemorrhoids prolapse, it becomes con-
gested, and bleeding can occur apart from def-
ecation at any time. The blood is bright red in
color because of arteriovenous communications.
The blood loss may be occasional or severe and
persistent enough to cause anemia. In massive
bleeding, the patient may have an urgent desire
to defecate. The volume of the blood may be con-
siderable, but it stops quickly.
3.4.2 Protrusion
Protrusion of the hemorrhoid occurs initially at
defecation and gets reduced spontaneously after
the act. Later, the protrusion occurs during defe-
cation, and the patient has to push it into the anal
canal after defecation. At this stage, the prolapse
can occur on coughing, sneezing, or passing fla-
tus. In advanced stage, it is permanently pro-
lapsed with the anal mucosa exposed.
3.4.3 Pain
Usually, hemorrhoids are associated with some
discomfort. When thrombosis occurs, pain may
be moderate to severe, depending upon the degree
of engorgement. Sever pain may be due to associ-
ated fissure, sepsis, strangulation, and ulceration
of pile mass.
3.4.4 Discharge and Irritation
The soiling of the underclothing with mucus
may be noticed when the hemorrhoids are per-
sistent and prolapsed. Mucoid discharge from
the anus occurs in any case with prolapsing
even temporarily. Irritation of the perianal skin
in third- and fourth-degree piles is present in
varying degrees of intensity. But the typical
skin changes that occur in pruritus ani are not
common.
3.4.5 Anemia
Repeated profuse anal bleeding causes iron
deficiency anemia (Fig. 3.1). In case of severe
anemia, one should always suspect another
possible occult cause for bleeding. It is advis-
able to check the hemoglobin regularly after
the hemorrhoidal disease has been successfully
treated to ensure that there is no other cause for
anemia.
Fig. 3.1 Interno-external hemorrhoids with severe
anemia
3 Hemorrhoids

14
3.4.6 Painful Mass in the Anal
Region
When thrombosis of the prolapsed haemorrhoid
occurs, patient may present with a painful mass
with sudden onset (Fig. 3.2). Rise in tissue ten-
sion within and outside the anal canal is respon-
sible for pain and edema. The condition can be
diagnosed by inspection alone. If surgery is not
performed, the natural history of thrombosed
hemorrhoid is one of slow resolution. The edema
and inflammatory swelling reduce in course of
4–5 days, and complete resolution occurs in
4–6 weeks leaving behind a skin tag.
3.5 Clinical Examination
A detailed history is very important in the diagno-
sis of hemorrhoids. The color and the character of
the anorectal bleeding and the relief obtained from
reduction of the prolapsed mass into the anal canal
lead to the diagnosis. The presence of hemorrhoid
does not exclude other causes of bleeding. Third-
degree hemorrhoid is a prolapsing mass, the outer
part of which is covered with skin, the inner por-
tion with red or purplish anal mucosa, and the
junction between these two areas being marked by
a linear furrow (Fig. 3.3). In long-standing cases,
the lining epithelium often undergoes metaplasia
to a squamous type. When this change has
occurred, the covering epithelium is seen as a pale,
white pannus extending from mucocutaneous
junction over the mucosal surface.
3.5.1 Digital Rectal Examination
Usually, uncomplicated hemorrhoids are not pal-
pable. Large hemorrhoids can be felt as soft ele-
vation of the mucosa of the anal canal just above
the dentate line. Piles are felt when thrombosed.
3.5.2 Endoscopic Examination
Proctoscopy permits accurate diagnosis of the
hemorrhoids as well as the degree of prolapse.
Sigmoidoscopy is essential to exclude any pathol-
ogy beyond the reach of the proctoscope.
One should always keep in mind other anorec-
tal pathological conditions may present with sim-
ilar symptoms. They include rectal prolapse
(partial or complete), polyps, and carcinoma.
Colonoscopy or air contrast barium enema is
indicated when no source of bleeding is evident
on anorectal examination, presence of occult
blood in stool, atypical bleeding for hemorrhoids,
and when patient is at high risk for developing
colonic neoplasms.
3.6 Treatment
The treatment of hemorrhoids is based on the
degree of prolapse, severity and nature of
symptoms, expertise of the surgeon, and the
facilities available. The treatment options include
dietary modification, medical treatment, office
Fig.3.2 Third-degree hemorrhoids Fig.3.3 Prolapsed thrombosed external hemorrhoids

15
procedures for early and less symptomatic
hemorrhoids, and operative intervention for
third- and fourth-degree hemorrhoids.
3.6.1 Dietary and Lifestyle
Modification
Increased fiber and water intake reduced strain-
ing at stools, and local hygiene is an integral part
in the management of all degrees of hemorrhoids.
Patient should be advised to take diet rich in fiber
(20–35 g/day). Fiber supplementation (psyllium,
methylcellulose, calcium polycarbophil) has
been shown to improve overall symptoms and
bleeding (Alonso-Coello et al. 2006). Fiber sup-
plement is usually recommended for patients
who are noncompliant for taking sufficient fiber
in diet. Psyllium with water adds moisture to
stools and thereby reduces constipation.
Lifestyle modifications play an important
role to improve symptoms in these patients.
Neglecting the first urge to defecate, spending
prolonged time at toilet, and straining are
common defecation errors which need to be
corrected.
3.6.2 Medical Treatment
In spite of lack of rigorous evidence in the litera-
ture, doctors continue to use topical and systemic
agents to relieve symptoms in patients with hem-
orrhoids. Most effective symptomatic relief can
be obtained by warm (40 °C) sitz baths for not
more than 15 mins or use of ice packs for limited
period. Topical ointments or creams containing
corticosteroid, local anesthetics, antiseptics,
decongestants, etc. have been shown to give
symptomatic relief. Micronized purified flavo-
noid fractions act by enhancing venous tone.
Topical glyceryl trinitrate has been reported
effective in strangulated internal hemorrhoids by
decreasing internal sphincter tone (Patti et al.
2006). Prolonged use of topical agents should be
avoided as they can cause local allergic effects
and sensitization of skin. Although topical agents
improve the symptoms, it is unlikely they will
eliminate or cause the disease.
Calcium dobesilate can be used locally as well
as systemically in the dose of 500 mg twice a day.
It decreases capillary permeability, platelet aggre-
gation, and blood viscosity. It also increases trans-
portation of lymph. Calcium dobesilate has been
found to be safe, fast acting, and efficient in treat-
ing acute symptoms of hemorrhoidal diseases.
3.6.3 Office Procedures
3.6.3.1 Injection Sclerotherapy
The technique was pioneered by Mitchell of
Clinton, Agbo SP, in 1871. He kept it secret and
sold to quacks just before his death. These quacks
would roam in the USA and were known as trav-
eling “Piles Doctor.” Eventually, Andrews of
Chicago got the secret from one of the quacks
and gave it to the medical profession in 1879.
Sclerotherapy is indicated for first- and
second-degree hemorrhoids but contraindicated
in thrombosed, prolapsed, ulcerated, infected,
and gangrenous hemorrhoids. The agents used
for sclerotherapy are 50 % phenol in vegetable
oil, quinine, sodium morrhuate, sodium tetra-
decyl sulfate, and hypertonic saline. 5ml of solu-
tion is injected into the interstitial tissue of
submucosa (unlike varicose where sclerosant is
injected into the vein). Total of 12–15 ml of solu-
tion can be used. The injection is given with a
Gabriel syringe through proctoscope at the base
of the hemorrhoid mass just below the anorectal
ring (Fig. 3.4). The sclerotherapy causes inflam-
matory reactions, fibrosis, scarring, and fixation
of mucosa to muscularis propria thereby shrink-
age and reduction of the pile mass.
The Gabriel syringe has two lateral rings on
the barrel and a ring at the end of the piston for a
secured grip. The needle is straight or slightly
angulated with a shoulder on it about 2 cm from
sharp end of the needle. The solution should flow
freely. Resistance means wrong placement of
needle. The amount of fluid to be given depends
on the laxity of mucosa. Following injection, red
mucosa turns purple. After an hour or so, the fluid
granulates down and may cause some soreness.
First injection is most effective. Subsequent
injections can be given after 1–2 years if symp-
toms reappear. Repeat sclerotherapy is difficult
3 Hemorrhoids

16
because of previous fibrosis. Injected area feels
like an indurated mass for 2–3 weeks, after which
it gradually subsides. Complication of sclerother-
apy includes pain, hemorrhage, local sepsis,
necrosis, ulceration, portal pyemia, prostatitis,
hematuria, and erectile dysfunction (Guy and
Soew-Choen 2003). Pain is due to sclerosant
tracking down or injection given low down on
sensitive area. That is why patient is kept on bed
for few hours with foot end elevated. Bleeding
can be stopped by pressure with proctoscope or
finger. Sclerotherapy can be given in patients on
anticoagulation. Senapati and Nicholls (1988)
have shown that fiber supplementation may be as
effective as injection sclerotherapy.
3.6.3.2 Rubber Band Ligation
It is a simple, inexpensive, and one of the most
widely used outpatient procedure for bleeding
and prolapsed first-, second-, and third-degree
internal hemorrhoids. The procedure was first
described in 1963 by Baron. The band results in
ischemic necrosis of the tissue which sloughs in a
weeks’ time leaving an ulcer which heals by
fibrosis resulting in fixation of tissue to the under-
lying sphincter. Banding should be avoided in
patients on anticoagulants.
Different types of ligators are available in the
market. The conventional Baron’s hemorrhoidal
ligator consists of 11-mm wide hollow drum
(Fig. 3.5a, b). The rubber band is placed over
the drum by a loading cone. A second drum
moves over it to push the rubber band into posi-
tion. The two drums are mounted on a handle
fitted with a trigger device. The hemorrhoidal
mass is drawn into the hollow drum by a spe-
cially designed hollow forceps or Allis forceps.
It must be made sure that the rubber band grips
the pedicle at least 2 cm above the sensitive
area, dentate line to avoid pain. The trigger is
pulled, the outer drum slides over the inner one
and pushes the rubber band to grip the pedicle of
the pile mass. The forceps is released and the
ligator is removed.
In a modified technique, a McGown suction
ligator is used whereby hemorrhoidal mass is
drawn into ligating barrel by suction thereby
avoiding the use of second hand or an assistant.
Being smaller in size, it bands lesser tissue than
other ligators.
a b
Fig.3.5 (a, b) Hemorrhoidal band ligator
Fig.3.4 Injection sclerotherapy

17
O’Regan invented a disposable syringe like
ligator to simplify the procedure for the patient as
well as surgeon.
Multiple hemorrhoidal masses can be ligated
in a single stage with no significant increase in
morbidity (Poon et al. 1986). Some surgeons pre-
fer to do it in multiple sittings after seeing the
response to first ligators. The procedure can be
repeated after 4–8 weeks.
About 60–70 % patients respond to single ses-
sion of band ligation with significant symptom-
atic relief, although repeat treatment may be
required at a later date. A meta-analysis of first
trials comparing treatment options for grade I to
III hemorrhoids found better response and better
long-term efficacy with hemorrhoidectomy than
banding, but there were lesser complications in
those patients who underwent banding treatment.
Compared to injection sclerotherapy, banding
showed better response to similar complication
rate (MacRae and McLeod 1995; Shanmugam
et al. 2005).
Pain is the most common complication which
occurs in 5–60 % of patients. Cataract blade is
used to cut the rubber band to relieve pain.
Delayed pain in the form of sensation of full
mass may occur after 24–48 h and is due to
edema over the band which extends down to den-
tate line. It is treated by complete bed rest and
anti-inflammatory drugs.
Bleeding may be primary or secondary after
5–10 days following banding which is due to
sloughing of the pile mass. Passage of blood with
the first bowel moment is common. Patient needs
complete bed rest and reassurance. Perianal and
pelvic sepsis has been reported (Guy and Soew-
Choen 2003; O’Hara 1980) in patient present
with anal pain, fever, difficult urination, and def-
ecation. Rarely, liver abscess and necrotizing
infection have been reported (Chau et al. 2007).
These patients need hospitalization and treatment
with intravenous fluids, antibiotics, drainage of
pus, and debridement.
3.6.3.3 Cryotherapy
The principle is based on cellular destruction by
rapid freezing followed by rapid thawing. The
freezing temperature is achieved with nitrous
oxide at −60 to −80 °C, or liquid nitrogen at −60
to −190 °C can treat hemorrhoids by necrosing
the vascular cushion due to thrombosis of micro-
circulation (Smith et al. 1979). The procedure is
time consuming and associated with profuse
foul-smelling discharge and irritation. In addition
to pain and slow healing, the inappropriate use of
cryotherapy can cause necrosis of internal anal
sphincter resulting in anal stenosis and inconti-
nence. Therefore, it is no longer recommended
for treatment of internal hemorrhoids.
3.6.3.4 Infrared Coagulation (IRC)
The infrared radiation is generated by a tungsten
Halogen lamp. A gold-plated reflector and spe-
cially made polymer tubing facilitate the process
(Fig. 3.6).
First described by Natti and popularized by
Neiger in 1979, the infrared light penetrates the
tissue to a level of approximately 3 mm in the
submucosa in the form of heat energy of
100 °C. This heat process is an actual burn, lead-
ing to tissue destruction and eventually to scar-
ring. It causes not only the disappearance of
vascular tissue but also the tethering of the hem-
orrhoids, resulting in no further bleeding or pro-
lapse. It works best for bleeding small first- and
second-degree hemorrhoids. The site of applica-
tion is similar to the area advised for sclerosing
agent or rubber band application. Three or four
coagulations can be performed at the base of each
haemorrhoid and it takes about 30 s for each
piles. All the three hemorrhoids can be treated in
one session. Repeat application may be needed in
Fig.3.6 Infrared coagulation equipment
3 Hemorrhoids

18
some patients after 2 months. There can be some
mucous discharge and a sensation of fullness and
discomfort until complete healing occurs. An
ulcerated area develops over the applied site after
4–5 days which usually heals in 4 weeks’ time.
A meta-analysis of five trials comparing dif-
ferent technique showed similar results 12 months
after treatment for IRC, RBL, and injection
sclerotherapy. However, IRC was associated with
fewer and less severe complications. They sug-
gested that IRC may be an optional alternative
method of treatment.
3.6.3.4.1 Complications
Transient discomfort during application of the
probe is common. If pain persists, it is because the
site chosen is too close to the dentate line.
Bleeding after infrared coagulation may occur in
the 6–8th post-application day and can be man-
aged by bed rest and other conservative methods.
3.6.3.5 Bipolar Diathermy or
Coagulation (BICAP
OR LigaSure)
This technique was designed to produce tissue
destruction, ulceration, and fibrosis by the local
application of heat. This effect is obtained by
bipolar diathermy, an electric current to generate
a coagulation of tissue at the end of cautery tip.
Heat does not penetrate as deeply as monopolar
coagulation. A 2-s pulse is applied to each hem-
orrhoid in a suitable location in the same manner
as infrared coagulation. It can be repeated as
many times as required. This technique has been
used in first- to third-degree hemorrhoids with
high success rate.
3.6.3.6 Direct Current Therapy
In this technique, direct current is applied through
an anoscope to the apex of the hemorrhoid. It is
not so effective for large pile masses and as such
has not become popular.
3.6.3.7 Anal Dilatation or Stretch
(Lord’s Procedure)
The proponents of this method were of the opin-
ion that stretching improves the venous return
thereby causes reduction in pile masses and some
symptomatic relief. But because of high rates of
incontinence due to sphincter damage, it has
almost been given up.
3.6.4 Surgical Treatment
Any surgical treatment of anorectum should be
undertaken seriously with special care, proper
judgment, and careful execution. The anal canal
deserves as much respect as urethra or common
bile duct. Surgical treatment is indicated for
patients who do not respond to conservative or
office procedures, patients with large external hem-
orrhoids, grade III to IV interno-external hemor-
rhoids, thrombosed, strangulated and gangrenous
hemorrhoids, and concomitant conditions like fis-
tula or fissure. Some patients with even lower
grades of disease may show preference for surgical
treatment. If properly executed, recurrence is
uncommon. Though surgery is the most effective
treatment for hemorrhoids especially grade III, it is
indicated only in about 5–10 % of patients.
Numerous surgical options are available. In
conventional procedures, hemorrhoidal tissue is
excised and either left open to heal by secondary
intention (Milligan Morgan hemorrhoidectomy)
or closed primarily (Ferguson’s hemorrhoidec-
tomy). Various modifications have come up using
different instruments for excision like electrocau-
tery, bipolar sessions, laser LigaSure, harmonic
scalpel, circular stapler and Doppler-guided hem-
orrhoidal artery ligator (DGHAL) alone or in
combination with resection (RAR).
3.6.4.1 Open Hemorrhoidectomy:
Milligan Morgan
The choice of anesthesia and patient positioning
are individualized and generally depend on
patient’s condition and surgeon’s preference.
Nowadays, any surgeons perform open hemor-
rhoidectomy as a day-care procedure.
Open hemorrhoidectomy was the procedure
commonly performed throughout the world up to
1960. Milligan et al. popularized the open tech-
nique. Since the procedure was relatively simple,
it was adapted at one time throughout the world.
This technique is popular in the UK and Europe.

19
The haemorrhoid complex is everted by apply-
ing artery forceps to reach the level of the anorec-
tal ring (Fig. 3.7a–d). A V shaped incision is
made in the anal and perianal skin. The point of
V should lie 1–1.5 cm from the anal verge. As the
dissection proceeds upward, the mucosa is
divided on each side of the hemorrhoidal mass to
converge toward the apex of the pedicle in order
to avoid a broad bulky mucosal pedicle. Care
should be taken not to injure the internal anal
sphincter during dissection. The apex of the ped-
icle is transfixed with 1/0 Vicryl suture with
round body needle. While incising the perianal
skin and anal mucosa, leave sufficient islands of
anoderm between the excised segments to pre-
vent anal stenosis. After completion of the opera-
tion, the perianal wound should look like a clover
or three pear-shaped wounds. Open hemorrhoid-
ectomy is an option when the wound cannot be
completely closed or in the presence of gangrene
or circumferential hemorrhoids. Though the
results are excellent, it is more painful in the
postoperative period, takes a little longer time to
heal, and incidence of postoperative stenosis is
relatively high.
3.6.4.2 Closed Hemorrhoidectomy
(Ferguson)
Ferguson and Heaton reported closed hemor-
rhoidectomy technique in 1959. Over the years,
this technique was widely accepted and practiced
and is more popular in the USA. Closed hemor-
rhoidectomy has three principle objectives: (1) to
remove as much vascular tissue as possible with-
out sacrificing anoderm, (2) to minimize postop-
erative serous discharge by prompt healing, and
(3) to prevent stenosis that may complicate heal-
ing of large raw wounds.
After positioning the patient, decision should
be made which hemorrhoid should be removed
a b
c d
Fig.3.7 (a–d) Steps of open hemorrhoidectomy
3 Hemorrhoids

20
first. Generally, the best defined, least complex
hemorrhoid and that seems to be main offender
should be tackled first. Tissue distortion should be
avoided all the time. The larger the hemorrhoids
are, the longer the incision. It should be with a ratio
of 3:1 (length to breadth). The technique of exci-
sion is similar to that of open technique. After
excision of long triangular segment of hemor-
rhoidal tissue to the level of the anorectal ring, suf-
ficient undermining of the wound edges is
accomplished to facilitate the removal of accessory
hemorrhoidal tissue and tension-free closure of the
wound. Starting from the pedicle, a running suture
with2/0Vicrylisusedforwoundclosure(Fig.3.8a,
b). No internal anal dressing is necessary. The
advantages of closed hemorrhoidectomy are less
postoperative discomfort, minimal inpatient stay,
practically no outpatient care, and no need for sub-
sequent dilatation. Occasionally, the surgery is
done by making a linear incision in the region of
the hemorrhoidal mass, undermining flaps care-
fully, followed by excision of hemorrhoidal tissue
without removing anoderm or skin. The wound
can then be closed with sutures thereby reducing
the risk of postoperative stenosis. A prospective
randomized trail comparing open with closed
hemorrhoidectomy in patients with grade III or IV
hemorrhoids demonstrated less postoperative pain
in close hemorrhoidectomy group (You et al.
2005). Though another study by HO et al. (1997)
concluded that closed hemorrhoidectomy was
associated with faster healing, there was no differ-
ence in postoperative pain and complication.
3.6.4.3 White Head (Submucosal)
Hemorrhoidectomy
The procedure is repeated for other hemor-
rhoidal mass. The operation is technically diffi-
cult, bloody with high rate of postoperative
stricture, loss of normal sensation, and develop-
ment of ectropion. The ectropion is so common
that it is called as “white head deformity.” Some
surgeons, however, claimed good results after
modifying the technique (Whitehead 1882;
Wolff and Culp 1988).
The submucosal hemorrhoidectomy of Sir
Allen Park (1956) gave good results in his hands.
According to him, because no anoderm or skin
was removed, the wound heals fast with less
induration, scaring, and stenosis.
3.6.4.4 Laser Hemorrhoidectomy
Both carbon dioxide (CO2) and Neodymium-
Yttrium-Aluminum-Garnet (Nd: YAG) laser have
been used for surgical management of hemor-
rhoids. Either instrument can be used to excise or
evaporate the tissue. When used as a cutting
instrument, the technique is exactly the same as
that for a blade. The duration of wound healing
after laser technique is almost equal to any other
technique, but there is higher risk of stenosis
(Wang et al. 1991).
3.6.4.5 LigaSure Hemorrhoidectomy
LigaSure (LigaSure TM, Valleylab, Covidien) is
a bipolar electrothermal device which is used to
excise the hemorrhoidal tissue with the intention
a b
Fig.3.8 (a, b) Primary closure after excisional hemorrhoidectomy

21
to reduce bleeding with minimal thermal damage
of adjacent tissues.
3.6.4.6 Hemorrhoidectomy by
Ultrasonic Scalpel (HUS)
Harmonic scalpel relies on ultrasonic waves pro-
ducing simultaneously cutting and coagulation
effect with minimal lateral thermal damage to the
adjacent soft tissue and minimal bleeding. That is
why this method is also known as bloodless ultra-
sonic scalpel hemorrhoidectomy (BUSH). This
method is making scientifically proven positive
waves in the method of management of grade III
and IV hemorrhoids all over the world (Bulus
et al. 2014). Ideally, HUS is indicated in one to
two columns of grade II and grade IV hemor-
rhoids. Though it can be used for all three-column
hemorrhoidectomy, a stapled hemorrhoidopexy
is more preferable in such circumferential dis-
ease in my view (Chung et al. 2005; Tsunoda
et al. 2011).
3.6.4.6.1 Mechanism
US blade vibrates longitudinally at a speed of
55.5 Hz per second, which is equivalent to
55,500 cycles per second, transferring mechani-
cal energy to tissue. An electrical signal causes
the peizoelectric ceramics in the hand piece of
the US blade to expand and contract, converting
electrical energy to mechanical motion which is
transmitted to the blade extender. As the ultra-
sonic wave leaves the blade extender, its motion
is amplified as it travels to the blade tip where
maximum motion occurs. The blade tip moves
longitudinally in a distance range of 50–100 μm.
3.6.4.6.2 Coaptive Coagulation
The coagulation effect occurs through the trans-
fer of mechanical energy to the tissue which
causes internal cellular friction thus breaking
down the hydrogen bonds. It leads to protein
denaturation thereby forming a sticky coagulum
that seals small vessels of size <3 mm. This
occurs at a temperature under 100 °C therefore
minimizing smoke and charring (Tsunoda et al.
2011). Comparatively, electrocautery causes
water vaporization and desiccation at a tempera-
ture between 100–150 °C, while the laser causes
tissue burning and charred scab formation at a
temperature of 150–400 °C.
As grip force is applied to the tissue; in com-
bination with the blade motion, the tissue gets
separated. Energy is transferred to the tissue
through the active blades under applied force
which minimizes lateral thermal spread.
3.6.4.6.3 Cavitation Effect
As the active blade of the US blade vibrates over
the static passive blade with the tissue included in
between, there is a cavity created with a low-
pressure zone that causes tissue dissection.
Vapors from the tissue fluid expand and spread in
adjacent tissue thus causing separation of tissue
layers and planes. This visualization of vascular
and tissue planes enhances the precision and
quality of dissection.
The US blade has several different surfaces
for cutting and coagulation (Fig.3.9).
The comparative advantages of US blade:
• Compared to other electrosurgical devices,
US blade offers better control and precision
for cutting and coagulation.
• The lateral thermal damage with US blade is
1–3 mm which is the least as compared to
bipolar (2–6 mm), laser (4–8 mm), or monop-
olar (4–12 mm) electrocautery (Abo-hashem
et al. 2010; Bulus et al. 2014).
• There is less smoke and charring.
• No stray energy (jumping current sparks to
adjacent tissue).
• There is no neuromuscular stimulation as it is
heat energy and not electrical energy.
• No electricity passing through patient’s body,
as in monopolar electrocautery, therefore
reducing potential risk of burns especially at
the exit cautery grounding plate area thus
making it safe to be used in patients fitted
with other electrosurgical devices like pace-
makers, etc.
3.6.4.6.4 Technique
The procedure can be done under spinal or local
anesthesia with IV sedation. Mark the area to be
dissected with US tip/nose spot coagulation dots
taking care to involve less anoderm but complete
3 Hemorrhoids

22
pedicle. Saline/lignocaine + adrenaline infiltra-
tion is done in the subcutaneous and submucosal
area. This achieves better hemostasis and also
causes separation of tissue planes between sub-
mucosa, where the vessels lie, and the internal
anal sphincter (IAS).
A charred plastic-like rolled up coagulum is
formed by the use of electric or ultrasonic devices
on skin surface. In my view, the skin incision is
better taken by a cold knife or scissors. This mini-
mum one to two drops of bleeding is worth the loss
than an augmented wound edge which may affect
the wound healing due to increased wound edema
and slough which is a potential reason for second-
ary wound infection and other potential complica-
tions. As it is, this minimal bleeding is reduced by
the infiltration and can be easily controlled by light
pressure for some time with a gauze piece held by
an assistant over the wound. Being in the correct
plane of dissection, which a surgeon will master
eventually after operating a few cases, is the key to
bloodless field of dissection.
The active blade is always placed under vision.
The corrugator cutis ani muscles are cut by the
US along the line of the marked incision thus
exposing the plane between the submucosa and
the IAS. The IAS is reflected laterally away from
the wound, and hemorrhoidal tissue is clamped
loosely and cut by low-power US setting bit by
bit. The pedicle of the hemorrhoid is first scored
coagulated at base by the US blade, and final cut-
ting of the pedicle is done by applying the US
slightly distal to this scored line in order to avoid
bleeding during final stage of pedicle dissection.
A word of caution though there is a tendency to
finish the pedicle cut quickly as by now, the sur-
geon is happy and confident due to the relatively
bloodless and quick surgery done so far. In this
haste, a small tug on the left over pedicle may
snap away before getting coagulated completely
by the US blade. This results in significant bleed-
ing. In the haste to control this bleeding, the sur-
geon may use electrocautery desperately just to
find increased bleeding as the vessels would have
retracted below the mucosa. A deep suture may
then be required with an absorbable suture mate-
rial in order to finally achieve hemostasis.
Therefore, it is safe for the surgeon to be patient
enough to allow the US blade to completely
coagulate and cut the tissue on its own.
Small oozing, if present, can be coagulated
using the tip of the US blade or its flat back sur-
face. It is the individual surgeon’s choice to either
leave the wound open as in Milligan Morgan
method or to close it with an absorbable suture as
in Ferguson’s method (Sohn et al. 2008).
Goligher, in his textbook, has mentioned that his-
tologically the wounds are the same after 1 week
55,500 cycles per second
Shown in slow motion for illustration purposes
Flat Back
Clamping surface
Concave Surface Blunt Nose
Cutting Edge or Knife Down
Fig.3.9 Ultrasonic scalpel blade surfaces (With Permission from Ethicon, Mumbai, India)

23
in open or closed methods (Armstrong et al.
2001; Tsunoda et al. 2011).
To sum up, US blade is safe, effective, causes
least lateral thermal damage, achieves good
hemostasis, coagulates and cuts simultaneously,
and causes less postoperative pain and other
complications ranging from infection to inconti-
nence and anal stenosis with greater patient satis-
faction (Sohn et al. 2008; Ivanou et al. 2007;
Kwok et al. 2005; Chung et al. 2002 and Khan
et al. 2001).
3.6.4.7 Stapled Hemorrhoidectomy or
Procedure for Prolapsed
Hemorrhoids (PPH)
In the context of hemorrhoids, the concept of
localized pile masses to be removed by surgery
underwent a paradigm shift when Antonio Longo
came on the scene in the 1990s.
In 1993, after having performed 500 hemor-
rhoidectomies and being unsatisﬁed with the
results, he looked for a “new surgical solution.” A
conventional circular stapler was used to perform
the prolapsectomy between 1993 and 1996.
In 1995, during the 24th International Congress
of Latin Mediterranean, Longo for the ﬁrst time
presented his hypothesis that hemorrhoidal tissue
is normal to the anal canal. The basic pathology of
the hemorrhoidal disease is the prolapse above the
hemorrhoidal tissue. It is not necessary to remove
the hemorrhoids. He proposed the correction of
prolapse by carrying out a resection of the pro-
lapsed suprahemorrhoidal rectal mucosa using sta-
pler. The original hypothesis was that by
repositioning the hemorrhoids in the anal canal, it
would be possible not only to cure the symptoms
but also to restore the anatomy and physiological
function of the anus while avoiding the typical
hemorrhoidectomy sequelae.
The paradigm shift was from the concept of
hemorrhoidectomy in whatever form and the
preservation of hemorrhoids while correcting the
prolapse.
The PPH instrument was devised, and he pre-
sented his concept and the technique of reduction
of mucosa and hemorrhoidal prolapse with a cir-
cular suturing device at the 6th World Congress
of Endoscopic Surgery in Rome, Italy, in 1998
(Longo 1998). He made the dramatic announce-
ment that the anal cushions are necessary for nor-
malization of anal canal lining and should never
be removed. The whole pathology of piles is due
to prolapse of mucosa and the submucosal anal
cushions. The surgical procedure performed
should be replacement of the cushions in their
normal place and not excision.
“If your pants are sliding down, you don’t cut
away the pants but pull them up.”
The original procedure devised by Longo was
called “procedure for prolapse and hemorrhoids.”
The instrument devised to carry it out was labeled
PPH01 (Fig. 3.10). It became popularly known as
“stapled hemorrhoidectomy.” Longo himself
called the procedure “stapled anopexy.”
Around the same time, Allegra et al. and
others including Pernice presented their experi-
ences with hemorrhoidectomy using a circular
stapler with disastrous results. Longo went to
great pains explaining the difference in the under-
lying concept of stapled hemorrhoidectomy and
stapled anopexy: two opposite concepts and pro-
cedures (Longo 2002).
Indications for stapled hemorrhoidectomy
include reducible grade III and grade IV hemor-
rhoids, circumferential hemorrhoids, and patients
in whom other forms of treatment have failed. It
is contraindicated in presence of perianal sepsis,
anal stenosis, and full-thickness rectal prolapse.
Earlier experience with the new technique of
stapled anopexy by surgeons who still thought of
it as stapled hemorrhoidectomy resulted in a long
Fig. 3.10 Stapler haemorrhoidopexy equipment: 33-mm
hemorrhoidal circular stapler, circular anal dilator, purse-
string suture anoscope, and suture threader
3 Hemorrhoids

24
list of complications that were due to the non-
appreciation of the underlying change in the eti-
ology. The principle highlights of the procedure
(Fig. 3.11a–f) are that:
(a) Procedure for piles and prolapse of hemor-
rhoid set initially used was called PPH01,
now modified to PPH03. This consists of a
circular stapler (HCS33), a suture threader
(STI00), a circular anal dilator (CAD33), and
a purse-string suture anoscope (PSA33).
(b) After anal dilatation by dilator, purse-string
suture using nonabsorbable monofilament
material, approximately 4 cm cephalad to the
a b
c d
e f
Fig.3.11 Steps of stapled anopexy: (a) fixation of anoscope, (b) purse-string suture, (c) insertion of stapler, (d) tight-
ening purse-string, (e) firing stapler, and (f) inspecting suture line

25
dentate line, is placed into the mucosa and
submucosa of the lower rectum avoiding the
muscular layer and vagina in females.
(c) The suture is placed sufficiently high so that
when stapler is fired, it does not incorporate
the dentate line, anoderm, and the underlying
internal anal sphincter.
(d) The suture is tied around the opened anvil,
which has been passed, and the stapler closed
while a gentle traction has been applied to
the suture brought out through the side win-
dows in the stapler.
(e) A donut of complete circular mucosa and
submucosa is removed and should measure
approximately 2 cm in its width.
The removal of a circular strip of mucosa and
submucosa above the hemorrhoidal tissue results
in disruption of the blood supply by superior
hemorrhoidal arteries and pulling up and flatten-
ing of the hemorrhoidal tissue which reduces the
prolapse. The reported literature on stapled ano-
pexy confirmed the benefits of the procedure as
reduced pain, shorter length of stay, early return
to work, no distortion of the anal opening, and
good long-term results in grade III piles.
Most of the reports mentioned that some
venous engorgement of the anal mucosa remains
in the postoperative period, and the additional
procedures of removal of skin tags may be
necessary.
Problems of the purse-string suture giving
incomplete donut have been reported and various
methods devised to overcome it. Hoffman from
California described in modification of putting a
washer with spikes to impale the mucosa instead
of a purse-string suture (Hoffman 2005).
3.6.4.7.1 Complications of Stapled
Anopexy
All surgical procedures carry an inherent risk of
operative and postoperative complications. The
main complications noted for these procedures
include postoperative bleeding (Fig. 3.12), sep-
sis, anastomotic dehiscence and stricture, inju-
ries to lower rectum and the sphincter complex,
rectovaginal fistula in females, urgency, and
tenesmus.
These complications occur in centers where
the understanding of the pathophysiology is not
appreciated and the procedure is carried out
without being formally trained to do so. Antonio
Longo mentioned that postoperative pain sup-
posedly due to muscular inclusion in the staple
line is possible in well-done operations and
may be due to the neural injuries or inclusion of
the anoderm in the donut. These cases are far
and few. The majority of the results are satis-
factory both for the patient and the surgeon
(Kaider–Person et al. 2007). In a systematic
review of 25 randomized, controlled trials com-
paring stapled with conventional hemorrhoid-
ectomy, Tjandara and Chan (Tjandra and Chan
2007) concluded that stapled anopexy is safe
with many short-term benefits (lesser operative
time, early return of bowel function, less pain,
shorter hospital stay, faster wound healing,
early return to work and higher patient satisfac-
tion). Long-term results were similar to con-
ventional hemorrhoidectomy. The findings of
this study were replicated in a large meta-anal-
ysis of 29 randomized clinical trials (Shao et al.
2008). Increased cost of instruments is bal-
anced by shorter operative time, shorter hospi-
tal stay, and early return to work.
To conclude, stapled hemorrhoidopexy is
safe and effective treatment for large symp-
tomatic piles with fewer early and late post-
operative complications compared to closed
hemorrhoidectomy.
Fig.3.12 Bleeding after stapled anopexy
3 Hemorrhoids

26
3.6.4.8 Doppler-Guided Hemorrhoidal
Artery Ligation (DGHAL)
Distribution patterns of the superior rectal artery
widely vary (bipartition in 82 %, trifurcation in
12 %) just at the entering points of its branches
into the rectal muscle layer. Thus, the position of
the rectal arteries is not predictable as all these
branches are end arteries. So their ligation will be
effective in controlling the bleeding and also the
prolapse. Aigner et al. 2004 reported in their
study that the superior rectal artery had three
times the caliber compared to healthy volunteers,
and blood flow was also nearly three times higher
in patients of symptomatic hemorrhoids. Their
study provides strong evidence that the arterial
blood supply is of relevance in the development
of hemorrhoidal cushions. Vascular dilatation
and increased blood flow suggest that there might
exist an increased arterial inflow rather than a
venous stasis or outflow problem in the develop-
ment of hemorrhoids. Thus, evidence-based
detection of these branches by Doppler and their
ligation become justified. Arterial supply
becomes relatively higher and arterial ligation
appears as a logical recent development.
Normally, only three arterial branches have been
described, but when detected through Doppler
probe, the number may vary from 12 to 15 (Rama
Kant 2010). The superior rectal artery may not
course in exactly defined positions of the rectal
mucosa (3’, 7’, 11’). The middle rectal artery
may be missing on both sides in 20.6 % of
patients (Aigner et al. 2004).
The concept of DGHAL was given by
Kazumasa Morinaga in 1995 and was approved
by the FDA in the same year. This is the latest
most innovative technology being carried out in
the world and emerging as minimal invasive pro-
cedure of choice in hemorrhoids all over world
(Dal Monte et al. 2007; Sohn et al. 2001; Ratto
et al. 2010; Giordano et al. 2009). The hemor-
rhoidal artery ligation operation (HALO) is a
new technique designed to eradicate piles with-
out the need for cutting. As such, it is relatively
pain-free, and most patients are back to work
after 24–48 h with only a minimum of discom-
fort. The basis of the operation is to restore the
hemorrhoids back to their anatomical position
and occlude the blood supply to the vascular
cushions forming the hemorrhoids resulting in
their shrinking.
3.6.4.8.1 Procedure
DGHAL is done under local, regional, or general
anesthesia in lithotomy or left lateral position
after nothing per orally for last 6 h and an enema
in the morning. A short course of antibiotic for
both aerobic and anaerobic may be advised. For
grades I or II hemorrhoids, only ligation will be
required which can be done even under 2 %
Xylocaine jelly and 5 % Xylocaine ointment
application, and the patient can be discharged the
same day. In grade III and IV hemorrhoids, anes-
thesia is required and patient should stay over-
night and discharged the next morning. In these
patients, HAL is supplemented by rectoanal
repair (RAR) to take care of prolapsing mucosa.
This technique uses a specially adapted proc-
toscope with an inbuilt Doppler probe which is
used to detect feeding hemorrhoidal artery which
is subsequently ligated, viz, Doppler machine
with display graph and inbuilt printer and HAL
proctoscope (Figs. 3.13 and 3.14). A miniature
Doppler ultrasound device, inserted after lubrica-
tion in the anal canal and rectum, locates branches
of arteries supplying the hemorrhoids 2–3 cm
above the dentate line by arterial sound of
Doppler and also the graphs at its screen. This
also provides information of the depth of the
artery and facilitates the ligation. Usually, we
start at 12 o’clock position first clockwise and
then anti-clockwise and ligate all significant
Fig. 3.13 Doppler-guided hemorrhoidal artery ligation –
equipment

27
arterial branches (Fig. 3.15). As soon as blood
vessels are tied off, the Doppler sound of artery
disappears and the hemorrhoid shrinks immedi-
ately and further over the subsequent days and
weeks. Usually, about four to nine branches are
ligated with 2/0 Vicryl on 5/8th circle needle with
taper end. Prolapsing and grade III and IV hem-
orrhoids also need RAR. This is done by another
equipment called RAR equipment (Fig. 3.16).
Scope is inserted in the rectum and focused on
the site of prolapsing hemorrhoid and then first
suture is taken deeper to fix deeper tissue and
then sutures are continued below stopping just
above dentate line. The last suture is taken after
removal of the RAR scope. The suture once tight-
ened will pull the hemorrhoid mass up and ensure
its fixation, leading to mucopexy (Fig. 3.17a, b).
Thus, almost a normal looking anal opening is
left at the end of procedure (Fig. 3.18a, b). A
small pack with 2 % jelly is left to be removed
3 h later. Patient is catheterized as after saddle
anesthesia he will not be allowed to sit and may
develop retention of urine. The catheter is
removed the next morning. Because the stitches
are placed in the lower rectum where there are
virtually no sensory nerves, the procedure is
pain-free. Most patients are back to work within
24–48 h with only minimum of discomfort.
Postoperatively, only dietetic restrictions,
stool softener, short course of antibiotics, and
local Xylocaine 2 % jelly application are advised.
No sitz bath is recommended.
3.6.4.8.2 Postoperative Complications
In a systematic review of 17 studies with a total
of 1996 patients, a subset of six studies with a
Fig.3.14 HAL proctoscope
with Doppler sensor (white),
sheath, and cable
Fig.3.15 Procedure of DGHAL
3 Hemorrhoids

28
follow-up of 1 year or more (850 patients treated
by the procedure) bleeding, pain on defecation,
and prolapse was reported in 10 %, 9 %, and
11 % of patients, respectively. A subset of nine
studies with a follow-up of less than 1 year (855
patients treated by the procedure) bleeding and
prolapse was reported in 6 % and 8 % of patients,
respectively. The proportion of patients with pre-
operative bleeding, pain, and prolapse ranged
from 45 % to 100 %, 12 % to 83 %, and 12 % to
100 %, respectively (Infantino et al. 2010;
Morinaga et al. 1995). Reports show low
Fig.3.16 RAR procedure, tightening the suture pulls all prolapsing piles up
a b
Fig.3.17 (a, b) Diagrammatic representation of RAR

29
complication rates and lower postoperative pain.
Bleeding, urinary retention, prolapse, and swell-
ing of external hemorrhoids were included among
complications. However, complications are eas-
ily managed by conservative approach.
3.6.4.8.3 Results
DGHAL is associated with recurrence rate of
6–13 %. Hemorrhoids can and do come back in
10–20 % of people following any hemorrhoid
surgery in the first 12 months. This is partly
because patients fail to control their food habits
and modify their lifestyle.
Pain, hospital stay, time to first bowel move-
ment, complete functional recovery, complica-
tions, and recurrence were significantly better for
the DGHAL patients as compared to other proce-
dures especially stapler hemorrhoidopexy.
DGHAL is most effective for second- or third-
degree hemorrhoids. It may not improve prolaps-
ing symptoms in advanced and circumferential
hemorrhoids. However short-term outcomes and
1 year recurrence rates of DGHAL did not differ
from those of conventional hemorrhoidectomy
(Bursics et al. 2004). Given the fact that there is
the possibility of revascularization and recur-
rence of symptomatic hemorrhoids, further stud-
ies on the long-term outcomes of DGHAL are
still awaited (Faucheron and Gangner 2008). In
the follow-up examination 12 months after RAR
procedure, there were 25 % of minor residual
hemorrhoidal prolapse, while only 5 % reported
residual symptoms (painful defecation and itching)
(Rama Kant 2010). Scheyer et al. in 2006 reported
little pain and minimal morbidity with about
60 % patient satisfaction in terms of resolution of
symptoms in 308 patients predominantly with
grade II and III hemorrhoids.
To summarize, DGHAL is a safe and effective
minimally invasive method of treating hemor-
rhoids with no risk of incontinence, has minimal
postoperative pain, and has lower recurrence rate.
Patient satisfaction is high and return to work is
early.
3.7 Postoperative Complications
of Hemorrhoidectomy
3.7.1 Pain
Fear of pain is the most important reason why
patients avoid hemorrhoidectomy. The pain is of
two types, persistent discomfort and painful
spasm. The persistent discomfort is due to the
raw area and lasts for a day or 2.
The spasm pain is caused by the contraction of
sphincter muscles. These spasms are involuntary
and may be aggravated by morphine injection.
Spasm may be precipitated by movements. The
most painful period in almost every case is that
associated with the first bowel movement. Pain is
markedly reduced in stapled hemorrhoidopexy.
The post-hemorrhoidectomy pain is managed
with analgesics and nonsteroidal anti-
inflammatory agents, sitz bath, and laxative.
a b
Fig.3.18 (a, b) Results after DGHAL and RAR
3 Hemorrhoids

30
Intake of diet high in fiber and fluid helps to mini-
mize pain. Oral metronidazole (Carapeti et al.
1998), topical diltiazem (Silverman et al. 2005),
and injection of botulinum toxin (Patti et al.
2006) have been found to have marginal benefit.
3.7.2 Urinary Retention
Retention of the urine occurs in about 10–32 %
patients. The contributing factors for urinary reten-
tion include the use of spinal anesthesia, fluid over-
load, rectal packing, rectal spasm, and reflex spasm.
Retention of urine responds to simple measures in
most cases. Hot water bags and injection carbachol
may help to relieve the retention. Some patients
may need catheterization. In older people, benign
prostate enlargement should be excluded.
3.7.3 Postoperative Bleeding
Postoperative hemorrhage may be early or late.
Early hemorrhage occurs as reactionary hemor-
rhage from the skin wound or the pedicle. It is
rare when the wound is sutured during surgery.
Early bleeding from the pedicle may be due to
loose ligature of the pedicle or slippage of liga-
ture. The patient may have to be taken to the
operation theater for controlling of the bleeding.
Secondary hemorrhage is more serious, for
the bleeding may be considerable and the blood
may accumulate in the rectum and missed for
some time. It is due to sepsis occurring in the
pedicle resulting in softening of the wall of the
main artery. It usually occurs between 7–10th
postoperative days. Inspection may show trick-
ling of dark blood from the anus. Rectal examina-
tion may reveal large soft clot, and on withdrawal
of finger, blood comes out. During proctoscopy,
blood clot may extrude through the lumen.
Delayed bleeding is usually not a preventable
condition. The patient is examined under anes-
thesia. Any clot is removed by a combination of
swabs and irrigation with saline. The bleeding
point is looked for, and if present, the bleeder is
under run using Vicryl in a small half circle or 5/8
needle. Bleeding can be controlled by passing a
Foley’s catheter, and traction of the catheter
brings the balloon into contact with the bleeding
area. Patient is given a proper antibiotic later.
3.7.4 Wound Infection
Infection is inevitable in a wound in such a con-
taminated area. But it is surprising that even
suturing of the skin wound does not lead to clini-
cal infection. Still rarely, perianal and ischiorec-
tal abscess have been reported. Any patient with
severe pain, fever, and urinary retention after
anorectal surgery should be examined carefully.
If the initial examination indicates the presence
of septic focus, the patient should be examined
under anesthesia. The treatment of sepsis in the
local area consists of drainage, debridement of
necrotic tissue, and parental antibiotics.
3.7.5 Fecal Impaction
Fecal impaction follows incomplete bowel action.
Though the bowel opens every day, it is incomplete.
Fecal material remains within the rectum and
becomes a large hard mass. The patient has a con-
tinued sensation of rectal fullness. In severe cases,
anesthesia may be required for digital evacuation.
3.7.6 Stenosis
The cause of postoperative anal stricture is exci-
sion of considerable portion of the anal mucosa
and anoderm. The fibrous tissue proliferation
leads to scarring and contraction of the anal ori-
fice and narrowing of anal outlet.
The stenosis may be in the anal verge or may
be within the anal canal. Stenosis in anal verge is
due to excessive removal of skin below the den-
tate line. With each bowel, action skin splits and
a chronic fissure forms. The anal orifice is scarred
and contracted.
Stenosis within the anal canal is due to gener-
ous excision of anal canal mucosa during surgery.
The stricture is usually short and continued to the
mucosa and submucosa. In severe cases, the
lumen may not even admit the tip of the finger. If
the stenosis is within the reach of the finger, regu-

31
lar dilatation with finger or Hagar dilator may
provide good result. Surgically, the strictures are
corrected by anoplasty to have a permanent cure.
An anoplasty should be considered for an anal
stenosis if medical treatment by bulk laxatives,
suppositories, dilatation, and enema has failed.
3.7.7 Recurrence
Nonsurgical therapy for hemorrhoid disease has a
recurrence rate of as high as 20 %, but after sur-
gery it is only 2 %. Patients with nonsurgical
therapy will readily accept to have repeat therapy
because recurrence occurs 1–3 years after the
first therapy. Recurrence after surgery is usually
in an accessory hemorrhoid, and the treatment is
decided on individual basis.
3.7.8 Incontinence
Anal leakage or soiling is common during the early
postoperative period, but frank incontinence of liq-
uid and stool is rare. After 6–8 weeks, most patients
with imperfect continence regain full control. Anal
dilatation at the time of hemorrhoidectomy may
result in some loss of control for motion or flatus.
The other cause for defective continence after hem-
orrhoidectomy is the loss of anal canal sensation
due to removal of sensory bearing anal canal epi-
thelium and replacement by scar tissue. In closed
technique, this complication never occurs.
3.7.9 Other Late Complications
Anal fistula, skin tags, ectropion, and mucosal
prolapse are some of the rare late complications
following haemorrhoid surgery.
3.8 Special Situations
3.8.1 Thrombosed Hemorrhoids
Thrombosed external hemorrhoids usually pres-
ent as a painful, pea size, tender mass in the peri-
anal region, frequently following an episode of
constipation or diarrhea. The pain reaches its
peak 48 h and starts subsiding from fourth day.
The overlying skin may necrose and ulcerate
leading to discharge, bleeding, and infection. If
the patient presents with severe pain or onset of
the condition within 48 h, excision is the preferred
treatment. It can be done under local anesthesia
as outpatient procedure (0.5 % lidocaine mixed
with equal amount of 0.25 % bupivacaine con-
taining 1:2,00,000 adrenaline). A short radial
incision is made over the swelling and the under-
lying clot is evacuated. The wound is left open. If
there is only discomfort and patient presents in a
resolving stage, conservative treatment in the
form of sitz baths, stool softeners, bulk-forming
fiber supplement, and analgesics should be initi-
ated. Proctoscopy should be postponed when the
patient is pain-free.
Thrombosed internal hemorrhoids are often
attributed to prolapse of the internal component
with inadequate reduction, resulting in venous
stasis and thrombosis of the vascular cushion.
Powerful sustained straining at defecation may
lead to thrombosis of internal hemorrhoids.
When this occurs the haemorrhoid prolapses
with edema of the corresponding perianal area.
If the patient has had trouble with internal hem-
orrhoid prior to this episode of thrombosis, the
correct treatment is early surgical intervention.
Emergency hemorrhoidectomy for thrombosed
hemorrhoids is technically easy and the patient
is relieved from pain remarkably. The manage-
ment of acute thrombosed internal haemorrhoid
is usually nonoperative because pain is not a
frequent complaint. Even though conservative
treatment is practiced, the continued discom-
fort, prolonged disability, and financial bur-
den may warrant urgent operation for all such
individuals.
3.8.2 Strangulated Hemorrhoids
Prolonged swelling of prolapsed third- or fourth-
degree hemorrhoids can make it irreducible,
leading to incarceration and strangulation. If not
treated, it can lead to necrosis or gangrene and
ulcerations. The presence of gangrene, prolapse,
and edematous hemorrhoids usually causes
3 Hemorrhoids

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