Arvind Dessertation Latest PDF

Introduction
The only way to keep your health is to eat what you don't want, drink what you
don't like, and do what you'd rather not.
Mark Twain
There are several very painful experiences that one suffers in stillness as it is a
discomforting topic to be even discussed. Haemorrhoids is such a common occurrence
in adults but is very rarely talked about because of the embarrassing nature of the
condition. Many people are even too embarrassed to consult their doctor about
haemorrhoids. Nearly every patient visiting the general or colon and rectal surgeon
with anal problems comes in complaining of "haemorrhoids". Treatment for
haemorrhoids is only needed if they are truly symptomatic. The mere presence of
haemorrhoids is not an indication for any therapeutic intervention.
Haemorrhoids if untreated can potentially pose serious medical problems and
can be a symptom of a bigger problem. Haemorrhoids, also called piles or varicose
veins of the anus and rectum are masses or clumps or cushions of tissues
consisting of muscle and elastic fibers with enlarged, bulging blood vessels and
surrounding supporting tissues present in the anal canal of an individual suffering
from the disease. Many myths exist regarding the etiology and pathophysiology of
internal haemorrhoids. The development of haemorrhoids has been attributed to
prolonged periods of driving, sitting on cold seats or benches, eating spicy foods, and
doing manual labour. In addition to this there are misconceptions regarding the
etiology of haemorrhoids among the lay members of our community.
The misconceptions related to haemorrhoids have been perpetuated throughout
many surgical texts. Haemorrhoids are part of the normal anatomy within the
anal canal and are believed to be important in maintaining continence.
When an individual coughs, strains or sneezes, these fibro vascular cushions engorge
and maintain closure of the anal canal in order to prevent leakage of stool in the
presence of increased intrarectal pressure. Therefore, surgical removal may result in
varying degrees of incontinence particularly in individuals with marginal preoperative
control about which most people are unaware. Haemorrhoids are of two types, the
one which is placed inside is named as Internal Haemorrhoids and is structured just
under the tissue that lines the inside of the rectum. They are not noticeable till they
become big and will make them to collapse and jut out through the anus. On the other
hand, the vein
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that forms outside the rectum and surround the anus is called External
Haemorrhoids. The main causes that utter into this painful position, is hereditary and
postponing of visits to toilet.
In India approximately 40,723,288 people are reported to have haemorrhoids.
1 million new cases are reported annually and prevalence increases with age, common
in age group of 45-65yrs. It is estimated that 50-85% of people around the world and
in India 75% of the population is estimated to have haemorrhoids. Current statistics
suggest that almost half of people in their fifties have piles.[1] Age is not the only
factor though, haemorrhoids can affect people of any age group or gender. Bleeding
haemorrhoids should be considered severe only if you start losing a lot of blood and
you get dizzy and weak. Even though haemorrhoids are usually the most common
reason for your rectum to bleed, one should still consult a doctor if he or she have this
symptom. There are lots of other serious conditions such as ulcerative colitis, anal
fissures, polyps and certain types of cancers that will cause rectal bleeding, that is why
it is crucial to eliminate the possibilities by consulting the doctor.
Even though a precise definition of haemorrhoids does not exist, they can be
described as masses or "cushions" of tissue within the anal canal that contain blood
vessels and the surrounding, supporting tissue made up of muscle and elastic fibres.
The anal canal is the last four centimeters through which stool passes as it goes from
the rectum to the outside. Most people think haemorrhoids are abnormal, but they are
present in everyone. It is only when the haemorrhoid cushions enlarge,
haemorrhoids can cause problems and be considered abnormal or a disease.
Haemorrhoids should not be considered a taboo subject especially now that there are
many remedies discovered in curing haemorrhoids. These treatments may range from
medical to surgical procedures.
Aims & Objective
The aim of the study is to compare the following points between Ultrasonic
Scalpel Haemorrhoidectomy and Diathermy Haemorrhoidectomy.
Post-operative pain
Post-operative analgesia requirement
Post-operative complication
Efficacy of treatment
Duration of hospital stay
Review of literature
HISTORICAL REVIEW
Haemorrhoids are one of the oldest diseases suffered by mankind well
recorded in ancient texts of Greeks, Egyptians, Hindus, And Bible. Many great
personalities have suffered from haemorrhoids like the Philistines, Napoleon
Bonaparte, Don Juan Demorann.[2]
Hippocrates thought haemorrhoidal disease facilitates purification of various
organisms expelling petrified matter also correlated liver disease, portal hypertension
and haemorrhoids. Duret suggested increase in portal venous pressure due to straining
during defecation as the cause of haemorrhoids.
John Morgan first attempted sclerotherapy to obliterate haemorrhoids in 1869
with iron persulphate. Anderson (1924) and Bacon (1949) outlined injection
treatment and later Albright used 5% phenol in almond oil. In 1774, John Louie
Petit proposed sub mucosal method of ligation of haemorrhoids. In 1835, Salmon
was the first to isolate the pedicle of haemorrhoid. In 1882, Whithead described the
circumferential amputation of haemorrhoids. In 1903, Mitchell described a method of
clamping of haemorrhoids and excision with partial wound closure. Earl and Bacon
popularized the technique later. In 1919, Miles modified Salmons original
technique of high excision with open haemorrhoidectomy by suggesting a lower
ligation to reduce the amount of raw tissue in the anal canal. In 1959, Ferguson and
Heaton described a technique of closed haemorrhoidectomy.
Blaisdell in 1954 invented the instrument and technique for outpatient ligation
of internal haemorrhoids using silk thread for ligation. This instrument was later
modified by Barron in 1963 who used rubber bands for ligation. Lords in 1968
described anal stretch for haemorrhoids and Noratas in 1971 proposed lateral
subcutaneous sphincterotomy to reduce the activity of internal sphincter, overactivity
of which was proposed as a cause. Lewis introduced cryosurgery in treatment of
haemorrhoids. Neiger introduced photocoagulation in 1979. Most recently, laser
haemorrhoidectomy has been tried. Longo in 1998 has described stapled
haemorrhoidopexy for painless treatment of haemorrhoids.
ANATOMY
The anal canal is the terminal portion of gastrointestinal tract, begins at the
anorectal junction is about 4 cms long and terminates at the anal verge. The anorectal
junction is angulated in relation to the rectum due to pull of puborectalis muscle
producing anorectal angle. It lies 2-3 cms in front of and slightly below tip of coccyx,
where the ampulla of rectum suddenly narrows and pierces the pelvic diaphragm,
which is opposite apex of prostrate in males.
The anal verge is marked by a sharp turn where the squamous epithelium
which lines the lower anal canal becomes continuous with skin of perineum.
[3]
Embryologically the superior two thirds of the anorectal canal is derived from the
distal part of hindgut, whereas the inferior one third of anorectal canal is derived from
ectodermal pit called the anal pit or proctoderm. The pit is created when the
mesenchyme around anal membrane proliferates to form a raised border.
The anal membrane thus separates the endodermal and ectodermal portions of
anorectal canal, the former location of this membrane is marked in adult by irregular
folding of mucosa called pectinate line.
The anal canal consists of:

An inner lining epithelium
A vascular sub epithelium
The internal anal sphincter
External anal sphincters and
Fibromuscular supporting tissue
The anal canal is attached posteriorly to coccyx by the anococcygeal ligament,

a midline fibro muscular structure which may possess some skeletal muscle elements,
which runs between the posterior aspect of external sphincter and coccyx.
RELATIONS OF ANAL CANAL
In both sexes the anal canal is related anteriorly to the perineal body. Perineal
body in males separates anal canal from membranous urethra and penile bulb, and
separates from lower vagina in females. Posteriorly the anal canal is related to the tip
of the coccyx and anococcygeal ligament and laterally to loose adipose tissue of
ischiorectal fossa.
INTERIOR OF THE ANAL CANAL
Divided into 3 parts

1. Upper part - about 15 mm long
2. Middle part - about 15 mm long
3. Lower part - about 8 mm long
1 ) Upper part - 15 mm long (mucous)
The upper part is lined by columnar epithelium similar to the rectum. It contain
secretory and absorptive cells with numerous tubular glands or crypts. Terminal
branches of superior rectal vessel pass downwards towards anal column. The
submucosal veins drain into submucosal rectal venous plexus and also through fibres
of upper internal anal sphincter into aintermuscular venous plexus.There are 6-10
vertical folds in the mucosa called the anal columns. Each column contains a terminal
radical of superior rectal artery and vein. The vessels are largest in leftlateral, right
posterior, right anterior quadrants of wall of anal canal, where subepithelial tissue
expands into three anal cushions. The lower end of columns form small cresenteric
folds called anal valves, between which lie small recesses referred as anal sinuses.
The anal valves and sinuses together form the dentate or pectinate line. About six anal
glands open into small depressions in anal valves called anal crypts.
2) Middle part - 15 mm long (pecten)
The middle part is a transitional zone, lined by bluish appearing mucosa because of a
dense venous plexus that lie between it and muscle coat. It is non- keratinized
stratified squamous epithelium lacking sweat/sebaceous glands, hair follicles but
contains numerous somatic nerve endings extends down to inter sphincteric groove,
which is the lower limit of pecten often has a whitish appearance referred to as the
white line of hilton.
3) Lower part 8 mm long (cutaneous)
The lower part is lined by hair bearing, keratinsing squamous epithelium
continuous with perianal skin.
MUSCLES OF ANAL CANAL
The anal canal is encircled by internal and external anal sphincters separated by the
longitudinal layer and has connection superiorly to puborectalis and transverse perinei
muscles.
Fig. 1: Musculature of the anal canal
Fig. 2: Lining membrane of anal canal

Fig 3: Anatomy of anal cushion
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1) Internal anal sphincter
The internal anal sphincter is a well-defined ring of obliquely oriented smooth
muscle fibres continuous with circular muscles of the rectum, terminating at the
junction of superficial and subcutaneous component of external sphincter. Thickness
of internal sphincter varies between 1.5 to 3.5 mm. The lower portion of sphincter is
crossed by fibres from conjoint longitudinal coat which passes into submucosa of the
lower canal.
Vascular supply
The vascular supply of internal sphincter is from the terminal branches of
superior rectal vessels and branches of inferior rectal vessel.
2) External anal sphincter
The external anal sphincter is a elliptical cylinder of skeletal muscle
surrounding the anal canal. The lowest portion occupies a position below and slightly
lateral to internal sphincter, a palpable groove at this level has been referred to as
inter sphincteric groove.
The lowest part is traversed by the conjoint longitudinal muscle. The
intermediate portion is attached to coccyx by posterior extension of muscle fibres
forming the anococcygeal ligament. The deep portion of external sphincter is devoid
of posterior attachment and proximally becomes continuous with puborectalis muscle.
Anteriorly the high fibres of external sphincter is attached to perineal body.
Vascular supply
Terminal branches of inferior rectal vessels with contribution forms median
sacral artery.
3)Conjoint longitudinal muscle
At the level of anorectal ring the longitudinal muscle coat of rectum is joined
by fibres of levatorani and puborectalis, the conjoint muscle thus formed descends
between internal and external anal sphincter. Many of these fibres traverse the lower
portion of external sphincter to gain insertion into perianal skin referred as corrugator
cutis ani. somefibres of conjoint longitudinal muscle may form a longitudinal layer of
muscle on the inner aspect of internal sphincter naming it muscularis sub mucosa ani.
Some fibres that traverse the internal sphincter and become inserted just below
anal valves returned as mucosal suspensory ligament. It has been suggested that the
role of conjoint longitudinal muscle is to affix the anal canal and avert the anus during
defecation.
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4) Anorectal ring
This is a muscular ring present at the anorectal junction, formed by fusion of
puborectalis muscle, deep external sphincter and internal sphincter, less marked
anteriorly where fibres of the puborectalis are absent.
ARTERIAL SUPPLY OF ANAL CANAL
The arterial supply of anal canal above pectinate line is by the superior,
middle rectal artery and the arterial supply below pectinate line is by the inferior
rectal artery.
VENOUS DRAINAGE OF ANAL CANAL
The venous drainage of the upper anal canal mucosa, internal anal sphincter
and conjoint longitudinal coat passes via terminal branches of the superior rectal veins
into the inferior mesenteric vein to portal system. The lower anal canal and
external sphincter drain via inferior rectal branch of pudendal vein into internal iliac
vein.
1) Internal rectal venous plexus (haemorrhoidal plexus)
The haemorrhoidal plexus lie in submucosa of anal canal and drains mainly in
superior rectal vein but communicates freely with external plexus and thus with
middle and inferior rectal veins, so internal plexus is a important site for porto-
systemic anastomosis. Veins present in three anal columns at 3, 7, 11 oclock
positions are large and they constitute potential sites for primary internal piles.
2) External rectal venous plexus
The external rectal venous plexus lie outside the muscular coat of rectum and
anal canal, communicating freely with internal plexus. The lower part of external
plexus is drained by inferior rectal vein into internal pudendal vein, the middle part by
middle rectal vein into internal iliac vein, upper part by superior rectal vein which
continues as inferior mesentric vein, a tributary of the portal vein.
3) Anal veins
The anal veins are arranged radially around the anal margin. They
communicate with internal rectal plexus and inferior rectal veins.
LYMPHATIC DRAINAGE OF ANAL CANAL
Lymphatics from the upper anal mucosa, internal anal sphincter and conjoint
longitudinal coat drain upwards into the submucosa and intramural lymphatics of the
rectum. The lower anal canal epithelium and external anal sphincter lymphatics drain
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Fig. 5: Venous drainage of anal canal
Fig. 4: Arterial supply of the anal canal

Fig. 6: Lymphatic drainage of anal canal
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downwards via perianal plexus into vessels, which drain into external inguinal lymph
nodes. The lymphatics of puborectalis muscle drain into internal iliac lymph nodes.
NERVE SUPPLY OF ANAL CANAL
The sympathetic nerve supply of anal canal above the pectinate line is from the
inferior hypogastric plexus (L1,2), the parasympathetic nerve supply is from pelvic
splanchnic nerves (S2,3,4) (pain sensations carried by both). The somatic nerve supply
below the pectinate line is from inferior rectal (S2,3,4) nerves. The function of the
anorectal region is not only to act as a reservoir for faeces but also to facilitate
effortless, unimpeded voiding during defecation.
PHYSIOLOGY
ANAL CONTINENCE
Maintaining anal continence is a complex matter because it is controlled by
local reflex mechanisms as well as conscious will. Normal continence depends on
highly integrated series of complicated events.
RESERVOIR FUNCTION OF RECTUM
The distal part of large intestine has a reservoir function that is important for
continence. Lateral angulations of sigmoid colon and the valves of houstonprovide
amechanical barrier and retard progressions of stools. The adaptive compliance of
rectum along with rectal capacity and distensibility also contribute to differences in
pressure patterns between distal and proximal levels of anal canal resulting in
development of force vector in the direction of rectum. Angulation between the rectum
and anal canal due to continuous tonic activity of puborectalis muscle as well as high-
pressure zone in anal canal contributeto the reservoir function.
SPHINCTERIC FACTORS
Activity of the anal sphincters is believed to be the most important factor for
continence. They are responsible for the high-pressure zone (average 25-120 mmHg)
in anal canal that appears to provide a barrier against high rectal pressure (average 5-
20 mmHg). The high-pressure zone as demonstrated by pull through recordings has
an average length of 3.5 cm and results from continuous tonic activity of both
sphincters.
Internal sphincter: The internal sphincter contributes mainly to the high-

pressure zone estimated to account for 55-85% of pressure recorded.
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External sphincter: Continuous tonic activity at rest and even during sleep has
been recorded in pelvic floor muscles and in external sphincter. External sphincter
is unique in this regard because other striated muscles are electrically silent at rest.
REFLEXES
The reflex response of external sphincter is represented by transient increase in

activity initiated by postural changes, perianal scratch, and increased intra abdominal
pressure. The reflex response of internal sphincter consists of transient relaxation
stimulated by rectal distension, valsalva maneuver, this does not involve peristalsis
because sphincter relaxes before peristalsis reaches sphincter. The transient relaxation
of internal sphincter allows rectal contents to be sampled by sensory epithelium of
anal canal, during this sampling continence is maintained by synchronous contraction
of external sphincter. The inhibition induced by rectal distension was thought to be
under parasympathetic control. However recent evidence suggests reflex is
predominantly of intramural origin.
MECHANICAL FACTORS
Angulation between rectum and anal canal is the most important component for
gross fecal continence due to continuous tonic activity of puborectalis muscle. As
measured by defecography the angle between axis of anal canal and rectum in resting
state is about 90 degree and radiographic studies have elucidated changes during
defecation.
Flutter valve theory: It has been suggested that additional protection of
continence might be afforded by intra abdominal pressure being transmitted
laterally to the side of the anal canal just at the level of the anorectal junction.
Flap valve theory: The flap valve theory was advanced by parks et al and
the theory proposed any increase in the intra abdominal pressure tends to
accentuate the anorectal angle and forces the anterior rectal wall to lie firmly
over upper end of anal canal producing a flap valve effect.
ETIOLOGY AND PATHOPHYSIOLOGY

Several theories have been postulated regarding the cause of haemorrhoids,
however the precise etiology still remains elusive. Frequency of haemorrhoids in
general population according to Buie (1960) is 52% in a large series of unselected
patients at the mayo clinic.
1. AGE
Peak between age 45 to 65 years and a subsequent decline after the age of 65
years. The presence of haemorrhoids in patients less than 20 years is unusual.
2. SEX
Both symptomatic and asymptomatic haemorrhoids are common in male.
3. SOCIO-ECONOMIC STATUS AND DIET
Haemorrhoids are particularly rare in communities which have departed least

from their traditional manner of life but more in economically developed
communities. There is a close relationship with western type of diet, which is more
refined and low in fibre, increasing the bowel transit time and forming hard stools.
4. OCCUPATION
People whose occupation required prolonged sitting or standing are more

prone for haemorrhoids.
5. VARICOSE VEIN THEORY[4]
The varicose vein theory stemmed from assumptions that dilatations of veins
of internal rectal plexus result from pathological change, is shown as invalid by
confirming the dilatations are in fact normal.
The fact that haemorrhoids are no more common in patients with portal
hypertension than in population at large is additional evidence against this theory. This
theory also fails to account for the fact that haemorrhoids frequently occur singly and
more common in right anterior position.
6. VASCULAR HYPERPLASIA THEORY[5]
The vascular hyperplasia theory proposes that the principal cause of

haemorrhoids seems to be congestion and hypertrophy of internal anal cushions as
they fail to empty during defecation, they are abnormally mobile and trapped by tight
anal sphincter, is also obsolete. The histological studies by Thomson showed no
vascular hyperplasia.
7. SLIDING DOWNWARDS OF ANAL CUSHIONS THEORY[6]
Sliding downwards of anal cushions is the latest proposed theory. The

association of haemorrhoids with straining and with irregular bowel habits is
compatible with this theory. Repeated stretching of submucosaltreitz muscle
causes disruption and results in prolapse. The studies of Haas, Fox, and Haas and
Bernstein support this theory. These authors found that the anchoring and supporting
connective tissue in haemorrhoids are disintegrated and fragmented.
8. INTERNAL ANAL DYSFUNCTION THEORY
Dysrythmia within the internal sphincter and higher anal resting pressure have
been demonstrated in patients with haemorrhoids. Hancock believed that an internal
sphincter abnormality may be a causative factor. Roe et al found a reduction in anal
pressure after haemorrhoidectomy and believed it might be possible that
haemorrhoidal tissue itself is responsible for rise in pressure. Sun, Read, Shorthouse
suggested that abnormally high pressures in anal canal in patients with haemorrhoids
may be due to increased vascular pressures in the anal cushions.[7]
9. PREDISPOSING AND ASSOCIATED FACTORS
Many factors has been implicated in the causation of haemorrhoidal disease

like chronic constipation, hereditary, erect posture, absence of valves in
haemorrhoidal plexus and draining veins, obstruction of venous return from raised
intra-abdominal pressure. Portal hypertension may lead to venous engorgement in
haemorrhoidal plexus and on rare occasions result in true varices.
Pregnancy undoubtedly aggravates pre-existing disease, usually becomes
asymptomatic after delivery suggesting hormonal changes in addition to direct
pressure effects. Paradoxically diarrhoeal states also predispose to
development of
haemorrhoids.[8]
PATHOLOGY
Histologically, haemorrhoids consist of dilated veins in the mucosa and
submucosa. There may be evidence of hemosiderin deposition from a previous
episode of bleeding depending on whether the haemorrhoids arise above or below the
dentate line. They may be covered by columnar, transitional or non-keratinzing
squamous epithelium. The organization and re-canalization of thrombi can lead to
florid papillary endothelial hyperplasia.[9]
Microscopic examination of tissue submitted with clinical diagnosis of
haemorrhoids, rarely may show non-specific granulomas, tuberculosis, malignant
lymphomas, koilocytotic changes, dysplasia/carcinoma in situ, invasive squamous cell
carcinoma or even malignant melanoma.
CLASSIFICATION OF HAEMORRHOIDS
CLASSIFICATION 1 CLASSIFICATION 2
A) Internal haemorrhoids A) Primary haemorrhoids

B) External haemorrhoids B) Secondary haemorrhoids
C) Interno-external
Haemorrhoids
CLASSIFICATION 1
INTERNAL HAEMORRHOIDS
Internal haemorrhoids are symptomatic, exaggerated submucosal vascular

tissue located above the dentate line and covered by transitional and columnar
epithelium. Can be divided into 4 categories.
First degree internal haemorrhoids
They bulge into the lumen of anal canal and produce painless bleeding.
Second degree internal haemorrhoids
They protrude at the time of bowel movement and reduce spontaneously.
Third degree internal haemorrhoids
They are those that protrude spontaneously or at time of bowel movements

and require manual reduction.
Fourth degree internal haemorrhoids
They are those that are permanently prolapsed and irreducible despite attempts
at manual reduction.
EXTERNAL HAEMORRHOIDS
External haemorrhoids comprise the dilated vascular plexus that is located

below the dentate line and covered by squamous epithelium multiple skin tags usually
accompany.
INTERNO-EXTERNAL HAEMORRHOIDS
Are those with of internal and external component of haemorrhoids.

CLASSIFICATION 2
PRIMARY HAEMORRHOIDS
Associated with anal pressure & anal tone. High anal canal pressure are
particularly recorded in men younger than 40 yrs with Istdeegre haemorrhoids & lower
resting anal pressure associate with in women more than 40 yrs with prolapsing piles.
SECONDARY HAEMORRHOIDS
Secondary haemrrhoids occur under pathological situation of increase intra

abominal pressure in patients with chronic obstructive airway disease or in patients
who strain from prostatism or urethral stricture. Also occur with ascites,
pregnancy, ovarian tumor, large rectosigmoid carcinoma, portal hypertension,
radiation therapy etc.
CLINICAL MANIFESTATIONS [10]
BLEEDING
As the name haemorrhoids implies bleeding is the principal and earliest

symptom. At first is slight and bright red and occurs during defecation as splash in the
pan, may continue intermittently for months to years. Bleeding usually occurs at the
end of defecation rarely may also be occult as guiac positive stools.
PROLAPSE
Prolapse is a much later symptom, to start with protrusion is slight and occurs
only at defecation and it does not reduce spontaneously but have to be replaced
digitally. Still if prolapse occurs often during exertion and it may go on to become
permanently prolapsed.
Fig. 7: Classification of internal haemorroids
Fig.8: Type of Haemorrhoids

DISCHARGE
A mucoid discharge is a frequent accompaniment of prolapsed haemorrhoids.

It is composed of mucous from engorged mucous membrane sometimes augmented by
leakage of ingested liquid paraffin. Pruritis almost certainly follows the discharge with
excoriation of perianal skin with accompanying discomfort.
PAIN
Pain per se is not a symptom of uncomplicated haemorrhoids, it usually occur

in complicated haemorrhoids.
ANAEMIA
Anaemia can be caused by bleeding haemorrhoids very rarely, so this can be

called as a complication rather than symptom.
DIFFERENTIAL DIAGNOSIS
RECTAL MUCOSAL PROLAPSE
It is frequently confused with prolapsing haemorrhoids. Patients with this

condition present with prolapse of rectal mucosa below dentate line. Bleeding may
occur from trauma to this displaced vascular mucosa. Precipitating factors are the
same as haemorrhoids, especially chronic straining at stools. However in many cases
haemorrhoids cushions are small, may progress to complete mucosal prolapse or anal
sphincteric dysfunction (primarily due to trauma especially surgical like internal
sphincterotomy or lords dilatation) may be there.
HYPERTROPHIED ANAL PAPILLAE
Hypertrophied anal papillae usually due to underlying anal fissure occasionally

papillae may enlarge to huge proportions to form fibrous anal polyp (but are not true
colorectal polyps). Rectal polyps, melanoma, carcinoma, rectal prolapse, fissure, inter
sphincteric abscess and perianal endometroma should be excluded while diagnosis.
CLINICAL EXAMINATION
General assessment of patient to ascertain general health status.

Systemic examination should be done to rule out bleeding disorders, liver disease
with portal hypertension, neoplastic growth in abdomen and pelvis,
hepatosplenomegaly, presence of free fluid in the peritoneal cavity, which are
responsible for causation of haemorrhoids.
RECTAL EXAMINATION
Position:
Left lateral (sims position):This is the most popular position for anorectal
examination with patient lying on left side, buttocks projecting over the edge of the
table with hips and knees are well flexed.[11]
Inspection:
Anal tags and IVth degree haemorrhoids are usually visible. IIIrd degree
haemorrhoids become visible on making the patient strain as in passing stools.
Thrombosed and strangulated external haemorrhoids can never be missed on local
examination.
Digital
examination:
This should be done gently explaining to the patient what is being done, with clear
instructions to the patient to open his mouth and breathe in and out deeply. After
wearing gloves and applying local anaesthetic jelly, the right index finger is laid flat
on anal verge, gentle pressure is exerted till sphincter yields and finger is slowly
pushed in by rotatory movement. Uncomplicated piles are not usually felt unless
thrombosed or fibrosed or sometime may be felt as a longitudinal fold when finger is
swept around lower rectum.
Proctoscopy:
Is crucial for diagnosis of haemorrhoids, the proctoscope is well lubricated and

gently inserted in the rectum. It is first introduced in the direction of umbilicus till
anal canal is passed and later directed posteriorly to enter the rectum. Now the
obturator is withdrawn and interior examined with light. The haemorrhoids will
protrude into the proctoscope as the instrument is being withdrawn. Note the position
of haemorrhoids imagining a watch held against the anus when the patient is in
lithotomy position will correspond to 3, 7 and 11o clock positions.
Fig. 9: Proctoscope
Fig. 10: Sims position

SIGMOIDOSCOPY AND COLONOSCOPY:
These investigations may not be possible in all cases but in cases suspicious of
sigmoid/rectal neoplasm, polyps may have to go through these investigations
mandatorily.
COMPLICATIONS OF HAEMORRHOIDS
HAEMORRHAGE
Profuse haemorrhage is not rare, most often it occurs in early stages of second
degree haemorrhoids, bleeding mainly occurs externally but it may continue internally
after haemorrhoids has retracted in which case rectum is found to contain blood.
Occasionally it can lead to severe anemia.
STRANGULATION
One or more of the internal haemorrhoids prolapse and become gripped by the
external sphincter. Further, congestion follows because the venous return is impended.
Second-degree haemorrhoids are most often complicated in this manner that is
accompanied by considerable pain. Unless the internal haemorrhoids can be reduced
within 1 or 2 hours, strangulation is followed by thrombosis.
THROMBOSIS
The affected haemorrhoid become dark purple and black and feels solid.
Considerable oedema of anal margins accompanies thrombosis.
ULCERATION
Superficial ulceration of exposed mucous membrane often accompanies

strangulation with thrombosis.
GANGRENE
Gangrene occurs when strangulation is sufficiently tight to constrict arterial

supply to haemorrhoid. The resulting sloughing is usually superficial and localized.
Occasionally a whole haemorrhoid sloughs off leaving a slow healing ulcer. Very
occasionally massive gangrene extends to mucous membrane within anal canal and
rectum and can cause spreading anaerobic infection and portal pyemia.
FIBROSIS
After thrombosis internal haemorrhoids sometime become converted into

fibrous tissue, which is earlier sessile but repeated traction during defecation causes it
to pedunculate to constitute a fibrous polyp. Fibrosis commonly occurs in
subcutaneous part of primary haemorrhoid.
SUPPURATION
Suppuration is uncommon, occurs due to infection of thrombosedhaemorrhoid.

Throbbing pain followed by perianal swelling and a perianal or submucous abscess
results.
PYELEPHLEBITIS (SYN. PORTAL PYEMIA)
Portal pyemia is surprisingly infrequent, theoretically infected haemorrhoids

should be a potent cause of portal pyemia. It can occur when strangulated
haemorrhoids are taken for surgery and have even been reported following banding.
INVESTIGATIONS
BLOOD EXAMINATION
To rule out anemia, Hb % is done.Total and differential, ESR, fasting blood

sugar, postprandial blood sugar, blood urea and serum creatinine to be done.
URINE EXAMINATION
To rule out infection or diabetes, sugar, microscopy of urine to be done.
STOOL EXAMINATION
To rule out occult blood in anemic cases.
CHEST X-RAY
To rule out causes of chronic cough like chronic bronchitis, pulmonary

tuberculosis which may secondarily cause haemorrhoids.
ECG
To rule out cardiovascular diseases.

MANAGEMENT OF HAEMORRHOIDS
MEDICAL OR NON-OPERATIVE MANAGEMENT
Conservative management of haemorrhoids can be accomplished in majority

of patients. These vary from advice with respect to
1. Defecation habits
2. Local hygiene
3. Dietary manipulations
4. Topical applications
OUTPATIENT AND MINOR PROCEDURES
1. Band ligation
2. Sclerotherapy
3. Cryosurgery
4. Infra red photocoagulation
SURGICAL PROCEDURES
1. Haemorrhoidectomy
Ultrasonic Scalpel
Diathermy
2. Submucoushaemorrhoidectomy
3. Staple haemorrhoidopexy
4. Laser haemorrhoidectomy
MEDICAL OR NON-OPERATIVE MANAGEMENT

1. DEFECATION HABITS
Neglecting the first urge to defecate, spending a prolonged time at the toilet,
straining are common defecation errors, which can be corrected.
2. LOCAL HYGIENE
Haemorrhoids particularly IIIrd and IVth degree are associated with mucous
staining and itching these symptoms require advice about anal hygiene to prevent
perianal dermatitis and to ameliorate symptoms. The use of hot sitz bath and warm
soaks also ameliorate symptomatic haemorrhoids.
3. DIETARY MANIPULATION
The rationale of adding bulk to diet is to eliminate straining at defecation.Burkilt and

Graham Stewart observed that stools lacking in adequate fibre are small, hard and
difficult to evacuate requiring prolonged straining. Consumption of plenty of fruits
and vegetables, consuming raw unprocessed wheat or oat barn (1/3 cup per day), an
alternative measure is to take psyllium seed (2 teaspoons per day), an adequate
volume of fluids must be consumed each day.
4. TOPICAL APPLICATIONS
A large variety of topical agents as creams, lotions, suppositories and local

anaesthetics have been employed with the purpose of improving haemorrhoidal
symptoms. Anecdotal evidence suggests symptomatic relief has been achieved by
topical medications. Topical nitric oxide has been reported as alternative for managing
strangulated internal haemorrhoids by decreasing internal anal sphincter tone.
Patients undergoing medical management should be reviewed frequently
for up to 1 year to be sure that their symptoms are improving and bleeding has
decreased. If complaints still persist or increase other treatment modalities should be
considered.
OUTPATIENT AND MINOR PROCEDURES

1. RUBBER BAND LIGATION[12]
Rubber band ligation is one of the most frequently applied methods for
treatment of internal haemorrhoids. The instrument for rubber band ligation was
originally described by Blaisdell in 1954 and later modified by Barron in 1963.
Principle
Rubber bands applied to the pedicle of mucosa of internal haemorrhoids causes
ischemia, necrosis and scarring preventing further bleeding or prolapse of the
respective haemorrhoids and gradually cuts off through the tissues and within a period
of seven to ten days these haemorrhoids slough off.
Procedure
Rubber band ligation is done as a minor operation theatre procedure. Soap water or
sodium biphosphate enema is given both on night before and the morning of the
procedure. Patient can be put in lithotomy or left lateral (sims position).
Patient
Ideally for a case of IInd degree haemorrhoids and some selected cases of IIIrd
degree haemorrhoids.
Technique
Fig. 11: Rubber band ligation

The proctoscope is well lubricated with local anaesthetic jelly and gently
introduced into the rectum, first in the direction of umbilicus till anal canal is passed
and later directed posteriorly to enter rectum. Now the obturator is withdrawn to
examine the interior of the proctoscope as the proctoscope is withdrawn slowly the
haemorrhoids protrude into the lumen of the proctoscope, the whole of the internal
cushion is made to prolapse into the lumen so that the base of cushion is easy to
recognize, the base of the cushion usually lies about 1.5 cm to 2 cm above the dentate
line, here the haemorrhoids can be grasped with the alligator forces and pulled into the
inner cylinder of the ligating drum without causing discomfort. Then with gentle
downward traction with alligator forceps and upward pressure with ligating drum, the
inner cylinder fills with the haemorrhoid and underlying vascular tissue forming the
pedicle. Now the trigger is pressed so that the rubber bands on the inner cylinder of
ligating drum strangulate about 1 cm diameter of tissue. The procedure is repeated for
another haemorrhoids.[13]
2. INJECTION SCLEROTHERAPY
John Morgan first attempted sclerotherapy to obliterate haemorrhoids as early

as 1869 by using iron persulphate. Anderson (1924) and Bacon (1949) outlined
injection treatment and later Albright used 5% phenol in almond oil in dose of 3.5 ml.
The work of Cabrera and Monfreaux in utilising foam sclerotherapy along with
Tessari's "3-way tap method" of foam production further revolutionised the treatment
of haemorrhoids with sclerotherapy. Sclerotherapy is a non-invasive procedure taking
only about 10 minutes to perform, the sclerosing solution additionally closes the
"feeder veins" under the skin, thereby making a recurrence of the spider veins in the
treated area less likely.
Principle
Injection of sclerosing agents into the haemorrhoid causes fibrosis of vascular
cushions due to effect of the irritant solution producing an inflammatory
reaction.sclerosis leading to mucosal fixation on the deeper plans & occlusion of
lakes. Indications
a) First degree haemorrhoids which bleed

b) Early second-degree internal haemorrhoids
c) Some Third degree internal haemorrhoids
Contraindications
a) Thrombosed piles
b) Prolapsed piles
c) In presence of
d) Proctitis
e) Fissure in ano
f) Fistula in ano
g) Pregnancy
h) Diabetes mellitus
Technique
No special preparation necessary other than a empty rectum. The proctoscope
is introduced and haemorrhoids are displayed, proctoscope is further introduced until
haemorrhoids almost disappear with only upper end visible. The injection is made at
this point above the main mass of the haemorrhoid into the submucosa or just above
the anorectal ring injecting 1 ml of sclerosant with the bevel of needle towards the
rectal wall. It is most important not to inject too deeply, particularly anteriorly,
because of the risk of entering the prostate, seminal vesical, or even in base of urinary
bladder causing hematuria, hematospermia&prostitis. Sufficient sclerosant should be
injected under the
mucosa to raise a white wheal, which eventually ulcerates and cause mucosal fixation,
thus preventing the haemorrhoids from decending into the lower anal canal. The
injection should produce elevation and pallor of the mucosa. All three piles can be
injected separately 1 ml in each site in single sitting. Technique can be repeated after 6
weeks.
FOAM SCLEROTHERAPY
Foam sclerotherapy is a technique that involves injecting foamed sclerosant
drugs within a blood vessel using a syringe. The sclerosant drugs (sodium tetradecyl
sulfate or polidocanol) are mixed with air or a physiological gas (carbon dioxide) in
a syringe or by using mechanical pumps. This increases the surface area of the drug.
The foam sclerosant drug is more efficacious than the liquid one in
causing sclerosis (thickening of the vessel wall and sealing off the blood flow), for it
does not mix with the blood in the vessel and in fact displaces it, thus avoiding
dilution of the drug and causing maximal sclerosant action. Experts in foam
sclerotherapy have created tooth paste like thick foam for their injections, which has
revolutionized the use in haemorrhoids.
2. CRYOSURGERY
Lewis introduced cryosurgery in treatment of haemorrhoids later followed by

Frazer and Gill (1967), Lewis et al (1969) and Lloyd William et al (1973).
Principle
The principle of cryosurgery is based on cellular destruction through rapid
freezing followed by rapid thawing.
Instrument
A cryoprobe through which nitrous oxide at -60 to -800 c or liquid nitrogen at -
1960 c is circulated.
Technique
The technique of cryosurgery involves the application of the cryoprobe in long
axis of haemorrhoid while nitrous oxide is circulated through it. Tip of the probe
develops white frost and adheres to haemorrhoid which becomes white reaching
maximum diameter of 6-7 mm after 2 minutes, freezing should be continued for 3
minutes and once flow is stopped it takes 10-12 seconds for probe tip to get thawed
and haemorrhoidal tissue detaches from the probe.
3. INFRARED PHOTOCOAGULATION
First described by Neiger in 1979.

Principle
Infrared light penetrates the tissue and is converted to heat causing tissue
destruction.4 infrared light acts by coagulating tissue protein or evaporating water in
the cells depending on the intensity and duration of application.
Instrument
Infrared coagulator has a 15 V tungsten halogen lamp as source, whose light is
reflected by a gold plated surface and carried through quartz light shaft to the side of
mucosa through a proctoscope.[14]
Technique
Through proctoscopy probe tip is pressed directly onto the base of the vascular
cushion. The use of 1.5 second pulse generates a tissue temperature of 100 0 C, which
results in 3 mm depth of coagulated protein4. The recommendation is to use for
duration of 1.5 seconds three times on each haemorrhoid.1 it is a very fast procedure
which can be complete in less than 30 seconds. Complications as sustained pain or
superficial bleeding are unusual.
SURGICAL PROCEDURES
1. HAEMORRHOIDECTOMY
Types
Open haemorrhoidectomy
Close haemorrhoidectomy
Submucoushaemorrhoidectomy
Laser haemorrhoidectomy
Indications
Third degree haemorrhoids.

Fourth degree haemorrhoids
Second-degree haemorrhoids which have not been cured by non-operative
treatment.
Fibrosedhaemorrhoids
Interno external haemorrhoids when external haemorrhoid is well defined
Haemorrhoids complicated by ulceration, fissure, fistula, large
hypertrophied and types papilla and extensive skill
a) OPEN HAEMORRHOIDECTOMY
Open haemorrhoidectomy is most commonly used in U.K. known as Milligan

Morgan operation named after surgeons who described it. Under general or spinal
anaesthesia the patient is put in lithotomy position. Anal sphincter is gently stretched
and the internal haemorrhoids are then prolapsed by traction on skin tags or skin of
anal margin. Each haemorrhoid is picked up with dissecting forceps and traction
exerted. Traction displays a longitudinal fold (pedicle) above haemorrhoid, which is
grasped with hemostat, the external haemorrhoid or skin tag connected to internal
haemorrhoid is also held with hemostat. These pair of hemostats when held out by
assistants forms a triangle. The operator takes the left lateral pair of hemostats in his
palm and places the extended fore finger in anal canal to support internal
haemorrhoid. In this way traction is applied to anal margin, with scissors a V shaped
cut is made on either side of the skin holding hemostat the cut traversing the skin and
corrugator cutis ani. Exerting further traction and little blunt dissection exposes lower
border of internal sphincter.
A transfixing ligature of vicryl is applied to pedicle at this level. Each
haemorrhoid dealt in this manner is excised 1.25 cm about 1 cm from knot. The
stumps of ligated haemorrhoids are returned into rectum by tucking with a piece of
gauze. The margins of skin wounds are trimmed so as not to leave overhanging edges.
Bleeding subcutaneous arteries having been secured, at the corners the three pieces of
petroleum jelly gauze are tucked into the anus. So as to cover the area denuded of
skin.[15]
b) CLOSED HAEMORRHOIDECTOMY
In 1931 Fansler described a technique where intra anal anatomic dissection

was conducted which was later developed and modified by Ferguson and Heaton in
1959. Technique
Proctoclysis enema is given 1 to 2 hours before procedure. Under general/ spinal
anaesthesia the patient is put in lithotomy position. A suitable retractor as Hill
Ferguson type is used. With scissors an elliptical excision is started at the perianal skin
to include external and internal haemorrhoids and is ended at the anorectal ring.
Fig. 12: Open Haemorrhoidectomy
a) The skin is cut to left lateral haemorrhoids
b) Transfixation of the pedicle
c) Ligation
Fig. 13: Close Haemorrhoidectomy

The mucosa and submucosa are dissected from the underlying internal sphincter with
care taken not to injure the muscle. The pedicle is transfixed and ligated with 3/0
vicryl or dexon 2. The entire wound is closed with running 3/o chromic catgut. The
strip of excision should not be more than 1 to 1.5 cm so that closure is without
tension1. If too much tissue is excised wound should be marsupialized and left open.
[16]
The largest and most redundant haemorrhoid should be excised first. With this
approach the original plans to excise three quadrants may be modified so that only
two- quadrant haemorrhoidectomy is necessary.[17,18,19]
NOTE: Depending on source of energy, Haemorrhoidectomy can be performed using
Ultrasonic Scalpel
Diathermy
ULTRASONIC SCALPEL HAEMORRHOIDECTOMY
Principle
The ultrasonic scalpel is an ultrasonically-activated instrument, which vibrates
at a rate of 55000 MHz per second.[19] It is known for its ability to coagulate small
and medium sized vessels by converting electrical energy to a mechanical one.A
ultrasonic scalpel cuts via vibration. The high frequency vibration of tissue molecules
generates stress and friction in tissue, which generates heat and causes protein
denaturation. This technique causes minimal energy transfer to surrounding tissue,
potentially limiting collateral damage. [20, 21, 26, 27]
Procedure
All patients received enema before the surgery. Spinal anaesthesia was given.
Patients were placed in the lithotomy position for surgery. In ultrasonic scalpel
haemorrhoidectomy, haemorrhoid pedicles were excised upto apex region using
the ultrasonic scalpel without damaging the internal sphincter with the help of
vascular forceps and the wounds were left open. In all patients, adjacent areas of
perianal skin and rectal mucosa were left intact to prevent anal stricture.
Patient
Ideally for a case of IIIrddegreehaemorrhoids and some selected cases of
IVthdegreehaemorrhoids.[21]
Post-procedure advice
Post procedure pain is relieved with oral analgesia. Hot sitz bath also helps
greatly to relieve the pain. Patient is advised to take liquid and semisolids for one day
following the procedure, so that attempts at defecation are minimal. Patients are
advised oral intake of bulk forming agents for at least 6-8 weeks.
COMPLICATIONS OF ULTRASONIC SCALPEL HAEMORRHOIDECTOMY [28]
1. Pain
Pain is the most common complication it is usually in the form of mild

discomfort subsiding with analgesics usually due to anal sphincter spasm.
2. Urinary retention
Urinary retention occurs in approximately 1% patients.
3. Bleeding
Bleeding may occur in approximately 7-10 days after ultrasonic scalpel

haemorrhoidectomy, bleeding is usually self-limited, but persistent hemorrhage may
require examination under anaesthesia and suture ligation of the pedicle.
4. Acute perianal sepsis (necrotizing infection)
Acute perianal sepsis is an uncommon life threatening complication. Severe

pain, fever and urinary retention are early signs of infection and should prompt
immediate evaluation of patient under anaesthesia. Treatment includes debridement of
necrotic tissue, drainage of associated abscess and administration of triple antibiotics.
DIATHERMY
Principle
Heat is produced with high frequency electric current. It uses 300 KHz to 3
MHz to activate nerve and muscles. This electic current used to stimulate coagulation
or destroy tissues at temperature higher than 1500C. [22, 23, 24]
Instruments used
1. Proctoscope
2. Allis forcep
3. Vascular forcep
4. Electrocautery device
Fig. 14: Instruments used in Ultrasonic Scalpel
Haemorrhoidectomy
Fig. 15: Ultrasonic Scalpel Haemorrhoidectomy (Intra-op)
Fig. 16: Diathermy Haemorrhoidectomy (Intra-op)

Technique
Lithotomy was given to patient on O.T. table and a proctoscope was inserted
into anal canal in order to obtain surgical field. Haemorrhoidal stems were lifted with
forceps to separate them from anal sphincter during surgery resection of
haemorrhoidal tissue from anal sphincter was perfomed using a electrocautery device.
[25,26,27]
c) SUBMUCOUS HAEMORRHOIDECTOMY[29]
The operation is carried out in lithotomy position with a special self-retaining

retractor. The submucous plane is infiltrated with saline and adrenaline, which
controls bleeding and helps dissection. A vertical incision is made through the mucosa
from top of the anal canal to the anal margin where any skin tag or external
haemorrhoidal component is removed. The mucosal flaps are lifted on both sides so
that the haemorrhoid is completely exposed. It is then dissected away from the
internal sphincter muscle. The pedicle is transfixed, ligated and excised, the mucosal
flaps are allowed to pull back in place and are approximated with several interrupted
catgut sutures. Prolapse of mucosa must be prevented by including part of the internal
sphincter muscle in the suture.
Though this technique was much to recommend due to less postoperative pain
and less chances of postoperative anal stenosis, drawbacks like longer time to perform
the surgery, considerable haemorrhage, and higher recurrence rate had withheld its
wider adoption.[30]
d) LASER HAEMORRHOIDECTOMY
Laser has been used with some success in patients for treatment of polyps and
rectal carcinoma. Laser has also been used for performing haemorrhoidectomy. Yu
and Eddy reported excellent success with Nd:Yag laser haemorrhoidectomy
performed in
134 patients, the procedure was done on outpatient basis. Iwagaki et al reported on
1816 patients who underwent CO2 laser haemorrhoidectomy with excellent results.
Laser surgery is said to be less painful.[31,32]
The initial enthusiasm due to the mystique of laser and myth of its painless
nature dampened slowly.The evaporation of haemorrhoids, the excision of external
haemorrhoids and other forms of superficial therapy have confused patients regarding
the effectiveness and most importantly the painless nature of this form of therapy.
Senogore et al showed in a prospective study that surgical haemorrhoidectomy done
with Nd:Yag laser offered no patient care advantage over the traditional Ferguson
closed haemorrhoidectomy. As refinement in technology occur, laser
haemorrhoidectomy may become more common.
2. STAPLED HAEMORRHOIDOPEXY
Most recently a modified circular stapler approach has been advocated for
surgical management of haemorrhoids. The so called procedure for prolapsed
haemorrhoids (pph) was described initially by Longo in 1998.[33,34,36]
Principle
Is based on the concept of interruption of the superior and middle
haemorrhoidal vessel and upward lifting of the prolapsed anorectal mucosa and
repositioning of the vascular cushions back into the anal canal which causes the
haemorrhoidal tissue to atrophy.
Indications
Mainly advocated for IIIrd and IVth degree internal haemorrhoids. Conversely
external haemorrhoids are not appropriately treated but the tags and external
component can be concomitantly excised if indicated.
Technique
A modified 33 mm circular stapler is used to perform the stapled
haemorrhoidopexy. This operation is facilitated by the use of the pph procedural set
consisting of a circular stapler (hcs 33), a suture threader (st 100) a circular anal
dilator (cad 33), and a purse string suture anoscope (psa 33). The technique of pph
involves placement of a purse string suture using non-absorbable monofilament
material approximately 2-4 cm cephalad to the dentate line. The suture is placed into
the mucosa and sub mucosa of the lower rectum avoiding the muscular layer and
vagina. Care must be taken to place the purse string sufficiently high so that when
fired it does not incorporate the anal mucosa and underlying internal sphincter. If this
were to occur, severe pain might ensure, in addition to the risk of stricture and
mucosal ectropion, these complications are avoided if purse string is placed atleast 2
cm above the dentate
line.
The single greatest advantage of stapled haemorrhoidopexy is reduction in
postoperative pain. The pain after pph is described as vague and dull and analogous to
Fig. 17: Stapled Haemorrhoidopexy
39
tenesmus. Michigan and coworkers prospectively randomized 40 patients to undergo
pphhaemorrhoidopexy versus Milligan Morgan haemorrhoidectomy. The average
postoperative pain score from day zero to day ten significantly lower in pph and also
patients had shorter hospital stay and a faster return to full activity. Postoperative
complication rates have been similar with that of conventional haemorrhoidectomy.
One downslide is the cost of the equipment. But undoubtedly this new technique is a
exciting development in the search of a relatively painless procedure to treat
haemorrhoidal disease.
COMPLICATIONS OF HAEMORRHOIDECTOMY
May be early or late:
EARLY COMPLICATIONS:
Pain
Retention of urine
Reactionary hemorrhage
Secondary hemorrhage
LATE COMPLICATIONS:
Anal stricture
Anal incontinence
Anal fissure
Abscess or fistula
TREATMENT OF COMPLICATION OF HAEMORRHOIDS
1. STRANGULATION, THROMBOSIS AND GANGRENE
The haemorrhoid is dissected and excised with 1.25 cm of adjacent skin. The
pear shaped wound is left to granulate, the relief of pain is immediate and permanent
in cases of strangulation and thrombosis. It was earlier believed that surgery would
promote pylephlebitis. If adequate antibiotic cover is given, pylephlebitis does not
occur and immediate surgery is justified. Besides adequate pain relief, bed rest with
frequent hot baths and warm saline compress, usually causes pile masses to shrink
considerably in 3-4 days, and then standard ligation and excision can be carried out.
Some surgeons consider operation at this stage increases the risk of postoperative
40
stenosis and delay surgery for a month or so. Inspite of low risk of pylephlebitis
caution should dictate a non-interventional policy whenever practical.
2. SEVERE HAEMORRHAGE
The cause of severe hemorrhage usually lies in a bleeding diathesis or use of a

anticoagulant. Such cases need local compression containing adrenaline with an
injection of morphine, blood is transfused if found necessary. Hemorrhage is to be
controlled after which ligation and excision of piles may be required.
3. THROMBOSED EXTERNAL HAEMORRHOID
Commonly termed perianal haematoma is a small clot occurring in perianal

subcutaneous connective tissue usually superficial to corrugator cutis ani muscle. This
condition appears suddenly and is very painful. On examination a tense, tender
swelling in lateral region of anal margin is noted. Untreated, it may resolve, suppurate,
fibroseor burst to extrude the clot or continue bleeding. In majority resolution or
fibrosis occurs. Thrombosedhaemorrhoids if noticed within first 36 hours is
treated as an emergency under local anaesthesia.
SPECIAL SITUATIONS
HAEMORRHOIDS IN PREGNANCY
Haemorrhoidal symptoms commonly occur and intensify during pregnancy

and in most instances they resolve after delivery. Haemorrhoidectomy is
indicated in pregnancy only if acute prolapse and thrombosis occur.
Haemorrhoidectomy is done under local anaesthesia in the second and third trimester
with patient put in left antero- lateral position. Prolapse and thrombosis, which occur
during delivery, is an indication for operation in immediate postpartum period.
HAEMORRHOIDS IN PORTAL HYPERTENSION
The incidence of haemorrhoids in portal hypertension is no greater than normal

population. Although massive bleeding is uncommon, it can be life threatening. Most
commonly it occurs during treatment of encephalopathy with administration of non-
absorbable antibiotics and potassium supplements which cause severe diarrhoea
causing breakdown of anal canal lining.The bleeding site is spotted with a proctoscope
under local anaesthesia (0.25% bupivacaine with 1:200,000 epinephrine) and a stick
tie
figure1 of eight suture with 3-0 vicryl incorporating mucosa, sub mucosa and internal
sphincter is placed. The associated coagulopathy should be corrected.
Haemorrhoidectomy should be reserved for rare cases when stick tie method fails to
control bleeding.
HAEMORRHOIDS IN INFLAMMATORY BOWEL DISEASES
Haemorrhoids are uncommon in inflammatory bowel disease. Most anal

problems result from perianal irritation and swelling caused by diarrhea rather than
haemorrhoids themselves. Surgical treatment may be indicated if necessary in
ulcerative colitis but relatively contraindicated in Crohns disease as the rate of severe
complications were high.
HAEMORRHOIDS IN PATIENTS WITH HIV & AIDS
Haemorrhoids in HIV and AIDS cases can be safely managed as in non-

infected patients in early stages. Patients with AIDS however are at high risk of
complication (infection, non-healing wounds) and probably should not undergo
surgery except under well-controlled circumstances.
Methodology
The present study is a comparative study from 1st July 2014 to 30th Sep 2016.
The data for which was drawn from patients visiting PanditDindayalUpadhyay
Hospitals and Medical College, Rajkot.
Materials and methods
In the present study, 50 cases of 3rd and 4th degree haemorrhoids were selected
with complaints of bleeding per rectum, pain during defecation, discharge and
irritation.A detailed history of each patient was taken with personal history, family
history, dietary history with systemic examination of respiratory, cardiovascular, per
abdominal examination to know any associated disease and to rule out any cause
predisposing to haemorrhoids and local examination including proctoscopy was done
as per proforma made for the study and the data entered in the proforma.
The patients were explained in detail about their disease and the modalities of
treatment as ultrasonic scalpel haemorrhoidectomy and diathermy haemorrhoidectomy
with the advantages and disadvantages of each. [36,37] Willing patients were selected
and examined and investigated as per proforma. Analysis was made on basis of
percentages, mean. 25 patients were treated by ultrasonic scalpel haemorrhoidectomy
& another 25 patients were treated by diathermy haemorrhoidectomy.
INCLUSION CRITERIA
Patients with complaints of bleeding per rectum, mass per rectum, pain,
irritation, discharge per rectum
Patients with 3rd& 4th degree haemorrhoids
Both male and female
Patients fit for surgery
EXCLUSION CRITERIA
Patients with 1st and 2nd degree haemorrhoids
Immunocompromised patients
Patients with bleeding disorders
Patients with deranged liver function tests
Pregnant & pediatric patient
Inflammatory bowel disease
SUBJECTS
A total of 50 cases included after admission they underwent thorough
investigation and preoperative investigation for assessment of fitness for anaesthesia.
Pateints who were fit, were explained about the procedure and were operated after
taking written informed consent.
PREPARATION
Proctoclysis enema was given to evacuate the rectum on the night before and
the morning of the planned day of procedure.
POSITION
Patient was put in lithotomy position while the procedure was performed.
PROCEDURE
Anaesthetically fit patients were taken on the operating table with an injectable
antibiotic ceftriaxone sodium 1gm given preoperatively at the time of induction of
anaesthesiaand patients were operated randomly by Ultrasonic scalpel
haemorrhoidectomy and diathermy haemorrhoidectomy.
POST-OPERATIVE CARE
Started clear liquids orally after 4-6 hours.
Analgesics were given in form of intramuscular diclofenac sodium for 24 hours.
After 24 hours oral administration of diclofenac tablet according to
requirement were given.
Patients were educated and encouraged to get ambulatory and were
encouraged to pass urine as early as possible.
Patients were examined at 6 & 24 hours post-operatively for pain assessment
and complications.
Antibiotics were continued for 7 to 10 days in all cases, longer in those
developing wound complications.
Patients were advised to take high fibre diet and plenty of fluids orally and hot
sitz bath.
Patients were encouraged to start normal activities as early as possible.
During study following points are taken into the consideration:
I. Total operative time.

II. Total intra operative blood loss.
III. Post-operative pain recorded at 1st POD, 3rd POD and 7th POD on VAS
IV. Post-operative analgesia requirement
V. Any post-operative complication in the form of bleeding, urinary retention or
constipation.
VI. Number of days of hospital.
EVALUATION OF PAIN USING VAS (Visual analogue score)

Post-operatively on day of operation patients were given intramuscular
diclofenac injection. POD 1 onwards patients were kept on oral diclofenac tablets.
Patients were evaluated for pain using visual analogue scale ranging from 0 to 10.
The scale used was:
SCORE PAIN
0-1 No pain
2-3 Mild pain
4-5 Moderate pain (Discomforting)
6-7 Severe pain (Distressing)
8-9 Very severe pain (Intense)
10 Unbearable pain.
0 - No pain.
Feeling perfectly normal.
1 - Very Mild
Very light barely noticeable pain, like a mosquito bite or a poison ivy itch.
Most of the time you never think about the pain.
2 Discomforting
Minor pain, like lightly pinching the fold of skin between the thumb and first
finger with the other hand, using the fingernails. Note that people react differently to
this self test.
3 Tolerable
Very noticeable pain, like an accidental cut, a blow to the nose causing a
bloody nose, or a doctor giving you an injection. The pain is not so strong that you
cannot get used to it. Eventually, most of the time you don't notice the pain. You have
adaptedto it.
4 - Distressing
Strong, deep pain, like an average toothache, the initial pain from a bee sting,
or minor trauma to part of the body, such as stubbing your toe real hard. So strong you
notice the pain all the time and cannot completely adapt. This pain level can be
simulated by pinching the fold of skin between the thumb and first finger with the
other hand, using the finger nails and squeezing real hard. Note how the simulated
pain is initially piercing but becomes dull after that.
5 - Very Distressing
Strong, deep, piercing pain, such as a sprained ankle when you stand on it
wrong or mild back pain. Not only do you notice the pain all the time, you are now so
preoccupied with managing it that you normal lifestyle is curtailed. Temporary
personality disorders are frequent.
6 - Intense
Strong, deep, piercing pain so strong it seems to partially dominate your
senses, causing you to think somewhat unclearly. At this point you begin to have
trouble holding a job or maintaining normal social relationships. Comparable to a bad
non- migraine headache combined with several bees tings or a bad back pain.
7 Very Intense
Same as 6 except the pain completely dominates your senses, causing you to
think unclearly about half the time. At this point you are effectively disabled and
frequently cannot live alone. Comparable to an average migraine headache.
8 Utterly Horrible
46
Pain so intense you can no longer think clearly at all, and have often
undergone severe personality change if the painhas been present for a long time.
Suicide is
47
frequently contemplated and sometimes tried. Comparable to child birth or a real bad
migraine headache.
9 Excruciating Unbearable
Pain so intense you cannot tolerate it and demand pain killers or surgery, no
matter what the side effects or risk. If this doesn't work, suicide is frequent since there
is no more joy in life whatsoever. Comparable to throat cancer.
10 Unimaginable Unspeakable
Pain so intense you will go unconscious shortly. Most people have never
experienced this level of pain. Those who have suffered a severe accident, such as a
crushed hand, and lost consciousness as a result of the pain and not blood loss, have
experienced level 10.
Mild (1-3)
Does not interfere with most activities. Able to adapt to pain psychologically
and with medication or devices such as cushions.
Moderate (4-6)
Interferes with many activities. Requires lifestyle changes but patient remains
independent. Unable to adapt to pain.
Severe (7-10)
Unable to engage in normal activities. Patient is disabled and unable to

function independently.
POST-PROCEDURE ADVICE
Post-procedure pain was relieved by oral analgesia if necessary. Hot sitz bath
was also advised postoperatively in all patients. Post-op pain evaluation was done
using visual analogue scale (VAS) ranging from 0 to 10. Score 4 considererd as
cut off value for post-op analgesia requirement. Patient was advised to take liquids
and semisolids for one day following the procedure so that attempts at defecation are
minimal. Oral intake of bulk forming agents was advised to all patients. All patients
were evaluated for post procedure pain, discomfort, bleeding, urinary retention, sepsis,
need for analgesia and days off work.
FOLLOW UP ADVICE
Patient was followed up on 7th day, one and third months for symptoms as
pain, bleeding, prolapse, irritation, mucous discharge. Patients were advised to take
oral analgesia if needed. Patients were also advised to take high fibre diet to avoid
straining on defecation. The patient was monitored for post procedure pain,
discomfort, bleeding, irritation, urinary retention, sepsis, recurrence and were
enquired whether pre- procedure symptoms had mostly resolved or residual symptoms
were present. Patients were requested to assess the form of treatment as excellent,
moderately successful or of little help based on their results post-procedure.
.
RESULT AND
ANALYSIS
TABLE 1: DISTRIBUTION OF CASES IN DIFFEREN AGE GROUPS
ULTRASONIC DIATHERMY
AGE IN YEARS SCALPEL TOTAL
No Of % No Of %
Cases Cases
11 -20 00 00 00 00 00
21-30 03 12 01 04 04
31-40 06 24 04 16 10
41-50 09 36 06 24 15
51-60 04 16 08 32 12
61-70 03 12 06 24 09
TOTAL 25 100 25 100 50
120
100
80
ULTRASONIC SCALPEL
60
ULTRASONIC SCALPEL
40
DIATHERMY
20
DIATHER
MY
DIATHER
MY
0
The maximum age recorded is 70 years. In both males and females USHG were more
common in the age group 41-50 years while in DHG between 50-60 years.
TABLE 2:DISTRIBUTION OF CASES IN BOTH SEXES
ULTRASONIC SCALPEL DIATHERMY
SEX TOTAL
No Of Cases % No Of Cases %
MALE 20 80 21 84 41
FEMALE 05 20 04 16 09
TOTAL 25 100 25 100 50
MALE
FEMALE
TOTAL
In this study out of 50 patients, 41 were male & 9 were female. The male- female ratio
is 4.5:1 respectively. Male were more affected of haemorrhoid in our study.
TABLE 3:DISTRIBUTION ON BASIS OF OPERATIVE TIME
OPERATIVE SCALPEL TOTAL
TIME IN No Of % No Of %
MINUTES Cases Cases
30 mins 12 48 5 20 17
31 60 mins 13 52 20 80 33
TOTAL 25 100 25 100 50
OPERATIVE
TIME IN
MINUTES
30 mins
31 60 mins
TOTAL
A. In ultrasonic scalpel haemorrhoidectomy

48 % cases took operative time of 30 minutes
52 % cases took operative time of 30 -60 minutes
B. In diathermy haemorrhoidectomy
20 % cases took operative time of 30 minutes
80 % cases took operative time of 30-60 minutes
Average time for ultrasonic scalpel haemorrhoidectomy is 20-35 mins and diathermy
haemorrhoidectomy process is 30-45 mins.
TABLE 4:POST-OPERATIVE REQUIERMENT OF ANALGESIA
POST- SCALPEL
OPERATIVE No Of % No Of % TOTAL
ANALGESIA Cases Cases
REQUIREMENT
1st DAY 20 80 22 88 44
3rd DAY 04 16 15 60 19
7th DAY 00 00 5 20 05

80% cases required analgesia for day 1
In this comparative study, postoperative analgesic requirement is more in diathermy

haemorrhoidectomy.
TABLE 5:DISTRIBUTION ON BASIS OF DURATION OF HOSPITAL STAY
HOSPITAL SCALPEL TOTAL
STAY No Of % No Of %
Cases Cases
24 HRS 13 52 00 00 13
48 HRS 09 36 12 48 21
72 HRS 03 12 13 52 16
TOTAL 25 100 25 100 50
24 HRS
48 HRS
72
HRS
TOTA
L

52 % patient required hospitalisation till 24 hrs
Postoperative duration of hospital stay is more in diathermy haemorrhoidectomy as

compare to ultrasonic scalpel haemorrhoidectomy.
TABL-E 6:DISTRIBUTION ON BASIS OF POST-OPERATIVE COMPLICATION-
PAIN
PAIN SCALPEL TOTAL
No Of % No Of %
Cases Cases
1st Day 24 96 25 100 49
3rd Day 06 24 15 60 21
7th Day 01 04 09 36 10
PAIN
1st Day
3rd Day
7th Day

96 % patient having pain on 1stpost-operative day
24 % patient having pain till 3rdpost-operative day
4 % patient having pain till 7thpost-operative day
100 % patient having pain on 1stpost-operative day
60 % patient having pain till 3rdpost-operative day
36 % patient having pain till 7th post-operative day
Postoperative complication pain is little high in diathermy haemorrhoidectomy as

compare to ultrasonic scalpel haemorrhoidectomy.
TABLE 7:DISTRIBUTION ON BASIS OF POST-OPERATIVE COMPLICATION-
BLEEDING PER RECTUM
BLEEDING SCALPEL TOTAL
PER No Of % No Of %
RECTUM Cases Cases
1st Day 01 04 03 12 05
7th Day 00 00 00 00 00
1 Month 00 00 00 00 00
1st Day
7th Day
1 Month

4 % patient having c/o bleeding per rectum on 1stpost-operative day
12 % patient having c/o bleeding per rectum on 1stpost-operative day
Postoperative complication of bleeding per rectum is little high in diathermy

haemorrhoidectomy as compare to ultrasonic scalpel haemorrhoidectomy.
TABLE 8:DISTRIBUTION ON BASIS OF POST-OPERATIVE COMPLICATION-
URINARY RETENTION
URINARY SCALPEL TOTAL
RETENTION No Of % No Of %
Cases Cases
1st Day 01 4 2 8 3
3rd Day 00 00 00 00 00
7th Day 00 00 00 00 00
URINARY RETENTION
1st Day
3rd Day
7th Day
C. In ultrasonic scalpel haemorrhoidectomy

4 % patient having c/o urinary retention on 1stpost-operative day
D. In diathermy haemorrhoidectomy
8 % patient having c/o urinary retention on 1stpost-operative day
Postoperative complication of urinary retention is little high in diathermy

TABLE 9: DISTRIBUTION ON BASIS OF RESUMPTION TO WORK
RESUMPTION SCALPEL TOTAL
TO WORK No Of % No Of %
Cases Cases
1st week 24 96 00 00 24
2nd week 01 04 10 40 11
3rd week 00 00 15 60 15
TOTAL 25 100 25 100
1st week
2nd week
3rd week
TOTAL

96 % patient started his routine work within 1st week
4 % patient started his routine work within 2nd week
60 % patient started his routine work within 3rd week
In this comparative study majority patients resume their routine work within 2 weeks.
Time taken by patient to start his/her routine work post-operatively is more in
diathermy haemorrhoidectomy.
TABLE 10: EVALUATION OF PAIN BY VISUAL ANALOGUE SCALE
POST-OP DAY ULTRASONIC DIATHERMY
SCALPEL
DAY 1 5.8 7.0
DAY 3 4.2 6.2
DAY 7 3.8 4.8
ULTRASONIC SCALPEL
DIATHERMY
The above data are average value of VAS score of patients in each group. Post-
operative complication pain according to VAS is little high in diathermy
DISCUSSIO
N
Haemorrhoidectomy is the most effective and definitive treatment for IIIrd and
IVthdegree haemorrhoids. Pain after haemorrhoidectomy continues to be a major
problem. The ultrasonically activated scalpel divides tissue using high-frequency
ultrasonic energy. Because the instrument operates at temperature less than
100C, less lateral thermal damage, it is associated with less undesirable tissue
desiccation, char formation and zone of thermal injury compared with
diathermy. The early and delayed complication rates of either surgery were
comparable to conventional haemorrhoidectomy, and no serious complications were
noted. As stated in previous studies, postoperative pain is felt at the highest level on
the 1st day and decreases later.[35,38] In our study, postoperative pain scores were
highest in day 1 in both groups. In comparison with Diathermy method, Ultrasonic
Scalpel haemorrhoidectomy had a shorter operating time and had less blood loss. The
VAS pain scores at day 1, 3 and 7 were less in USHG than DHG. Intra operative
bleeding is more in Diathermy group in comparison to Ultrasonic Scalpel group, so
the operative time is more in Diathermy group.[39,40]
A decreased lateral thermal injury (at the surgical site) is translated into
decreased postoperative pain. The main disadvantage of surgical
haemorrhoidectomy is the postoperative pain resulting from the surgical raw area in
the sensitive perianal skin. Much of this discomfort arises from the thermal injury
induced by the Diathermy. In different procedures it was found that ultrasonic
scalpel offers many benefits, including less pain, shorter hospital stay, reduced
analgesic requirement, less damage to tissues, quicker recovery and reduced
scarring. We found that duration of surgery was significantly shorter in the
Ultrasonic scalpel group
AGE DISTRIBUTION:
Studies No Range
Present Study 50 20-70
H Bulus et al 151 25-71
Comparing with other studies, the number of cases were higher in other groups
as in H Bulus et al study (151 cases), whereas the upper age limit was 70 yr and lower
limit was 25 yr.
SEX DISTRIBUTION:
In present study male : female is 4.5:1, which is comparable with H Bulus et al
who showed a 1.1:1 male : female ratio respectively.
Studies Male Female
Present Study 82 % 18%
H Bulus et al 58% 42%
ANAESTHESIA:
All 50 cases underwent ultrasonic scalpel haemorrhoidectomy and diathermy
haemorrhoidectomy under spinal anaesthesia. In H Bulus et al patient operated under
intravenous sedation and caudal block.
OPERATIVE TIME:
In our present study average time for ultrasonic scalpel haemorrhoidectomy is
20 to 35 mins and diathermy haemorrhoidectomy it is 30 to 45 minutes. In H Bulus et
al 18 min was operative time for ultrasonic scalpel and 25 min was for diathermy
haemorrhoidectomy.
ANALGESIA:
In our present comparative study

Compare with past study with H Bulus et al 64 % cases required post-
operativeanalgesia for 1st day & 42 % cases require for 3rd day & 28 % cases require
for 7th day
Post-operative Present Study H Bulus et al

Analgesia ULTRASONIC
SCALPEL
1st DAY 80% 64%
3rd DAY 16% 42%
7th DAY 04% 28%
Compare with past study with H Bulus et alrequire 44% cases post-operative analgesia
for 1 day & 32 % cases require for 3 day & 18% cases require for 7 day.
Post-operative Present Study H Bulus et al

Analgesia DIATHERMY
1st DAY 88% 44%
3rd DAY 60% 32%
7th DAY 36% 18%
POST-OPERATIVE STAY:

Compare with past study with Bursch et al require 66 % cases post-operative stay for
24 hours & 54 % cases require for 48 hours & 18 % cases require for 72 hours.
Post-operative Present Study Bursch et al

Stay ULTRASONIC
SCALPEL
24 HRS 52% 66%
48 HRS 36% 54%
72 HRS 12% 18%
A. In diathermy haemorrhoidectomy
Compare with past study with Schrey require 46 % cases post-operative stay for 24
hours & 44 % cases require for 48 hours & 18 % cases require for 72 hours.
Post-operative stay Present Study Schrey
DIATHERMY
24 HRS 00% 46%
48 HRS 48% 44%
72 HRS 52% 18%
POST PROCEDURE COMPLICATION:


96% patient having post-operative pain on 1stpost-operative day
00% patient having post-operative pain on 7thpost-operative day
In H Buluset al study 90 % cases having post-operative pain for 1 day, 06% cases
having pain for 7 days.
PAIN Present Study H Bulus et al

ULTRASONIC
SCALPEL
1st day 96% 90 %
7th day 00% 06%
100% patient having pain on 1stpost-operative day
20% patient having pain till 7thpost-operative day
In H Bulus et alstudy 88 % cases having post-op pain for 1 day, 06 % cases having
pain for 7 days.
PAIN Present Study H Bulus et al

DIATHERMY
1st day 100% 88%
7th day 20% 06%
BLEEDING P/R:
4 % patient having c/o bleeding per rectal on 1stpost-operative day
In H Bulus et al study 02 % cases having post-operative bleeding PR on 1 day.
Bleeding PR Present Study H Bulus et al

ULTRASONIC
SCALPEL
1st day 04% 02 %
7th day 00% 00%
1 month 00% 00%
12 % patient having c/o bleeding per rectal on 1stpost-operative day
In H Bulus et al study 16 % cases having post-operative bleeding PR on 1 day.

Bleeding PR Present Study H Bulus et al
DIATHERMY
1st day 12% 16%
7th day 00% 00%
1 month 00% 00%
URINARY RETNTION:

04% patient developed urinary retention on post-op day 1
URINARY Present Study H Bulus et al

RETNTION ULTRASONIC
SCALPEL
1st POD 04% 16%
2nd POD 00% 00%
3rd POD 00% 00%
08% patient developed urinary retention on post-op day 1
URINARY Present Study H Bulus et al

RETNTION DIATHERMY
1st POD 08% 28%
2nd POD 00% 00%
3rd POD 60% 00%
Evaluation of pain (VAS score):

1. In ultrasonic scalpel haemorrhoidectomy
Evaluation of pain Present Study H Bulus et al

ULTRASONIC
SCALPEL
1st DAY 5.8 5.4
7th DAY 3.8 4
2. In diathermy haemorrhoidectomy
Evaluation of pain Present Study H Bulus et al

DIATHERMY
1st DAY 7 6.8

7th DAY 4.8 5.2
VAS score was low in ultrasonic scalpel hemorrhoidectomy as compared to
diathermy haemorrhoidectomy in our present and comparative study
RESUMPTION TO WORK:

96% patient started his routine work within 1st week
Resumption To Work Present Study H Bulus et al
ULTRASONIC
SCALPEL
1st week 96% 92 %
2nd week 04% 08%
3rd week 0% 00%
40 % patient started routine work within 2nd week
60 % patient started routine work within 3rd week
Resumption To Work Present Study H Bulus et al

DIATHERMY
1st week 00% 90 %
2nd week 40% 06%
3rd week 60% 00%
NOTE: In our study, none patient complained of anal incontinence or abscess in

follow up.
SUMMAR
Y
Haemorrhoid is one of the oldest diseases suffered by mankind, though most of
the time not life threatening still it causes significant discomfort.
Ultrasonic scalpel haemorrhoidectomy has advantage of minimal lateral

thermal effect(1-3mm), minimal intra-operative bleeding, which allows the
surgeon better exposure, so surgery takes less time and causes minimal
mucosal damage, leading to faster wound healing, less post-operative
morbidity and minimal pain.
Diathermy haemorrhoidectomy has the disadvantage of damaging the
surrounding mucosa and it does not achieve sufficient vascular coagulation,
leading to longer operative time and inadequate exposure. The surgeon has to
suture deeply in the mucosa to stop the bleeding, causing post-operative pain,
anal stenosis and loss of workspace.
The present study was done to compare the effectiveness of ultrasonic scalpel
& diathermy haemorrhoidectomy in the treatment of IIIrd&IVth degree haemorrhoids.
Post-operative pain is a complication which is less in ultrasonic scalpel

haemorrhoidectomy in comparison to diathermy haemorrhoidectomy
because of less tissue destruction, less lateral thermal injury.
Post-operative bleeding per rectum as a complication is less in ultrasonic
scalpel haemorrhoidectomy compared to diathermy haemorrhoidectomy.
In the present study ultrasonic scalpel haemorrhoidectomy is effective
in symptomatic relief, less time consuming, less post-operative complication,
and have early resumption to work.
CONCLUSIO
N
This comparative study of 50 cases who underwent ultrasonic scalpel &
diathermy haemorrhoidectomy was done to compare the effectiveness of ultrasonic
scalpel & diathermy haemorrhoidectomy in treatment of symptoms of haemorrhoids
with reference to time off work, resumption to work post procedure complications like
pain and bleeding.
Ultrasonic scalpel haemorrhoidectomy is safe, effective and time saving
method, has less blood loss, postoperative pain and complications compared to
diathermy haemorrhoidectomy. The present study has some limitations. The number
of patients was not large and our follow up period was short. The long term results
and recurrence rate should be evaluated in larger prospective studies.
From the above done comparative study the following conclusions were derived:
Ultrasonic scalpel & diathermy haemorrhoidectomy both are beneficial

procedure in operation of apprehensive patient.
Youngest patient in the study was 20 years and eldest 70 years, so wide range
of patient acceptance for procedure was noted.
Spinal anaesthesia is required for the procedure in all cases.
Ultrasonic scalpel haemorrhoidectomy take about 20 to 35 minutes while
diathermy haemorrhoidectomy take about 30 to 45 minutes.
After ultrasonic scalpel & diathermy haemorrhoidectomy no severe
complications were noted which required hospitalization.
Ultrasonic scalpel haemorrhoidectomy found to be more effective based on
significant symptom improvement with follow up.
Post ultrasonic scalpel haemorrhoidectomy complications like
Pain & vague discomfort was seen in 96% cases on 1stpost-operative
day with decreasing on 3rd day of 34% cases.
Bleeding per rectal was seen in 4% cases on 1stpost-operative day
Post diathermy haemorrhoidectomy complication like
Pain & discomfort was seen in 100% cases on 1stpost-operative day &
only 60% cases on 3rd day.
Bleeding per rectal was seen in only 12% cases on 1st post-operative
day.
In conclusion ultrasonic scalpel haemorrhoidectomy is preferred for surgical
treatment of grade IIIrd and grade IVth haemorrhoids. It is safe and effective, and
causes less intra-operative blood loss, post-operative pain and complications
compared to diathermy haemorrhoidectomy.
PROFORM
A
Name: Age
Address: Sex:
Occupation (Sedentary /Manual Worker)

Diagnosis Condition on discharge
DOA: Duration of Hospital stay
DOO:
DOD:
History of presenting illness
1. Bleeding per rectum
Mode of onset
Amount of bleeding
Frequency
Relation to defecation
2. Discharge per rectum
Mucous
Purulent
Sero Purulent
3. Pain
Nature of pain
Relation to defecation
4. Bowel Habits
Constipation / Diarrhoea/Straining at stool
5. Pruritis/Irritation
6. Prolapse
At defecation reduced spontaneously
After defecation digital replacement
Permanently prolapsed
7. Micturition
Frequency
Nature
Straining
8. Feacal incontinence
Past History
Treatment of piles
Conservative
Laxative Abuse
History of diarrhea /enteritis /colitis
History of Jaundice
Personal History
Diet
Apetite
Bowel habits
Micturition
Loss of weight
Family History
H/o haemrorhoids
General examination
Anemia Pulse
Jaundice BP
Oedema Temperature
Lymphadenopathy
CVS CNS
RS
Local examination
Inspection
External haemorrhoids
Prolapsed internal haemorrhoids
Fissure in ano
Skin tags
Fistula in ano
Dermatitis
Urethra
Per rectum
State of Sphincter
Spasm
Stricture
Lax
Mass Palpable

Number

Position
Bleeding

Tenderness Ulcerative
growth Enlargement of
prostate Proctoscopy
Number of pile
Position of pile
Bleeding/discharge
Other masses/ulcer/ulcerative growth
Sigmoidoscopy, if indicated
Investigations
Urine Albumin
Sugar
Microscopy
Blood - Hb%/TC/DC/BT/CT/PT
Random Fasting/Postprandial blood sugar
Blood Urea, Serum Creatinine
Chest x-ray
ECG
Treatment
Bowel preparation
Position
Anaesthesia
Route of anaesthesia
Post-procedure complications
Pain
Discomfort
Bleeding P/R
Anal incontinenece
urinary retention
Sepsis
Post-procedure care
Oral feeds started
Antibiotics given No. of days
Analgesics given No. of days
Laxatives
Passed stools on day (Post procedure)
Complain
Symptoms at follow up at 7 days, 1 month and 3 month
Bleeding
Pain
Prolapse
Pruritis
Anal stenosis
Mucous discharge
Anal Incontinence
ABBREVIATIO
N
CO2- Carbon Dioxide
PPH Procedure for prolapsing haemorrhoids
ST Suture threader
CS Circular Stapler
CAD Circular and dilator
PSA Purse and string suture anoscope
HIV Human Immunodeficiency Virus
USHG Ultrasonic harmonic haemorroidectomy group
DHG Diathermy haemorrhoidectomy group
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KEY TO MASTER CHART
Y Yes
N No
wk Week
VAS Visual analogue score

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Introduction

The anal canal consists of:

The anal canal is attached posteriorly to coccyx by the anococcygeal ligament,

RELATIONS OF ANAL CANAL

Divided into 3 parts

MUSCLES OF ANAL CANAL

Fig. 2: Lining membrane of anal canal

ARTERIAL SUPPLY OF ANAL CANAL

VENOUS DRAINAGE OF ANAL CANAL

LYMPHATIC DRAINAGE OF ANAL CANAL

Fig. 4: Arterial supply of the anal canal

NERVE SUPPLY OF ANAL CANAL

Internal sphincter: The internal sphincter contributes mainly to the high-

The reflex response of external sphincter is represented by transient increase in

ETIOLOGY AND PATHOPHYSIOLOGY

Both symptomatic and asymptomatic haemorrhoids are common in male.

3. SOCIO-ECONOMIC STATUS AND DIET

Haemorrhoids are particularly rare in communities which have departed least

People whose occupation required prolonged sitting or standing are more

5. VARICOSE VEIN THEORY[4]

6. VASCULAR HYPERPLASIA THEORY[5]

The vascular hyperplasia theory proposes that the principal cause of

7. SLIDING DOWNWARDS OF ANAL CUSHIONS THEORY[6]

Sliding downwards of anal cushions is the latest proposed theory. The

8. INTERNAL ANAL DYSFUNCTION THEORY

9. PREDISPOSING AND ASSOCIATED FACTORS

Many factors has been implicated in the causation of haemorrhoidal disease

A) Internal haemorrhoids A) Primary haemorrhoids

Internal haemorrhoids are symptomatic, exaggerated submucosal vascular

First degree internal haemorrhoids

Second degree internal haemorrhoids

They protrude at the time of bowel movement and reduce spontaneously.

Third degree internal haemorrhoids

They are those that protrude spontaneously or at time of bowel movements

Fourth degree internal haemorrhoids

External haemorrhoids comprise the dilated vascular plexus that is located

Are those with of internal and external component of haemorrhoids.

Secondary haemrrhoids occur under pathological situation of increase intra

CLINICAL MANIFESTATIONS [10]

As the name haemorrhoids implies bleeding is the principal and earliest

Fig.8: Type of Haemorrhoids

A mucoid discharge is a frequent accompaniment of prolapsed haemorrhoids.

Pain per se is not a symptom of uncomplicated haemorrhoids, it usually occur

Anaemia can be caused by bleeding haemorrhoids very rarely, so this can be

RECTAL MUCOSAL PROLAPSE

It is frequently confused with prolapsing haemorrhoids. Patients with this

HYPERTROPHIED ANAL PAPILLAE

Hypertrophied anal papillae usually due to underlying anal fissure occasionally

General assessment of patient to ascertain general health status.

Is crucial for diagnosis of haemorrhoids, the proctoscope is well lubricated and

Fig. 10: Sims position

Superficial ulceration of exposed mucous membrane often accompanies

Gangrene occurs when strangulation is sufficiently tight to constrict arterial

After thrombosis internal haemorrhoids sometime become converted into

Suppuration is uncommon, occurs due to infection of thrombosedhaemorrhoid.

PYELEPHLEBITIS (SYN. PORTAL PYEMIA)

Portal pyemia is surprisingly infrequent, theoretically infected haemorrhoids

To rule out anemia, Hb % is done.Total and differential, ESR, fasting blood

To rule out infection or diabetes, sugar, microscopy of urine to be done.

To rule out occult blood in anemic cases.

To rule out causes of chronic cough like chronic bronchitis, pulmonary

To rule out cardiovascular diseases.

MEDICAL OR NON-OPERATIVE MANAGEMENT