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Surgery      Haemorrhoids      Presenter: Dr. Sachin
Haemorrhoids ?Engorgement of the haemorrhoidal venous plexuses        with redundancy of their coverings.
Haemorrhoids         haimorrhoides          bleedinghaima=blood              rhoos=flowing
Piles           pila (a ball)swelling          in anal canal     which may or may not bleed
Anal sphincters        Internal            Involuntary            Circular muscle layer            Upper ¾ of anal can...
above dentate lineArterial                           superior rectal A.supply        below dentate line               ...
Venous drainage     Internal haemorrhoidal plexus        in submucosa        drain in superior rectal vein        Commu...
Venous drainage     External haemorrhoidal plexus        Lies outside muscular coat of         anal canal        Communi...
Potential sites forPrimary Haemorrhoids
Anal veins Arrange  radially around anal margin Communicates with internal plexus & IRV Straining rupture these vein R...
Venous           SRVdrainage           MRV                  IRV
Aetiology                    Straining                  Constipation            Prolonged lavatory sitting                ...
Secondary causes       Local              anorectal deformity,                          hypotonic sphincter      Abdominal...
Pathogenesis Various  theories are :1. Portal hypertension and varicose veins2. Upright posture of human beings3. Hyperpl...
CURRENT VIEW Shearing  forces acting on anus Caudal displacement of anal cushions and  mucosal trauma Fragmentation of ...
Anal Cushions Haemorrhoidal venous plexuses together withsome arteriovenous anastomoses surrounded by    smooth muscle, el...
   Shield anal canal and sphincter during evacuation.   Complete the closure of the anal canal.   Contribute 15% of the...
11 o’clock             3 o’clock7 o’clock
Incidence    Difficult to evaluate.    Prevalence ~ 5%.    Peak of prevalence is between 45 and 65.    unusual before ...
Earliest symptom                       Bleeding        { A splash in the pan }                                           D...
Physical Examination Left   lateral decubitus position Any    rashes, condylomata, or eczema Any    abscesses, fissures...
Digital Rectal Examination The    resting tone of the anal canal voluntary contraction of the puborectalis and  external...
Diagnostic Tests Physical  examination. Proctoscopy. Flexible sigmoidoscopy Evaluation under anaesthesia in acute pain...
• Classified according to origin of haemorrhoid.• Above or below the Pecinate line?             External or Internal
External hemorrhoid Internal hemorrhoid    Below dentate line        Above dentate line   Varicosities of veins     Varico...
Gr I               Gr II                  Gr III                  Gr IVnot prolapse   returns spontaneously   manually ret...
Complications of hemorrhoids                      prolapse                               Gripped by Ext. sphincter        ...
ThrombosedExternal haemorrhoids
ProlapsedInternal haemorhoids
TREATMENT Conservative Dietary and lifestyle modification. Non operative/office procedures. Operative hemorrhoidectomy...
Dietary & Lifestylemodifications       Minimize straining at stool.                   and       Prevention of constipation
Dietary & Lifestylemodifications Drinking Fluids High-fiber diet Use of Fiber  supplements Stool softeners Exercise ...
Dietary & Lifestylemodifications    “you dont defecate in the library                    so   you shouldnt read in the bat...
Dietary & Lifestylemodifications  Ifprolapses,   gently push back   into anal canal  Use  moist towelettes or wet toilet...
Topical Treatment Include:     Pads,     Ointments,     Creams,     Gels,     Lotions     Suppositories.
 Used   now a days includes    Calcium dobesilate .25%    Anhydrous lignocaine 3%    Hydrocortisone acetate .25%    Z...
Sitz bath Sitz mean to sit Used in treatment of  Gr. IV hemorrhoids Duration:15-20 minutes Cold water is used     Dra...
Sitz bath Postoperative Warm water is used    Dialatation of blood vessels    Allow blood to pass through     swollen ...
Oral Medications Oral vasotopic drugs. Most common - purified flavonoid fraction. Actions:     Increases vascular tone...
Topical medications         Commonaly used is            Combination of Calcium dobesilate & docusate sodium
 Calcium   dobesilate:    Decrease   capillary permeablity,    Decrease   platelet aggregation    Stops   bleeding   ...
 Docusate     sodium:    Stimulant laxative,    makes bowel movement softer and easier     to pass    Reduces pain or ...
Office procedures Sclerotherapy Infra-redCoag Band Ligation Cryosurgery Manual Dilation of anus. Sphincterotomy (lat...
Sclerotherapy(Mitchell) For Gr I to II haemorrhoids. phenol, vegetable oil,  quinine, and urea  hydrochloride. Albright...
Sclerotherapy Causes    oedema,    inflammatory reaction    & intravascular thrombosis. Submucosal      fibrosis & sc...
Sclerotherapy Quick painless Follow  up after 6 weeks 2-3 further injections may  be required Free from major  compli...
Sclerotherapy Contraindications    Prolapsed pile    Infection Complications    retroperitoneal sepsis,    portal py...
Barron’Band Ligation Large Gr I & Gr II witout  external component 2 bands Not >2 hemorrhoids at a  time Follow up aft...
Barron’Band Ligation Band causes ischemic  necrosis ulceration and  scarring Fix connective tissue to  rectal wall necr...
Barron’Band Ligation Complications:  anal stenosis  Inclusion of dentate line   cause pain  vasovagal shock  sepsis  ...
cryosurgery Freezing    of hemorrhoidal tissue    liquid Nitrogen probe at -160oC for 3 minutes Applied   for 10-15 min...
Cryosurgery Painless Causes     necrosis of hemorrhoidal tissue Healing    completes in 4-6 wks Little   efficacy in p...
Infrared photocoagulation High  intensity infra red light 3-6 pulses of 1.5 sec each appllied to mucosa
Infrared photocoagulation Coagulate   vessels & fix underlying mucosa Useful for actively bleeding piles Painless and u...
BICAP Electrocoagulation Theoretically   similar to photocoagulation Probe   must be left in place for ten minutes. Poo...
Lord’s Maximal anal dilatation Spasmof int sphincter responsible for many symptoms of hemorrhoids Reserved    for large ...
Haemorrhoidolysis Therapeutic   galvanic waves Produce   chemical reaction Shrink   and dissolve hemorrhoidal tissue M...
Indications of surgery Mainly  driven by impact of symptoms on  quality of life 3rd and 4th degree piles 2nd degree not...
Milligan-Morgan (open)Haemorrhoidectomy           First described         over 2 centuries ago.
Milligan-Morgan (open)Haemorrhoidectomy
Milligan-Morgan (open)Haemorrhoidectomy
Final Operative Aspect in a Haemorrhoidectomy.               Wound left open
Ferguson’s (Closed)Haemorrhoidectomy Developed   in 1952 Haemorrhoidal  tissue excised. Mucosal wound and skin sutured ...
Harmonic Scalpel sutureless   technique shorter   operative time less   post-op pain. hospital   stay not required. C...
MIPHLongo introduced the technique in 1995.
MIPHStappler haemorrhoidopexy
Advantages   Lesser pain   Quick return to normal activity   Lesser mean hospital stayRisks   Higher chances of recu...
Laser surgery of hemorrhoid Pile mass excised or vaporised using laser  beam Allow precision and accuracy Rapid and uni...
HAL-RAR Hemorrhoidectomy   HAL - Doppler guided haemorrhoidal artery ligation   RAR - Recto anal repair proctoplasty (mu...
A.M.I. (DG) HAL/RAR®System
Complications of surgery Early   complications    Post operative pain lasting 2-3 weeks    Wound infection rarely    P...
Complications of surgery Late   complications    Anal stenosis    Anal fissure    Fecal impaction    Mild incontinenc...
Prevention Eat high fiber diet Drink Plenty of Liquids Fiber Supplements Exercise Avoid long periods of standing or s...
Thank you for your patience
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Hemorrhoids-

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HEMORRHOIDS IS A COMPLEX DISEASE WITH COMPLEX MANAGEMENT.THIS POWERPOINT AIMS TO RESOLVE THIS COMPLEXITY IN THE MOST CONVENIENT WAY

Published in: Health & Medicine
  • Thank you for sharing great information. The best prevention method for piles is to maintain soft stool so there is no strain during bowel movement; this decreases the pressure and strain during bowel movement. It is also a necessary to prevent piles, to pass stool as soon as the urge occurs. The natural treatment effectively stops bleeding from hemorrhoid, shrinks the hemorrhoids, heals damaged tissues, strengthens the vein tone thus, prevents hemorrhoids from returning. visit http://www.hashmidawakhana.org/treatment-of-bleeding-piles-hemorrhoids.html
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Hemorrhoids-

  1. 1. Surgery Haemorrhoids Presenter: Dr. Sachin
  2. 2. Haemorrhoids ?Engorgement of the haemorrhoidal venous plexuses with redundancy of their coverings.
  3. 3. Haemorrhoids haimorrhoides bleedinghaima=blood rhoos=flowing
  4. 4. Piles pila (a ball)swelling in anal canal which may or may not bleed
  5. 5. Anal sphincters  Internal  Involuntary  Circular muscle layer  Upper ¾ of anal canal  Upto to white line of hilton  External  Voluntary  Striated muscle layer  Inferior rectal nerve & sacral nerve  Three parts:  Subcut., superficial, deep
  6. 6. above dentate lineArterial   superior rectal A.supply  below dentate line  inferior rectal A.
  7. 7. Venous drainage Internal haemorrhoidal plexus  in submucosa  drain in superior rectal vein  Communicate with external plexus  Site of communication between portal and systemic veins  Veins at 3,7 and 11 o’clock position are large  Potential site for primary haemorrhoid
  8. 8. Venous drainage External haemorrhoidal plexus  Lies outside muscular coat of anal canal  Communicate freely with internal plexus
  9. 9. Potential sites forPrimary Haemorrhoids
  10. 10. Anal veins Arrange radially around anal margin Communicates with internal plexus & IRV Straining rupture these vein Ruptured vein present  as subcutaneous perianal hematoma
  11. 11. Venous SRVdrainage MRV IRV
  12. 12. Aetiology Straining Constipation Prolonged lavatory sitting Trauma Ageing Diarrhoea Lack of fibre rich diet hereditary
  13. 13. Secondary causes Local anorectal deformity, hypotonic sphincter Abdominal ascites gravid uterus, Pelvic uterine neoplasm, ovarian neoplasm, Pregnancy Portal hypertension paraplegia, Neurological multiple sclerosis
  14. 14. Pathogenesis Various theories are :1. Portal hypertension and varicose veins2. Upright posture of human beings3. Hyperplasia of corpus cavernosum recti4. Erosion and weakening of wall of veins due to infection secondary to trauma5. Hard faecal matter obstructing venous return6. Raised anal canal resting pressure
  15. 15. CURRENT VIEW Shearing forces acting on anus Caudal displacement of anal cushions and mucosal trauma Fragmentation of supporting structures Loss of elasticity of anal cushions Loss of retraction of cushions
  16. 16. Anal Cushions Haemorrhoidal venous plexuses together withsome arteriovenous anastomoses surrounded by smooth muscle, elastic and fibrous tissuein the subepithelial space both above & below the pecinate line.
  17. 17.  Shield anal canal and sphincter during evacuation. Complete the closure of the anal canal. Contribute 15% of the anal canal’s pressure. Congest during Valsalva manoeuvre or increased intra-abdominal pressure. Increase in the size is the starting point of haemorrhoids.
  18. 18. 11 o’clock 3 o’clock7 o’clock
  19. 19. Incidence  Difficult to evaluate.  Prevalence ~ 5%.  Peak of prevalence is between 45 and 65.  unusual before the age of 20.  Caucasians > Afro-Caribbeans.
  20. 20. Earliest symptom Bleeding { A splash in the pan } Discharge Prolaps H’oids Haemorrhoids & Pruritus Pain ( If complication ) Symptoms
  21. 21. Physical Examination Left lateral decubitus position Any rashes, condylomata, or eczema Any abscesses, fissures or fistulae
  22. 22. Digital Rectal Examination The resting tone of the anal canal voluntary contraction of the puborectalis and external anal sphincter. mass / any area of tenderness. Int. hemorrhoids are generally not palpable Appear as bulging mucosa on Anoscopy
  23. 23. Diagnostic Tests Physical examination. Proctoscopy. Flexible sigmoidoscopy Evaluation under anaesthesia in acute pain Anal manometry  if h/o soiling & incontinence
  24. 24. • Classified according to origin of haemorrhoid.• Above or below the Pecinate line? External or Internal
  25. 25. External hemorrhoid Internal hemorrhoid Below dentate line Above dentate line Varicosities of veins Varicosities of veins draining draining inferior rectal artery superior rectal artery Lined by Lined by squamous epithelium columnar epithelium Painful Pain insensitive Prone to thrombosis if May prolapse outside vein ruptures anal canal (Thrombosed pile) (prolapsed hemorrhoid)
  26. 26. Gr I Gr II Gr III Gr IVnot prolapse returns spontaneously manually returned remains prolapsed Grading of hemorrhoids (on history)
  27. 27. Complications of hemorrhoids prolapse Gripped by Ext. sphincter Impeded venous return Gangrene Strangulation Fibrosis Ulceration Thrombosis Suppuration Portal pyaemia
  28. 28. ThrombosedExternal haemorrhoids
  29. 29. ProlapsedInternal haemorhoids
  30. 30. TREATMENT Conservative Dietary and lifestyle modification. Non operative/office procedures. Operative hemorrhoidectomy Minimal invasive procedures
  31. 31. Dietary & Lifestylemodifications Minimize straining at stool. and Prevention of constipation
  32. 32. Dietary & Lifestylemodifications Drinking Fluids High-fiber diet Use of Fiber supplements Stool softeners Exercise Local hygiene
  33. 33. Dietary & Lifestylemodifications “you dont defecate in the library so you shouldnt read in the bathroom”
  34. 34. Dietary & Lifestylemodifications  Ifprolapses, gently push back into anal canal  Use moist towelettes or wet toilet paper instead of dry toilet paper.
  35. 35. Topical Treatment Include:  Pads,  Ointments,  Creams,  Gels,  Lotions  Suppositories.
  36. 36.  Used now a days includes  Calcium dobesilate .25%  Anhydrous lignocaine 3%  Hydrocortisone acetate .25%  Zinc 5%
  37. 37. Sitz bath Sitz mean to sit Used in treatment of Gr. IV hemorrhoids Duration:15-20 minutes Cold water is used  Draw heat out of sore piles  Reduce blood flow in them  Reduce pressure inside swollen piles
  38. 38. Sitz bath Postoperative Warm water is used  Dialatation of blood vessels  Allow blood to pass through swollen piles more quickly  Relaxes muscles so ease anal sphincter tone
  39. 39. Oral Medications Oral vasotopic drugs. Most common - purified flavonoid fraction. Actions:  Increases vascular tone  Increases lymphatic drainage  Anti-inflammatory effects.  Several recent studies have shown it to be effective.
  40. 40. Topical medications Commonaly used is Combination of Calcium dobesilate & docusate sodium
  41. 41.  Calcium dobesilate:  Decrease capillary permeablity,  Decrease platelet aggregation  Stops bleeding  Reduce thrombus formation  Improves mucosal inflammation
  42. 42.  Docusate sodium:  Stimulant laxative,  makes bowel movement softer and easier to pass  Reduces pain or rectal damage caused by hard stools or straining
  43. 43. Office procedures Sclerotherapy Infra-redCoag Band Ligation Cryosurgery Manual Dilation of anus. Sphincterotomy (lateral) Bicap electrocoagulation haemorrhoidolysis
  44. 44. Sclerotherapy(Mitchell) For Gr I to II haemorrhoids. phenol, vegetable oil, quinine, and urea hydrochloride. Albright solution:  5% phenol  in almond or arachis oil  with 140 mg of menthol  to make 30 ml Injected in submucosa around pedicle
  45. 45. Sclerotherapy Causes  oedema,  inflammatory reaction  & intravascular thrombosis. Submucosal fibrosis & scarring  minimises the extent of mucosal prolapse  and potentially shrinks the haemorrhoid as well. Injected in submucosa around pedicle
  46. 46. Sclerotherapy Quick painless Follow up after 6 weeks 2-3 further injections may be required Free from major complications Injected in submucosa around pedicle
  47. 47. Sclerotherapy Contraindications  Prolapsed pile  Infection Complications  retroperitoneal sepsis,  portal pyemia  necrotising fascitis  Prostatitis  Impotence  Rectovaginal fistula Injected in submucosa around pedicle
  48. 48. Barron’Band Ligation Large Gr I & Gr II witout external component 2 bands Not >2 hemorrhoids at a time Follow up after 1 month Success rate:50-100% occlude base of hemorrhoid above dentate line
  49. 49. Barron’Band Ligation Band causes ischemic necrosis ulceration and scarring Fix connective tissue to rectal wall necrosis in 24-48 hrs & slough off in 7 days May cause pain for 24-48 hrs and secondary hemorrhage occlude base of hemorrhoid above dentate line
  50. 50. Barron’Band Ligation Complications:  anal stenosis  Inclusion of dentate line cause pain  vasovagal shock  sepsis occlude base of hemorrhoid above dentate line
  51. 51. cryosurgery Freezing of hemorrhoidal tissue  liquid Nitrogen probe at -160oC for 3 minutes Applied for 10-15 minutes  Over upper part of hemorrhoidal area Profusewatery discharge is most common complication (in first 3 hrs)
  52. 52. Cryosurgery Painless Causes necrosis of hemorrhoidal tissue Healing completes in 4-6 wks Little efficacy in prolapsed hemorrhoids
  53. 53. Infrared photocoagulation High intensity infra red light 3-6 pulses of 1.5 sec each appllied to mucosa
  54. 54. Infrared photocoagulation Coagulate vessels & fix underlying mucosa Useful for actively bleeding piles Painless and uncomplicated
  55. 55. BICAP Electrocoagulation Theoretically similar to photocoagulation Probe must be left in place for ten minutes. Poor patient tolerance minimizes the effect of this procedure.
  56. 56. Lord’s Maximal anal dilatation Spasmof int sphincter responsible for many symptoms of hemorrhoids Reserved for large Gr II & Gr III hemorrhoids NOT eliminate redundant tissue Risk of incontinence
  57. 57. Haemorrhoidolysis Therapeutic galvanic waves Produce chemical reaction Shrink and dissolve hemorrhoidal tissue Most effective on internal hemorrhoids
  58. 58. Indications of surgery Mainly driven by impact of symptoms on quality of life 3rd and 4th degree piles 2nd degree not cured by conservative means Fibrosed hemorrhoid Interno-external hemorrhoid Bleeding sufficient to cause anemia Soiling Ulceration,thrombosis,gangrene
  59. 59. Milligan-Morgan (open)Haemorrhoidectomy First described over 2 centuries ago.
  60. 60. Milligan-Morgan (open)Haemorrhoidectomy
  61. 61. Milligan-Morgan (open)Haemorrhoidectomy
  62. 62. Final Operative Aspect in a Haemorrhoidectomy. Wound left open
  63. 63. Ferguson’s (Closed)Haemorrhoidectomy Developed in 1952 Haemorrhoidal tissue excised. Mucosal wound and skin sutured completely with a continuous absorbable suture.
  64. 64. Harmonic Scalpel sutureless technique shorter operative time less post-op pain. hospital stay not required. Comparative Increased cost to other techniques.
  65. 65. MIPHLongo introduced the technique in 1995.
  66. 66. MIPHStappler haemorrhoidopexy
  67. 67. Advantages Lesser pain Quick return to normal activity Lesser mean hospital stayRisks Higher chances of recurrence and prolapse May be unsuccessful in large hemorrhoids Pelvis sepsis and sphincter dysfunction
  68. 68. Laser surgery of hemorrhoid Pile mass excised or vaporised using laser beam Allow precision and accuracy Rapid and unimpaired healing Lesser bleeding and pain as laser seal off tiny blood vessels and nerves Can be combined with other modalities
  69. 69. HAL-RAR Hemorrhoidectomy HAL - Doppler guided haemorrhoidal artery ligation RAR - Recto anal repair proctoplasty (mucopexy) Combine two methods Artery ligated 3-4 cm proximal to dentate line Reducing blood flow to inner hemorrhoidal plexus Mucopexy combined for grade 3-4 hemorrhoid
  70. 70. A.M.I. (DG) HAL/RAR®System
  71. 71. Complications of surgery Early complications  Post operative pain lasting 2-3 weeks  Wound infection rarely  Post op bleeding  Swelling of skin bridges  Short term incontinence  Difficult urination
  72. 72. Complications of surgery Late complications  Anal stenosis  Anal fissure  Fecal impaction  Mild incontinence  Submucous abscess  Delayed bleeding  Skin tags  Recurrence
  73. 73. Prevention Eat high fiber diet Drink Plenty of Liquids Fiber Supplements Exercise Avoid long periods of standing or sitting Don’t Strain Go as soon as you feel the urge
  74. 74. Thank you for your patience

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