Dr. VIJAYA LAKSHMI LDr. VIJAYA LAKSHMI L
APOLLO BGS HOSPITALSAPOLLO BGS HOSPITALS
- The- The anal canalanal canal starts at pelvic diaphragmstarts at pelvic diaphragm
and ends at anal verge. Approximately 4cmand ends at anal verge. Approximately 4cm
- AAnatomic anal canalnatomic anal canal extends from analextends from anal
verge to dentate line.verge to dentate line.
- Surgical anal canalSurgical anal canal is anal verge tois anal verge to
anorectal ring, the circular upper border ofanorectal ring, the circular upper border of
puborectalis that is palpable by rectal exam.puborectalis that is palpable by rectal exam.
It is 1-1.5 cm from dentate line.It is 1-1.5 cm from dentate line.
- The- The anal vergeanal verge is the junction betweenis the junction between
anoderm and perianal skin.anoderm and perianal skin.
- The- The dentate linedentate line is a true mucocutaneousis a true mucocutaneous
junction located 1-1.5 cm from anal verge. Ajunction located 1-1.5 cm from anal verge. A
6-12mm transitional zone exists above the6-12mm transitional zone exists above the
line where squamous becomes cuboidal,line where squamous becomes cuboidal,
then columnar.then columnar.
- Anal sphincter mechanism- Anal sphincter mechanism made bymade by
internal and external sphincters.internal and external sphincters.
- The- The internal sphincterinternal sphincter is a specializedis a specialized
continuation of the circular smooth musclecontinuation of the circular smooth muscle
layer of the rectum. It is involuntary, andlayer of the rectum. It is involuntary, and
contracted at rest. Maintains resting analcontracted at rest. Maintains resting anal
tone. Innervated by ANStone. Innervated by ANS
- The- The intersphincteric planeintersphincteric plane is a fibrousis a fibrous
continuation of the longitudinal smoothcontinuation of the longitudinal smooth
muscle layer of the rectummuscle layer of the rectum
- The- The external sphincterexternal sphincter is a voluntary,is a voluntary,
striated muscle divided into three u-shapedstriated muscle divided into three u-shaped
loops (subcutaneous, superficial, and deep).loops (subcutaneous, superficial, and deep).
Acts as a single functional unit.Acts as a single functional unit.
- Continuation of the levator ani muscle,Continuation of the levator ani muscle,
specifically of thespecifically of the puborectalis musclepuborectalis muscle..
- Innervated by somatic nerve fibersInnervated by somatic nerve fibers
- Generates anal squeeze. Key role inGenerates anal squeeze. Key role in
maintaining anal continence.maintaining anal continence.
- Lined in its upper two-thirds by insensibleLined in its upper two-thirds by insensible
mucosa, below by a hairless, glandless cuffmucosa, below by a hairless, glandless cuff
of highly sensitive squamous epithelium, theof highly sensitive squamous epithelium, the
- The mucosa is seen to be thrown into 8-14The mucosa is seen to be thrown into 8-14
longitudinal folds of Morgagni just abovelongitudinal folds of Morgagni just above
dentate line and forming thedentate line and forming the anal cryptsanal crypts atat
their distal end.their distal end.
- ArterialArterial supply is superior, middle andsupply is superior, middle and
inferior rectal arteries (IMA, Int. Iliac, int.inferior rectal arteries (IMA, Int. Iliac, int.
pudendal artery).pudendal artery).
- Venous Drainage- Venous Drainage empties into portal andempties into portal and
caval systems. Upper and middle rectumcaval systems. Upper and middle rectum
into SRVinto SRVIMVIMV Portal vein. The lowerPortal vein. The lower
rectum and upper anal canalrectum and upper anal canal
MRVMRVIIVIIVIVC. The Lower anal canalIVC. The Lower anal canal
drains into the IRVdrains into the IRV IVC.IVC.
- Three submucosal internal hemorrhoidal- Three submucosal internal hemorrhoidal
plexusesplexuses aboveabove dentate line Lt lateral, Rtdentate line Lt lateral, Rt
anterior, Rt posterior quadrants-11,3,7anterior, Rt posterior quadrants-11,3,7
o'clock, drain into the superior rectal vein.o'clock, drain into the superior rectal vein.
- Below dentate line, external- Below dentate line, external hemorrhoidhemorrhoid
veins drain into pudendal veins.veins drain into pudendal veins.
- The anal cushions are disrupted to produce piles- The anal cushions are disrupted to produce piles
by the forces of defaecation.by the forces of defaecation.
- The Valsava effect of excessive straining- The Valsava effect of excessive straining
- The anal cushions may be structurally deficient.- The anal cushions may be structurally deficient.
- Weakness arising from the influence ofWeakness arising from the influence of
progesterone on smooth muscle and elastic tissueprogesterone on smooth muscle and elastic tissue
may explain the predisposition to haemorrhoids inmay explain the predisposition to haemorrhoids in
- Increase in pelvic vascularity may also contribute.Increase in pelvic vascularity may also contribute.
- The names 'haemorrhoids' and 'piles' are- The names 'haemorrhoids' and 'piles' are
essentially synonymous though differentlyessentially synonymous though differently
derived from the two main—and only certainderived from the two main—and only certain
—symptoms, respectively bleeding and—symptoms, respectively bleeding and
- The term ‘Haemorrhoids‘ restricted to- The term ‘Haemorrhoids‘ restricted to
abnormal clinical situationabnormal clinical situation
Parts of HaemorrhoidParts of Haemorrhoid
Divided into 3 partsDivided into 3 parts
►Pedicle- situated at anorectal ring. SeenPedicle- situated at anorectal ring. Seen
through proctoscope. Pink mucosa.through proctoscope. Pink mucosa.
►Internal haemorrhoid- commences belowInternal haemorrhoid- commences below
anal ring. Bright red or purple.anal ring. Bright red or purple.
►External associated haemorrhoid- lies b/wExternal associated haemorrhoid- lies b/w
dentate line and anal margin. Blue vein candentate line and anal margin. Blue vein can
be seen unless fibrosed.be seen unless fibrosed.
It is present only in well established cases.It is present only in well established cases.
Distal to dentate line. Covered with anodermDistal to dentate line. Covered with anoderm
Cause swelling discomfort & difficult hygieneCause swelling discomfort & difficult hygiene
Severe pain if thrombosedSevere pain if thrombosed
Are painlessAre painless
Bright red bleedingBright red bleeding
Prolapse associated with defecationProlapse associated with defecation
- Hereditary- Cong. weakness of vein wall- Hereditary- Cong. weakness of vein wall
- Theory : Downward sliding of anal cushionTheory : Downward sliding of anal cushion
associated with gravity, straining andassociated with gravity, straining and
irregular bowel habits.irregular bowel habits.
- Anatomy- Collecting radicles of SHV lieAnatomy- Collecting radicles of SHV lie
unsupported in loose connective tissue ofunsupported in loose connective tissue of
- Rarely Varicosity of the analRarely Varicosity of the anal
Anal varices in portal hypertension.
First DegreeFirst Degree
- Painless bleeding, no ProlapsePainless bleeding, no Prolapse
Second DegreeSecond Degree
- Bleeding, Seepage, Prolapse withBleeding, Seepage, Prolapse with
spontaneous reductionspontaneous reduction
Third DegreeThird Degree
- Bleeding, Seepage, Prolapse requringBleeding, Seepage, Prolapse requring
digital reductiondigital reduction
Fourth DegreeFourth Degree
- Prolapsed - Irreducible, Strangulated.Prolapsed - Irreducible, Strangulated.
1. Bleeding1. Bleeding
- Single layer of capillary epithelial cells- Single layer of capillary epithelial cells
Lamina propria - TraumaLamina propria - Trauma
- Lax-textured upper part of the anal cushion.- Lax-textured upper part of the anal cushion.
- Repeated trauma- Repeated trauma
- Bright red, Drips- Bright red, Drips
Inflamed permanently prolapsed pile
1. Inflammed, Edematous mucosa1. Inflammed, Edematous mucosa
2. Engorgement of the subanodermal veins2. Engorgement of the subanodermal veins
oedema contributes to bulk of 'prolapse'
Engorgement of the subanodermal veins
masquerades as prolapse in some
3. Thrombosis and clotting in the vein.3. Thrombosis and clotting in the vein.
Early venous clotting in an anal cushion Infarction of the pile.
Differential DiagnosisDifferential Diagnosis
1.1. Anal tagsAnal tags
2.2. Fibroepithelial PolypFibroepithelial Polyp
3.3. Sentinel PileSentinel Pile
A fibrous anal polyp
surmounting a pile
Sentinel pile at lower end of posterior
fissure with perianal dermatitis with
- Treatment options for internal hemorrhoids
determined by grade; however, composition
of external tags considered.
- Lower grades can be treated with
nonsurgical methods such as sitzbaths,
stool softeners, and fiber supplements
- Higher grades with either office-based
procedures (infrared coagulation therapy,
banding,sclerotherapy) or surgery.
- Avoidance of prolonged straining at stool- Avoidance of prolonged straining at stool
- Increase in dietary fiber- Increase in dietary fiber
- Stool softeners- Stool softeners
- Fiber supplements- Fiber supplements
- Topical anesthetic gel application -- Topical anesthetic gel application -
Lidocaine jelly, NTG creamLidocaine jelly, NTG cream
- Aim- Aim
- Techniques- Techniques
1. Rubber band ligation1. Rubber band ligation
Banding exposed mucosal part
of permanently prolapsed pile
a. A second banding
attempt will occasionally
improve on the
achievement of the first.
b. If the first 'polyp' is
insufficient but has
been banded too low
near the dentate line for
band can be placed
Rubber band ligationRubber band ligation
- Devices – Single operator and assistant-- Devices – Single operator and assistant-
Thomson One-man bander used within
the Naunton-Morgan anoscope
Irvin Moore's nasal conchal forceps for grasping
the pile for banding, shown with banding
2. Infrared photocoagulation and bipolar2. Infrared photocoagulation and bipolar
3. Sclerotherapy3. Sclerotherapy
4. Cryotherapy4. Cryotherapy
5. Laser treatment5. Laser treatment
6. Haemorrhoidectomy6. Haemorrhoidectomy
Milligan Morgan technique – Gold standardMilligan Morgan technique – Gold standard
► Sclerotherapy is commonly used to treat bleedingSclerotherapy is commonly used to treat bleeding
internal hemorrhoid. In this procedure, ainternal hemorrhoid. In this procedure, a
sclerosant is injected into the base of thesclerosant is injected into the base of the
► There are many types of sclerosants- chemicalThere are many types of sclerosants- chemical
► Mechanism - low-grade, long-standingMechanism - low-grade, long-standing
inflammation which scars the vein, mucosal tissue,inflammation which scars the vein, mucosal tissue,
collapse the vein walls, and cause to shrivel.collapse the vein walls, and cause to shrivel.
Advantages of sclerotherapyAdvantages of sclerotherapy
11 Easy and inexpensive to administerEasy and inexpensive to administer
Technique is simple to perform as an out-patientTechnique is simple to perform as an out-patient
procedure. No lengthy hospital stayprocedure. No lengthy hospital stay
22 It works fast and last longIt works fast and last long
After 7 to 10 days, the shriveled hemorrhoid fall offAfter 7 to 10 days, the shriveled hemorrhoid fall off
during normal bowel movement. Patient symptomsduring normal bowel movement. Patient symptoms
free at least 12 months.free at least 12 months.
33 Can be performed in elderly patientsCan be performed in elderly patients
The method of choice for treating in elderlyThe method of choice for treating in elderly
patients, who have fragile veins.patients, who have fragile veins.
44 Multiple hemorrhoids can be treated atMultiple hemorrhoids can be treated at
Up to 3 hemorrhoids can be injected.Up to 3 hemorrhoids can be injected.
Disadvantages of SclerotherapyDisadvantages of Sclerotherapy
►Unsuccessful for larger haemorrhoidsUnsuccessful for larger haemorrhoids
►Haemorrhoids return after treatment –Haemorrhoids return after treatment –
although not within 12 months of treatmentalthough not within 12 months of treatment
Indications for sclerotherapyIndications for sclerotherapy
-First-degree,even those which bleed-First-degree,even those which bleed
-Second-degree hemorrhoid, in which the-Second-degree hemorrhoid, in which the
prolapse is slight or barely noticeable, alsoprolapse is slight or barely noticeable, also
responds well to this procedureresponds well to this procedure
Contraindications of sclerotherapyContraindications of sclerotherapy
1.1. Acute prolapse-thrombosis-Acute prolapse-thrombosis- Third-degreeThird-degree
hemorrhoids not be treated because the risk ofhemorrhoids not be treated because the risk of
acute prolapse-thrombosisacute prolapse-thrombosis
Large second-degree also not treated - success isLarge second-degree also not treated - success is
not good.not good.
2. Severe bleeding or ulceration-2. Severe bleeding or ulceration-
accompanying other ano-rectal conditions-accompanying other ano-rectal conditions-
IBD,causes severe bleeding or ulcers in theIBD,causes severe bleeding or ulcers in the
colon’s mucosal tissue.colon’s mucosal tissue.
3. Fissures and Fistula3. Fissures and Fistula
Sclerotherapy - ProcedureSclerotherapy - Procedure
Preparation – defecation, Lubrication, LA gelPreparation – defecation, Lubrication, LA gel
Position - left lateral position,buttocks at tablePosition - left lateral position,buttocks at table
Injection – base of hemorrhoid, above dentateInjection – base of hemorrhoid, above dentate
line. Needle 1-2 cm deep,parallel to analline. Needle 1-2 cm deep,parallel to anal
canal.3-5 ml of sclerosant is injectedcanal.3-5 ml of sclerosant is injected
slowly. After procedure needle held inslowly. After procedure needle held in
place for about two minutes, then slowlyplace for about two minutes, then slowly
Max. 3 separate injections Given at theMax. 3 separate injections Given at the
Complications - RareComplications - Rare
1.1. BleedingBleeding - accidental puncturing an artery- accidental puncturing an artery
Delayed bleeding- too much solution or atDelayed bleeding- too much solution or at
wrong site-causes an ulcer to developwrong site-causes an ulcer to develop
Bleeding after 7-14 days - hospitalization.Bleeding after 7-14 days - hospitalization.
2.2. PainPain - improper selection of injection site- improper selection of injection site
Done above dentate line.Pain stop procedureDone above dentate line.Pain stop procedure
Short-lived.Short-lived. ManagedManaged by topical pain killersby topical pain killers
Complications & Follow upComplications & Follow up
3.3. Injection into veinInjection into vein - too easily injectable- too easily injectable
or pain in the liver area or unpleasant tasteor pain in the liver area or unpleasant taste
4.4. Injection into prostate -Injection into prostate -
Urinary retention – Most commonUrinary retention – Most common
Infertlity – sol. -> seminal vessel-> testicleInfertlity – sol. -> seminal vessel-> testicle
Prostitis – no treatment, antibioticsProstitis – no treatment, antibiotics
Abscess – surgery. Painful blood clotAbscess – surgery. Painful blood clot
formation – anal dilation/surgeryformation – anal dilation/surgery
Analgesics – Stool softeners - Follow upAnalgesics – Stool softeners - Follow up
Mechanism – tissue after being frozen,Mechanism – tissue after being frozen,
undergoes gradual necrosis, due partly toundergoes gradual necrosis, due partly to
thrombosis of microcirculation. Cryoprobethrombosis of microcirculation. Cryoprobe
Agents – Liquid nitrogen, Nitrous oxide gasAgents – Liquid nitrogen, Nitrous oxide gas
Procedure - Increasing margin of tissueProcedure - Increasing margin of tissue
around probe turns white, max. width ofaround probe turns white, max. width of
about 6-7 mm.Necrosis of the freezedabout 6-7 mm.Necrosis of the freezed
hemorrhoid occurs over several days-ahemorrhoid occurs over several days-a
week. Slough separates in 2-3 weeks.week. Slough separates in 2-3 weeks.
complete healing often requiring additional 2complete healing often requiring additional 2
weeks or more. Patient-analgesics andweeks or more. Patient-analgesics and
laxatives several weeks after treatmentlaxatives several weeks after treatment
► Anal discharge – Brown offensive fluidAnal discharge – Brown offensive fluid
►Recurrent haemorrhoidsRecurrent haemorrhoids
►Skin tagsSkin tags
►Because of the pain and the anal dischargeBecause of the pain and the anal discharge
most patients are unable to return to workmost patients are unable to return to work
for a as a weekfor a as a week
Candidates for SurgeryCandidates for Surgery
- Revised American Society of Colon and
Rectal Surgeons Management of
hemorrhoids by surgical treatment
1. Patients who do not respond to office-
2. Patients not capable of tolerating office
3. Patients with large external hemorrhoidal
4. Patients with grade III or IV mixed
Milligan Morgan techniqueMilligan Morgan technique
- Prone Jack-Knife position, butt taped apart.- Prone Jack-Knife position, butt taped apart.
- Bridges must be left between excisions- Bridges must be left between excisions
- Clover leaf shaped defect in anal canal &- Clover leaf shaped defect in anal canal &
perianal skin. Wounds are left open.perianal skin. Wounds are left open.
- Healing with scar contracture draws tissue- Healing with scar contracture draws tissue
back into anal canal and reattaches it toback into anal canal and reattaches it to
muscle coatmuscle coat
Closed HemorrhoidectomyClosed Hemorrhoidectomy
- Hill-Ferguson retractor in place, grab- Hill-Ferguson retractor in place, grab
cushion, place suture at apex 4cm abovecushion, place suture at apex 4cm above
dentate line, elliptical excision down todentate line, elliptical excision down to
sphincter. Close from ligated pedicle out tosphincter. Close from ligated pedicle out to
- Complications: urinary retention, bleeding,- Complications: urinary retention, bleeding,
stenosis, incontinence, infection.stenosis, incontinence, infection.
►In closed procedure the patients tend to
experience less pain compared with an
►However, occasionally a closed incision
may open up after surgery - If the external
skin is tight following a closed procedure
Modifications of haemorrhoidectomy :Modifications of haemorrhoidectomy :
- Diathermy dissectionDiathermy dissection
- Park’s submucosal excisionPark’s submucosal excision
- Radial clamps or staples or PPH - Less pain.- Radial clamps or staples or PPH - Less pain.
Learning curve. Rectal wall injury,Learning curve. Rectal wall injury,
rectovaginal fistula. Only a portion of therectovaginal fistula. Only a portion of the
prolapsed rectal mucosa and internalprolapsed rectal mucosa and internal
haemorrhoid is removed and fixed at thehaemorrhoid is removed and fixed at the
anorectal ringanorectal ring
Procedure for prolapse and haemorrhoidsProcedure for prolapse and haemorrhoids
- Synonyms- Synonyms
1. mechanical hemorrhoidectomy with a
2. Stapled hemorrhoidectomy
3. Circular stapler hemorrhoidopexy
4. Stapled circumferential mucosectomy,
5. Stapled anopexy
6. Stapled hemorrhoidopexy.
- Select grade II hemorrhoids
- Grade III hemorrhoids
- Uncomplicated grade IV hemorrhoids
- Patients for whom other treatment
modalities are not successful
- A specially designed circular stapler is
inserted through a circular anal dilator
- A portion of the prolapsed rectal mucosa
and internal hemorrhoids removed
- The remaining hemorrhoidal tissue drawn
back into correct anatomic position
- Hemorrhoidal swelling is reduced following
PPH because hemorrhoidal artery blood
flow is disrupted
Management of Infarcted pileManagement of Infarcted pile
- Turbulent flow in sacculated venous plexusTurbulent flow in sacculated venous plexus
- Thrombosis and clotting occurs.Thrombosis and clotting occurs.
- Considerable swelling and discomfortConsiderable swelling and discomfort
- Invites attempts at immediate ameliorationInvites attempts at immediate amelioration
- Conservative and surgical treatment.Conservative and surgical treatment.
- Natural thrombolysis restores circulationNatural thrombolysis restores circulation
- Resolution in about 10 days.Resolution in about 10 days.
- Nitroglycerin ointmentNitroglycerin ointment
- Severe – debridement haemorrhoidectomySevere – debridement haemorrhoidectomy
A. Short livedA. Short lived
1.Vasovagal - banding of piles, injection1.Vasovagal - banding of piles, injection
2.Pain post operatively2.Pain post operatively
3.Haemorrhage – Secondary haemorrhage3.Haemorrhage – Secondary haemorrhage
4.Infection – Rare4.Infection – Rare
5.Urinary – haemorrhoidectomy, Banding5.Urinary – haemorrhoidectomy, Banding
6.Anal cushion thrombosis - Banding6.Anal cushion thrombosis - Banding
B. PermanentB. Permanent
1.Impairment of continence – To prevent1.Impairment of continence – To prevent
important criteria is intact 'corpusimportant criteria is intact 'corpus
cavernosum recti' .cavernosum recti' .
2.Edema and tags2.Edema and tags
3.Stricture and Stenosis – Due to excessive3.Stricture and Stenosis – Due to excessive
4.Anal Fissure4.Anal Fissure