Surgical Treatment Options for Hemorrhoids
Classification of Hemorrhoids
Stapled Hemorrhoidopexy (PPH Procedure)
Harmonic Scalpel Hemorrhoid surgery
Laser Surgery for Hemorrhoids
Complications of Hemorrhoid Surgery
Knowing What to Ask Your Surgeon
Classification of Hemorrhoids
Hemorrhoids (piles) arise from congestion
of internal and/or external venous plexuses around the anal
canal. They are classified, depending on severity, into four
degrees. First degree hemorrhoids bleed but do not prolapse
outside of the anal canal; second degree prolapse outside
of the anal canal, usually upon defecation, but retract spontaneously.
Third degree hemorrhoids require manual placement back inside
of the anal canal after prolapsing, and fourth degree hemorrhoids
consist of prolapsed tissue that cannot be manually replaced
and is usually strangulated or thrombosed. Symptoms associated
with hemorrhoids include pain, bleeding, puritus ani (itching)
and mucus discharge. In IV degree prolapse, the area where
the rectal mucous membrane meets the anal skin (the dentate
line) is positioned almost outside the anal canal, and the
rectal mucous membrane permanently occupies the muscular anal
For more detailed about information, about the concepts of
hemorrhoidal anatomy as applied to rectal surgery, view our
video on Overview:
Anatomy of Prolapse and Hemorrhoids > get Real
Player , an alternative approach to the surgical treatment
of hemorrhoids. In order to explain the rational of the surgical
procedure for prolapse and hemorrhoids it is helpful to take
a moment to review some concepts of anatomy.
In many cases hemorrhoidal disease can be treated by dietary
modifications, topical medications and soaking in warm water,
which temporarily reduce symptoms of pain and swelling. Additionally,
painless non-surgical methods of treatment are available to
most of our patients as a viable alternative to a permanent
In a certain percentage
of cases, however, surgical procedures are necessary to provide
satisfactory, long?term relief. In cases involving a greater
degree of prolapse, a variety of operative techniques are
employed to address the problem.
Developed in the United Kingdom by Drs. Milligan and Morgan,
in 1937. The three major hemorrhoidal vessels are excised.
In order to avoid stenosis, three pear-shaped incisions are
left open, separated by bridges of skin and mucosa. This technique
is the most popular method, and is considered the gold standard
by which most other surgical hemorrhoidectomy techniques are
Developed in the United States by Dr. Ferguson, in 1952. This
is a modification of the Milligan-Morgan technique (above),
whereby the incisions are totally or partially closed with
absorbable running suture.
A retractor is used to
expose the hemorrhoidal tissue, which is then removed surgically.
The remaining tissue is either sutured or is sealed through
the coagulation effects of a surgical device.
Due to the high rate
of suture breakage at bowel movement, the Ferguson technique
brings no advantages in terms of wound healing (5-6 weeks),
pain, or postoperative morbidity.
can be performed as a day-case procedure. But due to poor
post-operative care in the community and high level of pain
experienced after the procedure, an in-patient stay is often
required (average of 3 days).
Hemorrhoidopexy (PPH Procedure)
Also known as Procedure for Prolapse & Hemorrhoids (PPH),
Stapled Hemorrhoidectomy, and Circumferential Mucosectomy.
PPH is a technique developed
in the early 90's that reduces the prolapse of hemorrhoidal
tissue by excising a band of the prolapsed anal mucosa membrane
with the use of a circular stapling device. In PPH, the prolapsed
tissue is pulled into a device that allows the excess tissue
to be removed while the remaining hemorrhoidal tissue
is stapled. This restores the hemorrhoidal tissue back to
its original anatomical position.
The introduction of the
Circular Anal Dilator causes the reduction of the prolapse
of the anal skin and parts of
the anal mucous membrane. After removing the obturator, the
prolapsed mucous membrane falls into the lumen of the dilator.
The Purse-String Suture
Anoscope is then introduced through the dilator.
This anoscope will push
the mucous prolapse back against the rectal wall along a 270°
circumference, while the mucous membrane that protrudes through
the anoscope window can be easily contained in a suture that
includes only the mucous membrane. By rotating the anoscope,
it will be possible to complete a purse-string suture around
the entire anal circumference.
The Hemorrhoidal Circular
Stapler is opened to its maximum position. Its head is introduced
and positioned proximal to the purse-string, which is
then tied with a closing knot.
The ends of the suture
are knotted externally. Then the entire casing of the stapling
device is introduced into the anal canal. During the introduction,
it is advisable to partially tighten the stapler.
With moderate traction
on the purse-string, a simple maneuver draws the prolapsed
mucous membrane into the casing of the circular stapling device.
The instrument is then tightened and fired to staple the prolapse.
Keeping the stapling device in the closed position for approximately
30 seconds before firing and approximately 20 seconds after
firing acts as a tamponade, which may help promote hemostasis.
Firing the stapler releases
a double staggered row of titanium staples through the tissue.
A circular knife excises the redundant tissue. A circumferential
column of mucosa is removed from the upper anal canal. Finally,
the staple line is examined using the anoscope. If bleeding
from the staple line occurs, additional absorbable sutures
may be placed.
What are the Benefits
of PPH over other Surgical Procedures?
1) Patients experience less pain as compared to conventional
2) Patients experience a quicker return to normal activities
compared to those treated with conventional techniques.
3) Mean inpatient stay was lower compared to patients treated
with conventional techniques.
What are the Risks
Although rare, there are risks that accompany PPH:
4) If too much muscle tissue is drawn into the device, it
can result in damage to the rectal wall.
5) The internal muscles of the sphincter may stretch, resulting
in short-term or long-term dysfunction.
6) As with other surgical treatments for haemorrhoids, cases
of pelvic sepsis have been reported following stapled haemorrhoidectomy.
7) PPH may be unsuccessful in patients with large confluent
hemorrhoids. Gaining access to the anal canal can be difficult
and the tissue may by too bulky to be incorporated into the
housing of the stapling device.
8) Persistent pain and fecal urgency after stapled hemorrhoidectomy,
although rare, has been reported.
9) Stapling of hemorrhoids is associated with a higher
risk of recurrence and prolapse than conventional hemorrhoid
removal surgery; according to a Canadian
study of 537 participants.
The Harmonic Scaplel
uses ultrasonic technology, the unique energy form that allows
both cutting and coagulation of hemorrhoidal tissue at the
precise point of application, resulting in minimal lateral
thermal tissue damage. Because the Harmonic Scaplel uses ultrasound,
there is less smoke than is generated by both lasers and electrosurgical
instruments. The Harmonic Scaplel cuts and coagulates by using
lower temperatures than those used by electrosurgery or lasers.
Harmonic Scaplel technology
controls bleeding by coaptive coagulation at low temperatures
ranging from 50ēC to 100ēC: vessels are coapted (tamponaded)
and sealed by a protein coagulum. Coagulation occurs by means
of protein denaturation when the blade, vibrating at 55,500
Hz, couples with protein, denaturing it to form a coagulum
that seals small coapted vessels. When the effect is prolonged,
secondary heat is produced that seals larger vessels. Because
ultrasound is the basis for Harmonic
Scaplel technology, no electrical energy is conducted to the
By contrast, electrosurgery
coagulates by burning (obliterative coagulation) at temperatures
higher than 150ēC. Blood and tissue are desiccated and oxidized
(charred), forming eschar that covers and seals the bleeding
area. The reduced postoperative pain after Harmonic Scalpel
hemorrhoidectomy compared with electrocautery controls, likely
results from the avoidance of lateral thermal injury.
Applied to Tissue
The protein coagulum
caused by the application of the Harmonic Scaplel is superior
at sealing off large bleeding vessels during surgery. It has
been my experience that this method is useful on large hemorrhoids
that may bleed during surgery, thus minimizing blood loss
and reducing the time needed for surgery.
For more detailed information,
view our video on Hemorrhoidectomy
Using Harmonic Scalpel > get Real
Surgery for Hemorrhoids
Skilled surgeons use laser light with pinpoint accuracy. The
unwanted hemorrhoid is simply vaporized or excised. The infinitely
small laser beam allows for unequaled precision and accuracy,
and usually rapid, unimpaired healing.
The result is less discomfort,
less medication, and faster healing. A hospital stay is generally
not required. The laser is inherently therapeutic, sealing
off nerves and tiny blood vessels with an invisible light.
By sealing superficial nerve endings patients have a minimum
of postoperative discomfort. With the closing of tiny blood
vessels, your proctologist is able to operate in a controlled
and bloodless environment.
Procedures can often
be completed more quickly and with less difficulty for both
patient and physician. Laser can be use alone or in combination
with other modalities. For more detailed information on combining
modalities in surgery, view our video on the performance of
both a Laser
& Harmonic Scalpel Hemorrhoidectomy. Get > Real
A study of 750 patients
undergoing laser treatment for hemorrhoids reported successful
results of 98%. The patient satisfaction was 99%.
For more detailed information,
view our page on Published Laser
A new technique to remove hemorrhoids is called atomizing.
The Atomizer™ is a medical device that was developed
specifically to atomize tissue. The term "atomizing hemorrhoids"
was coined because the hemorrhoids are actually reduced to
minute particles into a fine mist or spray, which is immediately
vacuumed away. An innovative waveform of electrical current
and a specialized electrical probe, the Atomizer Wand™,
was created for this purpose (patent pending).
With a wave of the Atomizer Wand, the hemorrhoids are simply
excised or vaporized one or more cell layers at a time. The
hemorrhoids are essentially disintegrated into an aerosol
of carbon and water molecules. Using the Atomizer, the tissue
is sculpted into a desired shape and smoothness. As a
result, the surgeon operates with minimal bleeding, and gets
better homeostasis than with traditional electrosurgical techniques.
With the Atomizer, the patient gets better postoperative results,
and fewer anal tags than with traditional operative techniques.
In the United States, the Ferguson hemorrhoidectomy is considered
the gold standard by which most other surgical hemorrhoidectomy
techniques are compared. A clinical study at the Hemorrhoid
Care Medical Clinic, of thirty patients, compared the traditional
Ferguson hemorrhoidectomy with the CO2 laser hemorrhoidectomy,
and the Atomizer hemorrhoidectomy, and revealed the following:
Figure 1: Hemorrhoidectomy: Atomizing vs. the CO2 laser.
The results of atomizing hemorrhoids are similar to that
of lasering hemorrhoids, except that there is less bleeding
using the Atomizer, and the Atomizer cost less. In both procedures,
it is noted that there is less discomfort, less medication,
less constipation, less urinary retention, and a hospital
stay is generally not required. Complications using the Atomizer
are rare, and excellent results are typical.
Atomizing hemorrhoids is offered exclusively in Arizona.
of Hemorrhoid Surgery
1) Severe postoperative pain, lasting 2-3 weeks. This
is mainly due to incisions of the anus, and ligation of the
2) Wound infections are uncommon after hemorrhoid surgery.
Abscess occurs in less than 1% of cases. Severe necrotizing
infections are rare.
3) Postoperative bleeding.
4) Swelling of the skin bridges.
5) Major short-term incontinence.
6) Difficult urination. Possibly secondary to occult urinary
retention, urinary tract infection develops in approximately
5% of patients after anorectal surgery. Limiting postoperative
fluids may reduce the need for catheterization (from 15 to
less than 4 percent in one study).
1) Anal stenosis.
2) Formation of skin tags.
4) Anal fissure.
5) Minor incontinence.
6) Fecal impaction after a hemorrhoidectomy is associated
with postoperative pain and narcotic use. Most surgeons recommend
stimulant laxatives, or stool softeners to prevent this problem.
Removal of the impaction under anesthesia may be required.
7) Delayed hemorrhage, probably due to sloughing of the vascular
pedicle, develops in 1 to 2 percent of patients. It usually
occurs 7 to 16 days postoperatively. No specific treatment
is effective for preventing this complication, which usually
requires a return to the operating room for one or more stitches.
What to Ask Your Surgeon
Before choosing the procedure you wish to have performed,
there are questions you should ask the surgeon:
1. What types of procedures have they performed?
2. How many of each procedure have they performed?
3. Why are they recommending one particular procedure over
4. How long will the procedure take?
5. Will this procedure require a hospital stay and how long
do they anticipate your hospital stay will last?
6. How long do they expect the recovery process to take?
7. How soon will you be able to return to "normal" activity?
8. Will having the procedure mean having to change how I live,
work or eat?
1. Endo-Surgery Inc, 2001, Ethicon Endosurgery,
Procedure for Prolapse and Hemorrhoids, 2001, http://www.jnjgateway.com/home.jhtml?page=viewContent
2. The University of Birmingham, National Horizon Scanning
Centre, Stapled Haemorrhoidectomy, United Kingdom, 2001,
1. Video: Overview:
Anatomy of Prolapse and Hemorrhoids (3 1/2 minutes), Ethicon
Endo-Surgery Inc. 2001, get > Real
2. Video: View
Actual Hemorrhoid Surgery using the Harmonic Scalpel (8
minutes), Ethicon Endo-Surgery Inc. 2001,
3. Video: Harmonic
Scalpel & Laser Hemorrhoidectomy (5 minutes), Rick
Shacket, DO. 2002, get > Real
4. Video: Hemorrhoid
Surgery Tutorial - The National Library of Medicine
5. Video: General
Anesthesia Tutorial - The National Library of Medicine
6. Video: Preparing
for Surgery Tutorial - The National Library of Medicine