Hemorrhoid

Hemorrhoids are a collection of blood in the venous system (engorged veins) that occurs in the anal region either internally or externally. There are so many risk factors to the development of hemorrhoids such as chronic constipation, anal intercourse especially for men who have sex with men and obesity.

1. Treatment Options for Hemorrhoids

There are many treatment options when dealing with the hemorrhoids such as hemorrhoid banding, hemorrhoidectomy, and hemorrhoid stapling. Each has an advantage over the other approaches.

Hemorrhoid banding is a fairly easy, pain free, in-office approach with very few recurrences compared to other modalities of treatment. The disadvantage of this approach is that the doctor can only put as many bands in one session; therefore the patient has to make frequent visits to the hospital especially in the case of multiple internal hemorrhoids. The underlying principle for this form of treatment is the strangulation of the blood supply of the hemorrhoids as they are highly vascularized structures, therefore, they cut off because of the selective ischemia caused by these bands.

Surgical hemorrhoidectomy is normally reserved for the failed outpatient treatment but factors such as the patient’s preference, the extent of the clinical signs and symptoms and the anatomy of the hemorrhoid are also considered when considering surgery.
Haemorrhoidectomy can be done using the open or the closed techniques in which both involve ligation and excision of hemorrhoid but in the open technique, the anal mucosa and the skin are left open to heal through secondary intention while in the closed technique, the
wound is sutured.

2. Indications

For symptomatic internal, external, or internal-external hemorrhoids.

3. How is the procedure done

The hemorrhoids are usually identified and they are injected with diluted adrenaline to minimize the bleeding during the surgery by vasoconstriction. The areas surrounding the hemorrhoids should also be injected with the dilute adrenaline.
The hemorrhoids are pulled away with a forceps and the diathermy is used to cut them out while ensuring minimal blood loss prevails.
The wound is left open for self-healing. Aim to ensure that there is no bleeding after the surgical excision is done.
A pad of gauze and cotton wool is firmly applied and well bandaged.
In this technique, the hemorrhoid should be excised together with the overlying mucosa. Then the wound is sutured with an absorbable suture completely. This technique is mainly used for internal hemorrhoids.

Hemorrhoid banding involves putting small round bands till the base of the hemorrhoid thus constricting its blood supply. In about 5-7 days, the hemorrhoid will shrivel and come out because of the limited blood supply.The banding is usually done with an anoscope, which is inserted through the anus and it easily fixes the band at the base of the hemorrhoid. If the patient has multiple hemorrhoids, this procedure is repeated until all hemorrhoids are taken care off. The time interval between the removal of one hemorrhoid to the other in the case of multiple hemorrhoids is about 1-2 weeks.

Surgical hemorrhoidectomy can be performed using the open (Milligan-Morgan technique) or the closed technique. The procedure is usually performed under general or regional anesthesia with the patient in the lithotomy or the jack-knife position.

4. Risk of this procedure

Hemorrhoidectomy is normally a well-done procedure but sometimes it can be associated with complications which are as follows:

Incontinence
Bleeding
Anal strictures
Acute retention of urine- this is seen especially in men which may require catheterisation so as to relieve the problem.
Pain
Swelling

5. How you prepare for the surgery

A proper physical examination and lab work should be done to rule out other fatal conditions such as rectal cancer or colon cancer that might present in a similar way to the hemorrhoids. The patient must communicate with the doctor about the current medications that they are taking especially the anticoagulants as this procedure could cause a lot of bleeding. In addition to this, any family history of a bleeding disorder should be disclosed to the doctor before the procedure.

6. Recovery after surgery

Rubber band ligation is an in-office procedure, therefore the patient can comfortably go home immediately after the treatment.

Surgical hemorrhoidectomy recovery is normally good in most patients. The wound heals faster in the closed technique compared to the open one with a high 95% success rate. The open technique is often prone to infections.

Avoid straining at all cost post-surgery.

Stool softeners and bulking agents are used to enhance defecation to avoid straining postsurgery. Appropriate pain medication and antibiotics postoperatively are also given.

It is normal if the patient bleeds a little per rectum after a few days. But if it persists for more than 7 days the patient should immediately go back to the doctor.

Avoid heavy lifting or any other strenuous exercise until the patient is fully healed, sitz baths are recommended at least once daily because they keep the anal area clean.

The patient needs to be reassessed during follow up to evaluate if the piles are healing well or are well healed.

7. Outcomes after Surgery

This approach offers very successful hemorrhoid treatment with few recurrences.

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