CLINICAL STUDY & MANAGEMENT OF HAEMORRHOIDS, A

COMPARATIVE STUDY OF CLOSED HAEMORRHOIDECTOMY V/S

OPEN HAEMORRHIODECTOMY

By

Dr. AMIT KUMAR

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore,

Karnataka, in partial fulfillment of the requirements for the degree of

M. S. (GENERAL SURGERY)
Under the guidance of
Dr. VIJAYA KUMAR R.

DEPARTMENT OF GENERAL SURGERY

M V J MEDICAL COLLEGE AND RESEARCH HOSPITAL
BANGALORE.
2011

i
 ACKNOWLEDGEMENT

I would, at the outset, like to express my sincere gratitude to my guide Dr. VIJAYA

KUMAR R. Professor, Department of General Surgery, M V J Medical College

and Research hospital, Bangalore for his thoughtful guidance, encouragement and

valuable insights during the entire period of this study.

I would like to express my appreciation and gratitude to Dr. N K RAY, Professor &

Head, Department of General Surgery, M V J Medical College and Research

hospital, Bangalore for his encouragement and suggestions during the entire course

of this study.

I am gratefully indebted to Dr. N. Srinivasan, Dr. Kshirsagar and

Dr. Chikkannachari .T.R., Professors, MVJ MC & RH Bangalore for their valuable

guidance and constant help during the preparation of this dissertation.

I would like to express my heartfelt thanks to my Associate Professors,

Dr. Ananthraman, Dr. N.K.Das and Dr. Aparajita Mookherjee. I would like

to thank my Assistant Professors, Dr. Ashok Kumar .B., Dr. R. N. Singh,

Dr. Ravikumar V, Dr. Adarsh Patil, Dr. Madhusudhan, Dr. Ravikumar B.R.,

Dr. Prashanth and Dr. Moin Mohammed for their help rendered to me during this

study, for their kind words and encouragement.

I received much wise counsel from Dr. T.Rajeshwari, our beloved Dean cum

Director, and I am indeed indebted to her.

vi
I am grateful to the Management, MVJMC & RH for permitting me to do this study

and to use the institute facilities for the purpose.

I would like to thank the Department of Anaesthesiology, the Anaesthsiologist, and

my fellow postgraduates for their support, cooperation and constant help during the

whole study period.

I am much indebted to my patients, without whose co-operation this work could not have

been completed.

I am extremely thankful to Mr Suresh for assisting me in the statistical analysis of

the study.

I would like to thank my family for their constant encouragement and help. My

heartfelt gratitude to all my patients who submitted themselves most gracefully and

whole heartedly participated in this study.

Date:

Place: (Dr. AMIT KUMAR)

vii
 LIST OF ABBREVIATIONS USED

BT : Bleeding Time

CT : Clotting Time

DC : Differential Count

ECG : Electrocardiogram

Hb : Haemoglobin

P/R : Per rectum

RBS : Random Blood Sugar

TC : Total Count

Yrs : Years

viii
 ABSTRACT

Background

Haemorrhoid is a common clinical entity encountered in surgical practice. The most

common method of treatment of haemorrhoids is by haemorrhoidectomy which

involves excision of pile mass, either by open haemorrhoidectomy (Milligan-Morgan)

or closed haemorrhoidectomy (Ferguson) method. The aim of study is to compare

closed v/s open haemorrhoidectomy regarding post-operative wound healing, pain and

postoperative course.

Objectives

To compare open haemorrhoidectomy with closed haemorrhoidectomy in regard to

 Post operative pain.

 Rate of healing.

 Postoperative course

Methods

Source of data: In patients of M V J medical college and Research hospital

Method of collection of data sixty patients will be randomized into open and closed

haemorrhoidectomy group of thirty each.

Results

60 cases of symptomatic grade 2nd and 3rd haemorrhoids were treated. 30 each in open

haemorrhoidectomy and closed Haemorrhoidectomy. The mean age of 35 yrs with

range of 17-80 yrs. Patients were followed up to 3 month with above mentioned

criteria .

ix
Interpretation

 In my study there are more number of cases seen below mean age of 35 yrs

of age both in males and females with male predominance.

 The most common presentation in haemorrhiods are bleeding per rectum 90%

of cases with mass and pain are 55% and 30% respectively .

 In the study group open haemorrhoidectomy had more complications in regard

to pain (p< 0.05%), bleeding (p<0.05%) and serous discharge on 1st post

operative day.

 After 3 weeks follow up pain (p<0.05) is significantly seen open group.

 73% of cases in closed group were healed at 3 weeks, in comparison to 43% in

open group.

 Pain (p<0.05%) and soiling was higher in open group compared to closed

group. The findings were statistically significant, as suggested by the p value.

 A comparable number of patients were found to be healed both in open and

closed hemarrhoidectomy at 6 weeks follow up.

Conclusion

The most commonly done surgical procedure in the treatment of haemorrhiods is open

haemorrhiodectomy but closed haemorrhiodectomy found to be beneficial in regard to

less post operative pain, early wound healing.

Keywords

Haemorrhoids , haemorrhoidectomy

x
 TABLE OF CONTENTS

SL NO CONTENTS Page No

1 INTRODUCTION 1

2 OBJECTIVES 2

3 REVIEW OF LITERATURE 3 – 54

4 METHODOLOGY 55 – 58

5 RESULTS 56 – 67

6 DISCUSSION 68 – 71

7 CONCLUSION 72

8 SUMMARY 73

9 BIBLIOGRAPHY 74 – 76

10 ANNEXURE 77

xi
 LIST OF TABLES

Sl No TABLES Page no

1 Age and sex distribution 60

2 Sex distribution 61

3 Presenting symptoms of study group 62

4 Post procedure complication 63

5 After 3 weeks follow up 64

6 Healing after 3 weeks follow up 65

7 After 6 weeks follow up 66

8 Healing after 6 weeks follow up 67

9 Comparison of age and sex distribution 68

10 Comparison of post procedure complication 69

11 Comparison at follow up at 3 weeks 69

12 Comparison of healing at 3 weeks 70

13 Comparison at follow up at 6 weeks 70

14 Comparison of healing at 6 weeks 71

xii
 LIST OF FIGURES

SL No FIGURES Page No

1 Rectum and anal canal 7

2 Arteries of rectum and anal canal 15

3 Veins of rectum and anal canal 18

4 Tributaries of superior rectal vein and position of internal 19

Haemorrhoids

5 Closed Haemorrhoidectomy 48

6 Open Haemorrhoidectomy 50

7 Haemorrhoid at 7 O’ Clock Position 57

8 After Dissection of Haemorrhoid at 7 O’ Clock 57

9 After Closer of Haemorrhoid at 7 O’ Clock 58

xiii
 LIST OF GRAPHS

Sl No GRAPHS Page No

1 Age distribution 60

2 Sex distribution 61

3 Presenting symptoms 62

4 Post-procedure complications 63

5 After 3 weeks follow up 64

6 Healing after 3 weeks follow up 65

7 After 6 weeks follow up 66

8 Healing after 3 weeks follow up 67

xiv
 INTRODUCTION

Hemorrhoids are one of the most common ailments to afflict mankind, but it is

impossible to give an accurate figure for their prevalence. Although many patients

present with symptomatic disease, many do not and some never have symptoms,

whether such individuals can be considered to have a disease must remain a moot

point.1

Hemorrhoids have plagued humans since they attained the erect posture. The word

‘hemorrhoid’ is derived from Greek word hemorrhoids, meaning flowing of blood

(haem=blood, rhoos=flowing). The word ‘piles’ comes from Latin word pila meaning

a pill or ball. To be accurate, we should call the disease as piles when the patient

complains of a swelling and ‘haemorrhoids’ when he or she complains of bleeding.1

The most common method of treatment of haemorrhoids is by haemorrhoidectomy

which involves excision of pile mass, either by open haemorrhoidectomy (Milligan-

Morgan) or closed haemorrhoidectomy (Ferguson) method. The aim of study is to

compare closed v/s open haemorrhoidectomy regarding post-operative wound

healing, pain and ostoperative course.

1
 OBJECTIVES

To compare open haemorrhoidectomy with closed haemorrhoidectomy in regard to

 Post operative pain.

 Rate of healing.

 Postoperative course

2
 REVIEW OF LITERATURE

HISTORY1

The art of proctology is based on the study of haemorrhoids and it seems appropriate

to trace the history of development of our current understanding of this rather

incompletely understood subject.

Haemorrhoidal disease has been referred to in the Edwin Smith Papyrus (1700 BC), in

the code of Hammurabi in Babylon (2250 BC) and in the papyrus of Eber (1500 BC).

It is mentioned in Sushruta Samhita (2500 BC) as Arsha Roga. Hippocrates (400 BC)

recommended cautery with a hot iron and simple excision of prolapsing piles.

The first book of Samuel in the Old Testament also refers to haemorrhoidal disease as

emerods. Galen in 2nd century AD considered bleeding from the anus as an

autotherapeutic form of blood letting.

The Italians following Galenic teachings referred to Profluvio de Sangue suggesting

an overflow of blood. The ancient French referred to flux d’or – flow of gold and the

ancient Germans called it the golden ader – golden veins implying that proctological

symptoms may have been the prerogative of the rich. Polite society in the 17th century

referred to haemorrhoidal disease as le mal de St. Phiacre.

The medieval period was one of “pile pondering” and etiological thinking began. In

1295 Landfrank, one of the fathers of French proctology wrote “Chirurgic magna”. In

3
1749 Morgagni attributed haemorrhoidal disease to erect posture of man.

“Haemorrhoids are exceedingly rare in animals except for a few fat old dogs”.2

In 1855 Verneuil suggested occlusion of superior haemorrhoidal veins by fecal bolus

caused anal varicosities. In 1879 Daret said straining at stool was the main cause of

rise in haemorrhoidal vein pressure. In 1877 Hilton described the white line as the

lowermost fibres of the internal anal sphincter as seen through the perianal skin when

stretched tight. In 1896 Stroud described the pecten, which was further described by

Miles in 1919.

Advances in treatment

Clamp, cautery and ligature methods had been described in ancient times including

the Sushruta Samhita.

 Riverius 1657 advised topical application of nitric acid.

 In 1774, Jean Louis Petit became the father of subepithelial

haemorrhoidectomy.

 In 1818, Boyer advised partial division of the sphincter.

 In 1829, Fecamier and 1864 Maisonneuve advised anal dilatation.

 In 1869, Morgan described injection treatment using persulphate of iron.

 In 1879, Andrews of Chicago introduced the phenol secret of Dr. Mitchell to

the

 Medical profession using 30% phenol in arachis oil.

 In 1882, Whitehead advocated total excision of a pile bearing area with

primary suture, in which an entire tube of mucosa and submucosal vascular

tissue was removed. The subsequent wound breakdown and severe stenosis

4
 was called the Post Whitehead deformity. This procedure had since been

abandoned.

 The 20th century is often described as the era of the pectin band.

 In 1919, Miles described the wide V-shaped excision of perianal skin and

division of the pectin band.

 In 1928, Blanchard revived fixation techniques by submucous injection of 5%

phenol in arachis oil.

 In 1937, Milligan described the low ligation technique, which later became

associated with the name of Naunton Morgan as the Milligan-Morgan

technique nicknamed as the Smash and Grab haemorrhoidectomy or the 5-

minute job.

 In 1951, Eisenhammer popularized internal anal sphincterotomy.

 In 1959, Ferguson popularized the closed haemorrhoidectomy technique.

 In 1954, Blaisdell revealed his instrument for office ligation using a silk

ligature, this was the forerunner of Barron’s 1964 instrument for elastic band

ligation.

 In 1967, Cryosurgery was first used in management of haemorrhoids by Fraser

and Gill.

 In 1969 and 1973, Lewis popularized it in the USA and in 1973 Lloyd

Williams in United Kingdom.

 In 1977, Nath developed the infrared coagulator, which was popularized by

Neiger in 1979 in the treatment of haemorrhoidal disease.

5
SURGICAL ANATOMY OF ANAL CANAL

Anal canal begins where lower end of ampulla off the rectum suddenly narrows,

passing downwards and backwards to end at the anus. It is about 3.8 cm long in the

adult, its anterior wall being slightly shorter than its posterior and in the empty

condition its lumen has the form of an anteroposterior or triradiate longitudinal slit.3

Relations of anal canal

1. Anteriorly

 In both sexes – perineal body

 In males – membranous urethra and bulb of penis

 In females – lower end of vagina

2. Posteriorly

 Anococcygeal ligament

 Tip of the coccyx

3. Laterally

 Ischiorectal fossa

Interior of anal canal

 It is divided into three parts:

 Upper part (mucous) – It is about 15 mm long.

 Middle part (Transitional zone or pecten), it is about 15 mm long.

 Lower part (cutaneous) – It is about 8 mm long.

6
Fig 1: Rectum and Anal Canal

7
 a. Upper part (Mucous)3

Pink columnar epithelium lining the rectum extends into anal canal. The upper half

(15 mm) of the anal canal is also lined by mucous membrane and is plum coloured

owing to the blood in the subjacent internal rectal venous plexus. The epithelium in

this region is variable in character; in some cases it is stratified columnar in type, in

other it is mainly stratified squamous with patches of stratified columnar, together

with stratified polyhedral cells and a single layer of simple columnar cells like those

lining the rectum. In this part of the anal canal the mucous membrane presents six to

ten vertical folds, the anal columns, which are well marked in the child but are

sometimes not so well defined in the adult.

Each column contains a terminal radicle of superior rectal artery and vein, these

radicles being largest in the left lateral, right posterior and right anterior quadrants of

the wall of the anal canal; enlargements of venous radicles in these three sites

constitute primary internal haemorrhoids. The lower ends of the columns are joined

together by small cresentric valve like folds of mucous membrane, the anal valves,

above each of which lies a small recess or anal sinus.

The sinuses, deepest on the posterior wall of the canal, may retain faecal matter and

become infected, leading to abscess formation in the wall of the anal canal; the anal

valves may be torn by hard faeces, producing anal fissure.

The line along which the anal valves are situated is termed the pectinate line; it lies

opposite the middle of the sphincter ani internus and is commonly considered to be

the site at which the anal membrane is situated in the early fetus; thus it represents the

place of junction of the endodermal part of anal canal (developed from cloaca) and the

ectodermal part (derived from the anal pit or proctodeum).

8
 b. Middle part (Transitional zone or pecten)3

It is the next part of the anal canal, which extends for about 15 mm below the anal

valves. It’s epithelium is stratified and is intermediate in thickness between the

epithelium lining the upper part and the skin lining the lower part. Transitional zone

also overlies part of internal rectal venous plexus and is shiny and bluish in

appearance. Its submucosa contains fairly dense connective tissue, in contrast with the

lax connective tissue, in upper half of anal canal, suggesting a firm support and

anchorage of the lining of pecten to the surrounding muscle coats of this part of the

anal canal.

The transitional zone ends, below at a narrow wavy zone, commonly called the “white

line of Hilton”; this line is bluish pink in colour and is only rarely recognizable

macroscopically.

It’s only interest lies in the fact that it is situated at the level of interval between the

subcutaneous part of external sphincter and the lower border of the internal sphincter,

and on digital examination of anal canal an anal intersphincteric groove can be felt at

this site.

3
c. Lower part (Cutaneous)

It is about 8 mm long lying below the white line and is lined by true skin, which may

be dull white or brownish in colour and contains sweat glands and sebaceous glands.

9
Anal cushions

These are small submucous masses comprising of fibroelastic connective tissue,

smooth muscle, dilated venous space and arteriovenous anastomoses. Usually anal

cushions forms at left lateral (3 O’ clock), right posterior (7 O’ clock) and right

anterior (11 O’ clock) positions in the upper anal canal. Smaller cushions may also

present between them.

The opposition of these anal cushions assists the sphincter in maintaining watertight

closure of anal canal. Excessive straining at stools may cause enlargement of these

cushions and formation of haemorrhoids.4

Anatomical and surgical importance of the dentate (pectinate) line

It forms the embryological watershed between visceral structures above and somatic

structures below the line.

 The mucosa above the line has an autonomic nerve supply and is thus

insensitive to cutting and pricking, whereas the skin below is supplied by

inferior rectal branch of the pudendal nerve and is acutely sensitive to these

stimuli.

 The venous drainage of the mucosa is upwards into the inferior mesenteric and

portal circulation, whereas that of skin below is to the systemic circulation.

This is relevant to the spread of malignant tumours.

 The lymphatic drainage above the dentate line is upwards and is similar to that

of the rectum whereas below lymph drains down and out to the inguinal lymph

nodes. The lymphatic spread of malignant tumours and of infections in this

area will thus differ.

10
  Internal haemorrhoids develop just above this line.

 The anal glands open into anal sinuses above the anal valves at this level and

infection in an anal gland may lead to an anal abscess, which may extend into

the ischiorectal space or the perianal space.

 A crack or fissure in the skin of the anal canal extending from the dentate line

to the anal verge, and usually lying in the midline, is associated with local

inflammation and spasm of sphincter, causing severe pain on defaecation in

this sensitive area with its rich somatic nerve supply. A fissure in ano is

sometimes caused by rupture of one of the anal halves.

 In the finer control of continence, stimulation of nerve endings in the region of

the dentate line may initiate reflex or voluntary changes in the sphincter tone. 4

Musculature of anal canal

Muscles of anal canal can be regarded as forming tube within a funnel. The sides of

the upper part of the funnel are the levator ani muscles and the stem of the funnel is

the external sphincter, which is continuous with levator ani. The tube inside the stem

of the funnel is the internal sphincter.

Internal anal sphincter

This is involuntary in nature. It is thickened continuation of the circular muscle coat

of the rectum. It surrounds the upper 3/4th of the anal canal, which commences where

rectum passes through the pelvic diaphragm and ends at the anal orifice. This

sphincter is 2.5 cm long and 2.5 mm thick. When exposed during life, it is pearly

white in colour and its individual transversely placed fibres can be seen clearly.

11
Spasm and contracture of this muscle play a major role in fissure and other anal

affections.

External anal sphincter

Earlier, it is sub-divided into deep, superficial and subcutaneous portions, which is

now considered to be one muscle (Goligher). It is voluntary and it is made up of

striated muscle. It surrounds the whole length of anal canal. It is supplied by inferior

rectal nerve and perineal branch of 4th sacral nerve.

Anorectal ring

It is a muscular ring, formed by fusion of puborectalis, deep external sphincter and

internal sphincter. It is easily felt by a finger in the anal canal. Surgical division of this

ring results in rectal incontinence. The ring is less marked anteriorly where the fibres

of the puborectalis are absent.5

Conjoint longitudinal coat

It is formed by fusion of the puborectalis with the longitudinal muscle coat of the

rectum at the anorectal junction, between external and internal anal sphincters, soon it

becomes fibroelastic and at the level of white line it breaks up into a number of

fibroelastic septa which spread out fanwise, pierce the subcutaneous part of external

sphincter and are attached to the skin around the anus. The most lateral septum forms

the perianal fascia and most medial one, the anal intermuscular septum, is attached to

the white line. In addition, some of the strands pierce obliquely the internal sphincter

and end in submucosa below the anal valves.

12
Surgical significance of the anal musculature

Continence depends on the integrity of the sphincter mechanism and its nerve supply,

and on maintenance of the anorectal angle. Incontinence may result from injury to the

pudendal nerve or damage to the sphincter by over zealous stretching, injury or

surgical incisions.4

BLOOD SUPPLY OF THE ANAL CANAL

Arterial supply

Superior haemorrhoidal artery

Superior haemorrhoidal artery, the terminal branch of inferior mesenteric artery

reaches the back of the upper end of rectum opposite the third piece of sacrum. Here it

divides into two main branches, the right and the left, the level of bifurcation shows

considerable individual variation.

These branches descend on the rectal wall at first posteriorly, then inclining more

towards the lateral aspect one generally breaking up into smaller branches. They

penetrate the muscle coat to reach the submucosa in which they proceed-downward as

straight vessels, which run in the column of Morgagni. They terminate usually above

the anal valves as a capillary plexus.

The right branch divides into two major branches, which run down the right anterior

and right posterior aspect of rectum while the left branch continues undivided down

the left lateral aspect.

13
As the superior haemorrhoidal veins closely accompany the arteries, this arrangement

of arterial branches is said by Miles to account for the occurrence in cases of internal

haemorrhoids of two main haemorrhoids on the right side but only one on the left

side. This arrangement is said to account for the positions of three primary piles but

WHF Thompson (1975)6 has disproved this hypothesis in an injection preparation of

cadavers.

Middle haemorrhoidal artery

These arise from anterior division of internal iliac or rarely from their inferior vesical

branches and proceed medially and forward below the pelvic peritoneum in the tissue

of the lateral ligaments to reach the rectal branches of superior and inferior

haemorrhoidal vessels. The variations are found, as middle haemorrhoidal artery may

be absent, double or treble on one or both sides.

14
Fig 2: Arteries of Rectum and Anal Canal

15
Inferior haemorrhoidal artery

It is derived indirectly from the internal iliac through its internal pudendal branch,

passing through the Alcock’s canal in the fascia of the outer wall of the ischiorectal

fossa, it runs medially and slightly forward breaking up into branches, which

penetrate the external and internal sphincters and reach the submucosa and

subcutaneous tissue of the anal canal. They communicate with the branches of the

inferior haemorrhoidal artery of the opposite side and possibly from the middle

haemorrhoidals of both sides. Thus, the anal part of mucous membrane is supplied by

the inferior haemorrhoidal artery.

Middle sacral artery

This artery arises from the back of the aorta about 1 cm above its bifurcation and runs

down in front of the last two lumbar vertebrae, the sacrum and coccyx and behind the

aorta, left common iliac vein and the presacral nerve, the superior haemorrhoidal

vessels and rectum. Some of its terminal branches may descend along the

anococcygeal raphae of the levator muscle to reach the anal canal and rectum to

contribute to their blood supply.

Venous drainage

The submucous or internal haemorrhoidal plexus lies in the upper part of anal canal

and lower rectum. They unite to form the superior haemorrhoidal vein, which drains

into the inferior mesentric vein (portal system). Subcutaneous or external

haemorrhoidal plexus of veins drain the anal orifice and lower anal canal. They inturn

drain into inferior haemorrhoidal vein, which enters the systemic circulation via the

internal iliac vein. The middle haemorrhoidal vein, which is relatively unimportant,

16
also enters internal iliac vein. There are communicating veins between these two

plexus of veins. The veins have discrete dilatations along their course particularly

below the dentate line in the sub-anodermal tissues.7

Lymphatic drainage

Above the pectinate line, the lymphatics drain with those of the rectum into the

internal iliac nodes. Below the pectinate line, the lymphatics drain into the medial

group of the superficial inguinal nodes.

Nerve Supply

Above the pectinate line, the anal canal is supplied by the autonomic nerves, both

sympathetic (inferior hypogastric plexus, L1, L2) and parasympathetic (pelvic

splanchnic S2, S3, S4) nerves. Pain sensation is carried by both of them. Below the

pectinate line, it is supplied by somatic (inferior rectal S2, S3, S4) nerves. Internal

sphincter is contracted by sympathetic nerves and relaxed by the parasympathetic

nerves. The external sphincters are supplied by the inferior rectal and perineal branch

of fourth sacral nerve.

17
Fig 3: Veins of Rectum and Anal Canal

18
Fig 4: Tributaries of Superior Rectal Vein and Position of Internal

Haemorrhoids

19
SURGICAL PHYSIOLOGY8,9,10

Skin of the perianal region and modified skin below the pectinate line exhibits the

same sensitivity to simple touch, pain, heat and cold, as does the skin of the rest of the

body.

Anal mucosa above the pectinate line is insensitive to ordinary tactile and painful

stimuli, but sometimes produce vague sensation of discomfort, which is more acute

near anal valves.

The highly sensitive area plays an important role in defaecation reflex. In lower

animals distension of lower rectum causes relaxation of external sphincter. But in man

and other social animals external sphincter remains contracted till proper environment

is available for defaecation. Anal nerve endings also differentiate between flatus and

faeces.

The importance of retaining lower part of the rectum in wide excision has been

stressed since a long time.

Anal continence

It depends on an acquired capacity to suppress the natural urge to defaecate. The

proper exercise of such control requires possession not only of a muscular controlling

apparatus but also of a sensory mechanism to provide information that the rectum is

full.

20
Sensory component

The normal sensation of rectal distension due to faeces generated in the wall of the

rectum proper and is mediated via the sacral parasympathetic nerves. Todd (1959)

suggested that sensation in the anal canal also contributes to the afferent side of

mechanism of anal continence, particularly in regard to differentiation between faeces

and flatus, which is important in the conscious exercise of continence. This sensory

apparatus in the anal canal is important in differentiation of contents of the rectum and

to facilitate the appropriate voluntary motor response.

Motor component

The muscular control is provided by the internal and external sphincters.

Anorectal manometry in haemorrhoids

Anal sphincter tone normally ranges from 60-110 cms of water with episodes of

spontaneous falls in resting anal pressures termed sampling reflexes. Higher sphincter

pressures with higher than normal distribution of type I muscle fibres in the external

sphincter suggest a state of tonic contraction of muscle in some patients (Teramato,

1981). Birmingham manometric studies classified patients with haemorrhoidal disease

into those with high anal pressure – the so called hypertensive pile patients who are

more often young males presenting with symptoms of bleeding; those with low anal

pressures often multiparous and older women presenting more often with prolapse.

21
ETIOPATHOGENESIS OF HAEMORRHOIDS

Several theories have been proposed but no single theory has been found satisfactory.

1. Campbell and Cleave identified dietary factors resulting in constipation as a

cause. Cleave termed it the “Saccharine disease”. They found a lower

incidence in tribal Africa and it is possible to speculate that high fibre intake in

rural societies may be the reason for the low incidence but there has been no

positive or negative evidence that the incidence of haemorrhoidal disease has

decreased since the advent of the bran mania of the 1970s. Other possible

explanations could be that patients are more likely to complain in western

societies because medical services and pharmaceutical preparations are more

readily available.

2. Virchow and Allingham considered haemorrhoids to be hemangiomatous and

erectile in nature.

3. Steltzner called it the corpus cavernosum recti.

4. Graham Stewart11 suggested that they are varicosities of the superior

haemorrhoidal plexus of veins and could be divided into two types: Vascular

haemorrhoids, which bleed and mucosal haemorrhoids, which prolapse.

5. Theory of ageing: Jackson and Robertson12 and wear and tear theory of

Adams and Gass9 suggest that age related fragmentation and loss of elastic

and anchoring tissue aggravated by daily trauma of staining leads to

haemorrhoids.

22
6. Rangabhashyam and Manohar13 attributed it to perineal descent syndrome

especially in patients with constantly prolapsing and in recurrent

haemorrhoids. He also found a high incidence of amoebiasis in patients with

haemorrhoids. Squatting position tends to cause bearing down on pelvic floor

and predisposes to prolapse of the pile masses.

7. Nesselrod considered anal infection as the principal factor and Mc Givney

described high incidence of round cell infiltration as an evidence of infectious

process.

8. Haas10 considered haemorrhoids as normal parts of human anatomy and that

symptomatic haemorrhoids must be treated.

9. Role of heredity1: Leicester found a positive family history in 50% but there

is no firm evidence of an inherited predisposition as diet and defecatory habits

are usually related to customs and environment.

10. Role of defaecatory habits: Though not backed by studies it is a frequent and

reliable observation that many patients with haemorrhoidal disease are those

who sit for 10-15 minutes on a comfortable lavatory taking with them some

reading material. Such patients are obsessed by the necessity to have a regular

act of defaecation and are determined to sit there till they do.

11. Venous obstruction by fecal bolus was suggested by Verneuil.

12. Morgagni attributed it to erect posture of man.

23
 13. Secondary haemorrhoids: the relation to definite organic disease is also

controversial: Congestion and hypertrophy of the anal cushions may occur due

to:

 Failure to empty rapidly

 Abnormal mobility

 Trapping by a tight anal sphincter

Factors favouring venous hypertension in haemorrhoidal veins include:

1. Veins traverse the anal musculature: Allgower stated that venous outflow

from the haemorrhoidal plexus partially runs through the internal sphincter

and that sphincter hyperfunction leads to a vicious circle of venous

engorgement, pain at defaecation and a further rise in sphincter tone. Read

noted that increased sphincter tone in patients with haemorrhoids disappeared

after haemorrhoidectomy suggesting it to be the effect rather than the cause.

2. Absence of valves leading to increase in pressure with rise in intraabdominal

pressure as in ascites or pelvic tumors of pregnancy.

3. Hormonal factors like FSH, Prolactin and Glucocorticoids according to Saint

Pierre play a role in pregnancy piles.14 Weakness arising from the influence of

progesterone on smooth muscle and elastic tissue possible explains the

predisposition to haemorrhoids in pregnancy, although a general increase in

pelvic vascularity also contributes. Many women date their haemorrhoids not

to actual pregnancy but to parturition when the supporting tissues of the anal

cushions may be torn.7 Pressure of the fetus on the superior rectal veins

causing obstruction has been postulated.

24
4. Communication between portal and systemic circulations: Jacobs in 198015

in his study showed that incidence of symptomatic haemorrhoids in portal

hypertension is 28% whereas that in the general population is 50% (Buie et al,

1937). The prevalence of anorectal varices in cirrhotics without portal

hypertension was 19% where as it was 59% in cirrhotics with portal

hypertension with history of bleed from esophageal varices. Hirschowitz10

states that haemorrhoids do not necessarily occur in patients with esophageal

varices. Swart10 stated that because of the long distance between the portal

and the haemorrhoids veins based on the Hagen-Pouisseuill equation, venous

pressure in the haemorrhoids does not increase appreciably and they are not an

important site of collateral circulation between the venacava and portal

system. McPherson16 in a study of 128 consecutive cases of portal

hypertension did not encounter a single case, which he could attribute to

cirrhosis.

5. Faecal mass in rectum may compress these veins – Parks ampullary pump

theory.

6. Relation to carcinoma rectum: Causative relation has not been proved.

Chronic straining due to obstruction or sensation of incomplete emptying and

obstruction to middle rectal vein have been postulated. Other authors state that

the relation is merely coincidenta

25
SYMPTOMS

Patients with haemorrhoidal disease experience varying degrees of the following

symptoms, bleeding, anal swelling, pain, discomfort, discharge, hygiene problems and

pruritis. Usually, but not invariably, the larger the cushions and the more they

prolapsed the more troublesome are the symptoms.1

BLEEDING

This is the most common complaint and usually the earliest in the development of the

disease. The blood is invariably bright red and is often first noticed on the lavatory

paper, particularly after passing a non-blood stained hard stool. The type of bleeding

in haemorrhoidal disease is different from that produced by a rectal neoplasm or

ulcerative proctitis but may be similar to that experienced by patients with fissure in

ano or even when there is perianal dermatitis with severely macerated skin.

Haemorrhoidal disease can be generally distinguished from these last two conditions

by the absence of pain or pruritis.

Later in the development of the disease the bright red bleeding may become profuse,

dripping into the pan-like a tap or spattering the sides like a jet to mark the end of the

act of defaecation. This profuse bleeding occurs when the cushions are prolapsed

beyond and congested by the sphincter. Such bleeding is pathognomonic of

haemorrhoidal disease.1

Bleeding unrelated to defaecation occurs even later in the progression of the disease

and may occur continuously as a bright red bloody mucous discharge.

26
This tends to happen particularly in the elderly whose inner vascular cushions,

covered with mucous membrane, lie permanently outside the anus. In them, the

sphincter tone is poor and congestion is minimal, so bleeding is rarely profuse.

Younger patients with grossly hypertrophied cushions occasionally prolapse and

reduce spontaneously apart from during or after defaecation, often at times of physical

activity, sporting exertion or ecstasy. The higher anal tone in these sufferers often

congests the cushions and so bleeding can be embarrassingly profuse. Such patients

are the most prone to bleed enough to become anaemic

PROLAPSE AND LUMPS

Prolapse and lumps protruding through the anus are the real piles. As a rule, prolapse

of haemorrhoids develop in later stages. It occurs initially at defaecation in the height

of straining effort and slipping immediately afterwards, later the piles tends to be in

prolapsed condition even after cessation of straining effort. Patients find it necessary

to replace them digitally into the anal canal. Finally, the stage is reached where piles

are more or less permanently prolapsed with anal mucosa exposed and in contact with

under clothing.

PAIN AND DISCOMFORT

Uncomplicated haemorrhoidal disease is usually painless. Presence of severe pain

indicates another diagnosis or a complication. Thrombosed prolapsed internal piles

(strangulated) indicate a clinically obvious, very painful complication.

27
A thrombosed external vascular channel will also be painful and obvious externally.

In the absence of such clear external stigmata of thrombosis, acute mindriveting pain

suggests an alternative diagnosis such as fissure, abscess or carcinoma. Discomfort or

a dull pain in the anus after defaecation is not uncommon in the presence of congested

prolapsed cushions and is characteristically relieved by reduction of prolapse.

Prolapsed cushions in those with low anal canal tone are usually painless.1

DISCHARGE, HYGIENE DIFFICULTIES AND PRURITIS

A constant mucous discharge from the anus with or without blood staining is

characteristic of patients whose internal cushions, covered with mucous membrane,

are constantly prolapsed beyond the anal verge. At best this soils their underclothes, at

worst it macerates the skin.1

28
NATURAL HISTORY AND COMPLICATIONS

Data on natural history of untreated haemorrhoidal disease are scanty. We do not

know what proportion of people who suffer at sometime from bleeding, prolapse, pain

or pruritis subsequently have no further trouble or have intermittent minor symptoms

or what proportion later have severe complications. We do not know why some

patients become progressively worse and develop complications.1

Complications

Profuse haemorrhage

It is not rare. Most often, it occurs in the early stages of second degree. The bleeding

occurs mainly externally, but it may continue internally after the bleeding

haemorrhoid has retracted or has been returned. In these circumstances, rectum is

found to contain blood.2

Strangulation

One or more of the internal haemorrhoids prolapse and become gripped by the

external sphincter. Further congestion follows because the venous return is impeded.

Second-degree haemorrhoids are most often complicated in this way. Strangulation is

accompanied by considerable pain, and is often spoken by the patient as an acute

“attack of piles”. Unless, the internal haemorrhoids can be reduced within 1 or 2

hours, strangulation is followed by thrombosis.2

29
Thrombosis

The affected haemorrhoid become dark purple or black and feels solid. Considerable

oedema of the anal margin accompanies thrombosis. Once the thrombosis has

occurred, the pain of strangulation largely passes off, but tenderness persists.2

Ulceration

Superficial ulceration of the exposed mucous membrane often accompanies

strangulation with thrombosis.2

Gangrene

Gangrene occurs when strangulation is sufficiently tight to constrict arterial supply of

the haemorrhoid. The resulting sloughing is usually superficial and localized.

Occasionally, a whole haemorrhoid sloughs off, leaving an ulcer, which heals

gradually. Very occasionally, massive gangrene extends to the mucous membrane

within the anal canal and rectum and can be the cause of spreading anaerobic

infection and portal pyaemia.2

Fibrosis

After thrombosis, an internal haemorrhoid sometimes becomes converted into fibrous

tissue. The fibrosed haemorrhoid is at first sessile, but by repeated traction during

prolapse at defaecation, it becomes pedunculated and constitutes a fibrous polyp that

is readily distinguished by its white colour from an adenoma, which is bright red.

Fibrosis in an external haemorrhoid favours prolapse of an associated internal

haemorrhoid.

30
Suppuration

Suppuration is uncommon. It occurs as a result of infection of a thrombosed

haemorrhoid. Throbbing pain is followed by perianal swelling and perianal or

submucous abscess results.2

Pylephlebitis (Portal Pyaemia)

Theoretically, infected haemorrhoids should be a potent cause of portal pyaemia and

liver abscess. Although cases do occur from time to time, this complication is

surprisingly infrequent. It can occur when patients with strangulated haemorrhoids are

subjected to ill-advised surgery and has even been reported to follow banding.2

31
ASSESSMENT OF THE PATIENT

History

The definitive diagnosis of haemorrhoidal disease can be made almost always if a

careful history is taken, paying particular attention to the colour and character of

bleeding, the relation of discomfort to defaecation and the unequivocal history of

relief from reduction of the prolapse into anal canal. The importance of detailed

assessment by endoscopy in establishing the diagnosis is to exclude the other often

more dangerous causes of rectal discharge, prolapse, anal pain and bleeding.1

Inspection

Discharge from averted anal canal mucosa in third degree piles is readily seen if the

patient is examined when comfortable and relaxed in the left lateral position and when

he or she can be persuaded to bear down. This maneuver will also allow

differentiation of true full thickness rectal prolapse from simple internal cushion

prolapse. A good light, careful inspection and palpation may be required to

differentiate haemorrhoidal discharge from a chronic fistula in ano or from perianal

Crohn’s disease.

Palpation

It is the next most important method of assessment. The examination must be

performed slowly with adequate lubrication: local anaesthesia may be required. In the

absence of an episode of thrombosis, acute anal pain is a rare feature of

uncomplicated haemorrhoidal disease. It’s presence should make one suspect a fissure

in ano, which is best diagnosed by inspection, an abscess, which is should be detected

readily by its localized induration, redness and pain, or anal carcinoma which can be

32
recognized by palpating its hard edge on digital examination. Solitary rectal ulcer may

sometimes be identified by palpation.

ENDOSCOPY

Proctoscopy

This will demonstrate the presence of internal vascular cushions and may show them

to be bleeding. The differentiation of causes of rectal or anal bleeding is the most

important objective of the assessment. Other causes of bright red rectal bleeding must

be excluded before attributing the cause to haemorrhoid.

Sigmoidoscopy

This will demonstrate the normality of rectal mucosa and so exclude inflammatory

bowel disease. It should also exclude solitary rectal ulcer, mucosal polyps or

carcinoma of the rectum. Bright red rectal bleeding can come from sigmoid

neoplasms, so the assessment of rectal bleeding should include flexible

sigmoidoscopy to 60 cms. This counsel of perfection may not be possible in all

circumstances but should be the aim. Full sigmoidoscopy is mandatory whenever

there is blood mixed with stool. If there is any doubt whatsoever concerning the

diagnosis, the rest of the colon will need investigation, preferably by colonoscopy, or

by barium enema, if colonoscopy is not readily available.

33
CATEGORIZATION OF DEGREES

It has been traditional to grade haemorrhoidal disease into four degrees, depending on

the extent of prolapse. This is to use the term “piles” in its true meaning.

 First-degree piles: are cushions that do not descend below the dentate line on

straining and they bleed.

 Second-degree piles: are cushions that protrude below the dentate line on

straining and can be seen at exterior, only to disappear again immediately

straining stops.

 Third-degree piles: are cushions that descend to the exterior on straining or

defecation and remain outside until they are digitally replaced into the anal

canal.


Fourth-degree piles: is the term sometimes used to describe mucosal covered

internal cushions that are permanently prolapsed outside the anal verge.1

34
MANAGEMENT

A wide variety of treatment options are available for haemorrhoidal disease, ranging

from advise on diet and bowel habit, through a number of non-operative methods of

mucosal fixation and widening of anus, to a host of different techniques of excision of

internal anal vascular cushions and external vascular channels.

The choice of method depends on the severity and type of symptoms, on the degree of

prolapse and on expertise of operator and equipment available.

CONSERVATIVE MANAGEMENT

1. Medical management

 Advise

 Changing defaecation habits

 Diet manipulation

 Vasotopic drugs

 Topical applications

2. Invasive therapy

 Mucosal fixation

 Injection or sclerotherapy

 Rubber band ligation

 Cryotherapy

 Photocoagulation

3. Bipolar diathermy (BICAP)

4. Direct current therapy

35
MEDICAL MANAGEMENT1

Advise

Advise is the best directed at those patients who have only minor symptoms and who

have obviously an incorrect diet or hygiene habits. It is suitable only for those who are

amenable to suggestion and have intelligence and ability to take it. If the patients

principal complaint is loose stools, itching and smearing of blood on tissue paper, it is

best to begin with advise about a high fiber diet, avoiding diarrhoeagenic foods or

drink and thorough gentle perianal lavage after defaecation.

Changing defaecation habits

Three errors of bowel habit that seem to be prevalent in patients with haemorrhoidal

disease are:

 Insistence on having atleast one bowel movement daily.

 Neglect the first urge to defaecate in the morning because it is not convenient

to do so.

 Insistence on trying to pass the last portion of stool from the rectum or anal

canal in the belief that, if it is not passed, discomfort will persist all day.

Diet manipulation

Aim of dietary advice is to increase the bulk of the stool. Natural food rich in fibre,

especially fruits are highly recommended. Psyllium seed preparations, wheat

products helps to normalize bowel movements, especially when they are combined

with sufficient fluid intake of atleast 5-8 ounce of water per day.1

Vasotopic drugs

Hydroxyethylrutosides have been suggested as they reduce oedema and inflammatory

swelling.1

36
Topical applications

Aim of topical treatment is to lubricate, anaesthetize the anal canal so that it can

defaecate eventually. Now various preparations are available are composed of

antiseptic, anaesthetic, anti-inflammatory or anti-thrombotic drugs. Examples include

Anusol, Xyloproct and Proctofoam. Topical preparations help in acute exacerbation of

haemorrhoids but never help in reducing the prolapse or changing the stage of lesion.

INVASIVE THERAPY

Principles

Three broad methods have developed in parallel with each one relating to hypothesis;

these are:

 Prevention of prolapse by mucosal fixation.

 Prevention of congestion or venous impedance by stretching or by dividing the

 Internal sphincter.

 Excision of the engorged internal vascular cushions.1

Mucosal fixation

Mucosa and the submucosal vascular cushions can be fixed to the underlying muscle

coat by creating submucosal fibrosis or full thickness ulceration. The fibrosis or

scarring prevents or minimizes prolapse of the cushions through or into the anal canal

during defaecation. Methods of fixation includes:

 Ligation or suture

 Injection of an irritant sclerosant

 Creating an ulcer by strangulation, burning or freezing.1

37
INJECTION OR SCLEROTHERAPY

Indications

This is ideal for first-degree internal haemorrhoid, which bleed. Early seconddegree

haemorrhoids are often cured by this method but a proportion relapses.

Technique

Patient should have an empty rectum, but no special preparation is necessary. A

proctoscope is introduced and the haemorrhoids are displayed. The injection is made

above the main mass of each haemorrhoid into the submucosa at or just above, the

anorectal ring. Using a Gabriel’s syringe or more commonly a disposable instrument

with the bevel of needle directed towards the rectal wall, 3-5 ml of 5% phenol in

almond oil is injected. The injection should produce elevation and pallor of the

mucosa. The solution spreads in the submucosa upwards to the pedicle and

downwards into the internal haemorrhoid and to secondary haemorrhoids if present,

but it is prevented by the muscular septum from reaching the external haemorrhoid.

There is slight, transient bleeding from the point of puncture. The injection is painless,

but a dull ache is common for few hours. There is no special after treatment. If there

is only one haemorrhoid present, it may be cured by one injection; if all three

haemorrhoids are equally enlarged, each is injected at the same session. Often three

sessions at six weekly intervals are required.2

Complications

 Pain from badly sited injection or from submucosal extravasation.

 Haemorrhage from the puncture point.

38
  Lower urinary tract sepsis and even impotence in the male from grossly

misplaced injection.

 Tight encircling submucosal band formation.

 Bacteraemia in 8%.1

RUBBER BAND LIGATION1,11,12

Principle

It produces fixation of mucosa by causing ulceration rather than a simple submucosal

inflammation.

Equipments used

A number of instruments have been advised. The original Barron ligator gives the

smoothest operation and is sufficiently robust for frequent use. It is the most

commonly used. The rubber O-rings are 2-3 mm and are loaded onto the 11 mm inner

drum. The McGiveny ligator is simpler and cheaper but less sturdy. Von Hoorn’s

banding equipment makes it a one-handed procedure using a 1.8 cm proctoscope with

a large rubber band stretched over its tip. Thomson’s device is a modified McGiveny

applicator used with a proctoscope. Other makes include the Preston gun and a

complex multiaction machine popular in France. Recently, ligating device attached to

the end of a video endoscope has been described.

39
Indications: II or III degree haemorrhoids.

Technique

The base of the cushion lies 1.5 and 2 cms from the pecten and here the mucosal

tissue can be grasped with forceps and drawn into a preloaded inner drum. A rubber

band is discharged by pressing the trigger. Barron recommended only one ligation

should be performed at each session spaced at 3 weeks interval. Subsequent authors

recommend two or even all three ligations at the same sitting. Additional procedures

include phenol injection into the strangulated tissue or freezing it.

Complications

Pain

Most common at the time of ligation or a few moments later. Usually mild but

occasionally may warrant removal of the band, which is not very easy, and use of an

alternative method. It is felt as discomfort in 20% and severe in 3%.

Bleeding

1% when the necrosed tissue separates, the plane of cleavage between dead and live

tissue is vascular granulation tissue that frequently bleeds.

Pelvic cellulitis

In 1980, O’Hara reported a case of fatal clostridial infection resulting from banding

haemorrhoids. Perforation and deep ulceration.

40
CRYOSURGERY

Lewis introduced cryosurgery in treatment20 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.21

Instrument

A cryoprobe through which nitrous oxide at -60 to -800 C or liquid nitrogen at -1960 C

is circulated.22

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.

Postoperative care and complications of cryosurgery

Patients can be sent home 20-30 minutes after the procedure. Profuse discharge

associated with foul smell and irritation from necrosis was the rule. Cryotherapy

involves pain and healing time was very long. Some cases even reported destruction

of anal sphincter with anal stenosis and incontinence.22

41
PHOTOCOAGULATION1

This technique was developed by Nath et al in 1977 for hemostasis, adapted to

haemorrhoidal disease by Neiger 1979.

Principle

A 1.5 second pulse of infrared irradiation is given to attain tissue temperature of 1000

C and produce a 3 mm diameter and 3 mm deep burn. The tissue reaction is similar to

cryo or EBL and dead tissue separates after 10-14 days. Re- epithelization is usually

complete in 4 weeks.

Equipment

A 15 V Wolfram halogen lamp with a gold plated reflector which focuses the rays

through a quartz light shaft to the side of mucosa through a proctoscope.

Technique

Upto 6 coagulations can be performed at the base of each haemorrhoids can be given.

Indications

I, II and III degree haemorrhoids.

Complications

Eye damage is a possibility.

Pain – due to incorrect site. But of the techniques available it is least painful.

Bleeding – Less common.

42
BIPOLAR DIATHERMY (BICAP)

Principle

BICAP produces tissue destruction, ulceration and fibrosis by the local application of

heat.

Equipment

The disposable Circon ACMI BICAP (Stanford, CT) haemorrhoid probe used bipolar

RF current to coagulate the blood vessels.

Current is passed through the tissue as it travels between adjacent electrodes located

at the tip of the probe. Because the current path is short, its advantage over other

methods is that the depth of penetration is limited even after multiple applications.

Technique

Using a disposable non-conductive anoscope, the side of the probe is applied directly

and firmly to the haemorrhoid above the dentate line. The generator is used on the

infinity setting and is activated by foot switch. A white coagulum approximately 3

mm depth is produced. All haemorrhoids are treated in one session. No local

anaesthetic is required.

DIRECT CURRENT THERAPY1

Equipment

Monopolar low voltage instrument including a generator unit, attachable handle,

single use sterile probes, a grounding pad and a non-conductive anoscope.

43
Method
The probe is placed onto and then into the haemorrhoid. Now electric current upto 16

mA is passed through the probe. The mode of action of this device is not thermal but

by the production of NaOH at the negative electrode. The major disadvantage of this

method is to apply a probe for a period of 10 minutes to haemorrhoid.

44
OPERATIVE TREATMENT OF HAEMORRHOIDS

1. Overcoming anal canal fibrosis or anal hypertension

 Anal stretch procedure

 Internal sphincterotomy

2. Suture

3. Haemorrhoidectomy

 Closed haemorrhoidectomy

 Open haemorrhoidectomy

 Whitehead haemorrhoidectomy

 Laser haemorrhoidectomy

 Diathermy haemorrhoidectomy

Anal stretch procedure

Lord suggested in 1968 that internal haemorrhoids are caused by circular constricting

fibrous bands in the wall of lower rectum or in anal canal leading to abnormal rise of

intrarectal pressure during the act and consequent venous congestion. Lord had

popularized 8 finger dilatation resulting in incontinence. Presently, 4-6 finger

dilatation is used.13

It is recommended for patients with thrombosed internal haemorrhoids and in young

men < 45 years with painful or bleeding haemorrhoids with anal hypertension. It

should not be done in multiparous women or in patients > 60 years because of risk of

incontinence (10%). It is preferred for anal fissure rather than haemorrhoids.

45
Complications1

 Bleeding and bruising

 Splitting of skin usually posterior quadrant – may lead to cellulitis.

 Mucosal prolapsed

 Incontinence upto 10% - has gained medico-legal importance

Internal sphincterotomy

Internal sphincterotomy has been used in a selected group of patients with

haemorrhoids who had high resting anal pressures. The operation is usually performed

as a subcutaneous technique using a cataract knife under local or general anaesthesia;

alternatively an open internal sphincterotomy may be performed.

Complications

 Prolapse

 Perianal haematoma

SUTURE1,7

Farag (1978) revived an ancient technique when he described suture of what he

described as perforating veins at the base of the cushion. Wanas likened these veins to

those with high pressure leaks associated with incompetent perforators of leg. A 3-0

non-absorbable mattress suture is placed at base of vascular cushions occluding the

perforating veins and attaining mucosal fixation as well. All three are ligated at one

session.

46
CLOSED HAEMORRHOIDECTOMY

In 1931 Fansler22 described a technique where intra anal anatomic dissection was

conducted which was later developed and modified by Ferguson and Heaton in 1959.

They had three principle objectives:

 To remove as much vascular tissue as possible without sacrificing anoderm.

 To minimize postoperative serous discharge by prompt healing with the

immediate lining of the anal canal with stratified squamous epithelium

(anoderm).

 To prevent the stenosis that may complicate healing of large raw wounds by

granulation tissue.

Indications

 Excessive bleeding, uncontrolled with rubber band ligation.

 Severe prolapse or pain.

 Symptomatic haemorrhoids in patients who have other anorectal conditions

requiring operation.

Relative contraindications

 Crohn’s disease

 Portal hypertension

 Leukaemia

 Lymphoma

 Bleeding diathesis

47
Fig -5 Closed Technique of Haemorrhoidectemomy

48
Technique

Insertion of a Hill-Ferguson anal retractor after anaesthetizing the patient, and

haemorrhoid is exposed. Light elliptical incision with scalpel extending from the level

of anorectal ring above to the perianal region below. This incision is deepened down

to the underlying sphincter musculature and haemorrhoid is dissected off the

structures from either side and from perianal region. Now haemostasis should be

secured and pedicle is clamped and tied off. Now close the haemorrhoidectomy

wound by suturing the gap in the lining of anal canal caused by excision. After

surgery patient is left with three sutured wounds extending into perianal region. No

dressing required in the anal canal. But the anal orifice and perianal region are

covered with piece of dry gauze and pad of cotton wool held in position by “T”

bandage.

Postoperative care and complications are similar to that of open haemorrhoidectomy.

Variations in technique include – use of left lateral position by Ferguson, prone jack

knife position by Khubchandani, adjuvant sphincterotomy and marsupialisation by

Ruiz-Moreno.

49
OPEN HAEMORRHOIDECTOMY14,15

Open haemorrhoidectomy is practiced most frequently in UK as the Milligan -

Morgan operation usually under spinal anaesthesia or general anaesthesia in lithotomy

position.

Fig. 6: Ligation and Excision of Haemorrhoids – By Open Technique

a. The skin is cut to the left lateral haemorrhoid;

b. Transfixation of the pedicle; (c) ligation

Technique

The skin covered component of each of the main piles is seized with artery forceps

and retracted outwards, the purple anal mucosal component is grasped and drawn

down and out. With a V-shaped incision, the anal and perianal skin dissection is

carried out to free the cushions off the internal sphincter for 1.5-2 cms and pedicle is

transfixed and ligated with either absorbable or non-absorbable suture. The isolated

50
haemorrhoid is then excised a few millimeter below the apical ligature, the

transfixation suture being left long. Adequate bridge of skin and mucosa should be

left in between. The final word “if it look like a clover, the trouble is over, if it looks

like a dahlia, it is surely a failure”.

The anal canal is packed with paraffin wax impregnated gauze and dressings applied.

Variations of technique

Addition of sphincterotomy and anal dilatation – critical evaluation of the two has not

substantiated any benefit with added risks to continence. Postoperatively laxatives,

non-constipating, non-narcotic analgesics and antibiotics are prescribed. The pack is

removed after 24 hours and sitz bath prescribed.

Excessive use of intravenous fluids has been implicated as an independent risk factor

in urinary retention.

Complications

1. Pain – 71%

2. Acute retention of urine – 16.4%

3. Reactionary or secondary haemorrhage – 7.6%,

Those requiring re-operation – 1%

4. Other rare complications include:

 Anal stenosis – 2.9%

 Anal fissure – 0.5%

 Abscess – 0.6%

 Fistula in ano – 1.2%

 Long-term incontinence16

51
Other complications include skin tags, pseudopolyps and epidermal cysts. Anal

leakage and soiling is common (50%) during early postoperative period but settlesin

6-8 weeks. Causes include anal dilatation, loss of sensation and transient reduction in

anal canal pressures. Return of anal canal pressure to normal has been described.

CIRCULAR HAEMORRHOIDECTOMY12,17,18

In 1882, Whitehead described excision of entire pile bearing area upto the muscle

with primary closure. Similar techniques have been described for prolapsed grade IV

haemorrhoids in the form of circular haemorrhoidectomy with anoplasty using the

Hospital Leopold Bellan (HLB) technique, also called radical haemorrhoidectomy.

More recently, circular staplers have been used for the same purpose with advantages

of reduction in time and blood loss.

LASER HAEMORRHOIDECTOMY

Use of carbon dioxide laser for haemorrhoidectomy has been described recently (Chia

YW, 1995). It has been said to be less painful as the laser burns and seals vessels and

nerves simultaneously but according to others (Dozois RR)19, it offers no advantage

over conventional haemorrhoidectomy. Its role is still being evaluated.

52
MANAGEMENT OF HAEMORRHOIDS IN SPECIAL CIRCUMSTANCES1

Pregnancy

Haemorrhoidal disease can develop for the first time during pregnancy or become

exacerbated by the presence of gravid uterus. There is often increased constipation

and increased venous compression in the pelvis. Conservative measures should be

used if at all possible as symptoms usually rapidly resolve postpartum. Thus, patients

should be advised about diet and be prescribed laxatives and topical agents. However,

if prolapse and thrombosis occur, there is no clearcut answer as to whether surgery

should be employed. Anal stretch should not be done because of increased risk of

incontinence in a patient whose sphincter is already under jeopardy from pregnancy

and subsequent birth trauma. A haemorrhoidectomy can be performed using

intravenous sedation and local anaesthesia provided the pregnancy is otherwise

uncomplicated. A closed haemorrhoidectomy in left lateral decubitus during 2nd and

3rd trimesters (Milsom, 1992). If prolapse and thrombosis occur during delivery

(Schottler et al) recommend haemorrhoidectomy immediately postpartum.1

Inflammatory bowel disease

Exacerbation of haemorrhoidal disease is not uncommon in patients with

inflammatory bowel disease. One might conclude that treatment of haemorrhoids is

relatively safe for patients with ulcerative colitis, but hazardous for those with

Crohn’s disease. Haemorrhoidectomy in ulcerative colitis is preferred when rectal

inflammation is in remission and when it is unlikely that a pouch procedure will be

considered in the future.

53
Immunocompromised states

Drug therapy

Patients who are receiving immunosuppressive therapy such as steroids,

chemotherapeutic agents or anti-rejection drugs, and who develop haemorrhoids,

should be treated conservatively as possible. If surgery becomes necessary,

appropriate precautions should be taken to prevent sepsis and necrosis of wounds.

Thus, a complete bowel preparation should be used and antibiotic prophylaxis should

be continued for five days.1

Leukaemia and Lymphoma

Biopsy should be contemplated and if haemorrhoids are diagnosed they should be

treated conservatively. Surgery should be performed only when the haematological

disorder is quiescent and then only using small excisions for prolapsed haemorrhoids

and prophylactic antibiotics should be given.1

54
 METHODOLOGY

Source of data

The present study is a prospective study from August 2008 to March 2010. The data

for which was drawn from patients visiting M V J Medical College and research

hospital , Bangalore a total of 60 cases.

Materials and methods

In the present study 60 cases of 2nd and 3rd degree haemorrhoids were chosen

withcomplaints of bleeding per rectum, pain during defecation, mass per rectum,

discharge and irritation. A detailed history of each patient was taken with personal

history, family history, diet 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. Investigations included haemoglobin, total count, differential count,

erythrocyte sedimentation rate, blood sugar, bleeding time, clotting time, blood urea,

serum creatinine and urine routine. Other investigations like Chest x-ray,

electrocardiogram, sigmoidoscopy and colonoscopy were done only in selected cases.

The patients were explained in detail about their disease and the various modalities of

treatment as Open haemorriodectomy, closed haemorrhoidectomy, Rubber band

ligation, cryotherapy, sclerotherapy with the advantages and disadvantages of each.

Willing patients were selected and examined and investigated as per proforma.

Analysis was made on basis of percentages, mean, standard deviation, binomial

probability tests.

55
Inclusion criteria

 Patients with complaints of bleeding per rectum, mass per rectum, pain,

irritation, discharge per rectum

 Patients with 2nd and 3rd degree hemorrhoids suitable for surgery

Exclusion criteria

Haemorrhoids associated with complications (ulceration, recurrent cases, strangulation)

Preoperative preparation

Patients were prepared the previous day, perianal region, perineum and back were

shaved. 0.5 ml of tetanus toxoid injection was given intramuscularly, written consent

was taken, Preanaesthetic evaluation was done and a soap water enema was given the

night before and on the morning of the surgery. Patients were kept nil orally from the

previous night. Antibiotics were given on the day of surgery, before the procedure.

Patient was explained about the effects and complications of the procedure.

56
 Fig 7: Haemorrhoid at 7 O’ Clock Position

Fig 8: After Dissection of Haemorrhoid at 7 O’ Clock Position

57
Fig 9: After Closer of Haemorrhoid at 7 O’ Clock Position

58
 RESULTS

In the present prospective study the following data for clinical studies was obtained

from M V J medical college and Research Hospital, Bangalore. 60 cases of

symptomatic second and third degree hemorrhoids cases were chosen during the

period from August 2008 to March 2010.

59
 Table - 1

Age and sex distribution

Age in years Male Female Total

< 30 12 08 20

31-40 12 05 17

41-50 18 - 18

>50 04 01 05

Total 46 14 60

Graph 1

Age and sex distribution

60

50

40
Male
30
Female
Total
20

10

0
< 30 31-40 41-50 >50 Total

Age distribution with sex

In my study there are more number of cases seen below 30 yrs of age both in males

and females with male predominance.

60
 Table –2

Sex Distribution

Sex No. of cases %

distribution (n=60)

Male 46 76

Female 14 24

Graph 2

Sex Distribution

80
70
60
50
Male
40
Female
30
20
10
0
No . of cases %

Sex distribution

76 % of my cases are male and 24% are females.

61
 Table 3
Presenting symptoms of study group

Presenting symptoms Number %

Bleeding 54 90

Mass 33 55

Painful defecation 18 30

Constipation 14 23

Anal irritation 15 25

Graph 3

Presenting symptoms

60

50

40

30

20

10

0
Bleeding Mass Pain Constipation Anal
irritation

Presenting symptoms

The presenting symptoms of the 60 cases who underwent open and closed

haemorrhoidectomy are as follows:

The most common presentation in haemorrhiods are bleeding per rectum 90% of

cases with mass and pain are 55% and 30% respectively

62
 Table 4

Post Procedure Complication

Complications Open Closed

Haemorrhoidectomy Hamorrhoidectomy

n=30(%) n=30(%)

Serous discharge 20(66) 12(40)

Pain 23(76) 15(50)

Minor bleeding 20(66) 12(40)

Urinary retention 03(10) 02(06)

Graph 4

Post Procedure Complication

25

20

15
Open Haemorrhoidectomy
(n=30)
10 Closed Hamorrhoidectomy
(n=30)
5

0
Serous Pain Minor Urinary
discharge bleeding retension

Post procedure complication

In the study group open haemorrhoidectomy had more complications in regard to pain

(p< 0.05%), bleeding (p<0.05%) and serous discharge on 1st post operative day.

63
 Table 5

After 3 Weeks Follow up

Complications Open Closed

Hemorrhoidectomy hemorrhoidectomy

n=30(%) n=30(%)

Pain 18(60) 10(33)

soiling 16(53) 10(33)

Graph 5

Follow up After 3 Weeks

18
16
14
12
10
8
6
4
2
0
Pain Soiling

Open hemarrhoiectomy Closed hemarrhoidectomy

Post procedure complications

After 3 weeks follow up

After 3 weeks follow up pain (p<0.05) is significantly seen open group

64
 Table 6

Healing after 3 weeks follow up

Open Closed

Hemorrhoidectomy hemorrhoidectomy

n=30(%) n=30(%)

Healing 13(43) 22(73)

Graph 6

Healing after 3 weeks follow up

Healing

Open Hemorrhoidectomy
n=30(%)
Closed hemorrhoidectomy
n=30(%)

Healing after 3 weeks follow up

73% of cases in closed group were healed at 3 weeks, in comparison to 43% in open

group.

65
 Table 7

After 6 Weeks follow up

Complications Open Closed

Hemorrhoidectomy hemorrhoidectomy
n=30(%) n=30(%)
Pain 10(33) 03(10)

soiling 11(36) 06(20)

Graph 7

After 6 Weeks follow up

12

10

0
Pain Soiling

Open hemarrhoidectomy Closed hemarrhoidectomy

After 6 weeks follow up

Pain (p<0.05%) and soiling was higher in open group compared to closed group. The

findings were statistically significant, as suggested by the p value.

66
 Table 8

Healing after 6 Weeks follow up

Open Closed

Hemorrhoidectomy hemorrhoidectomy

N=30(%) n=30(%)

Healing 26(86) 28(93)

Graph 8

Healing after 6 Weeks follow up

Healing

Open Hemorrhoidectomy
N=30(%)

Closed
hemorrhoidectomy
n=30(%)

Healing after 6 weeks follow up

A comparable number of patients were found to be healed both in open and closed

hemarrhoidectomy at 6 weeks follow up.

After 3 month follow up

Both in open and closed group had completely healed wound with no anal stricture

67
 DISCUSSION

1) Age and sex distribution

Table 9

Age and sex distribution

Procedure Open Haemorrhoidectomy Closed Haemorrhoidectomy

Present study Arbman et. al.23 Present study Arbman et. Al.23

Mean Age 35 48 38 49

(in years) (20-60) (21-80) (17-80) (25-81)

Male/Female 23/7 26/13 23/7 22/16

Ratio

The age and sex distribution among both the procedures was compared with a study

done by Arbman et.al.

In our study, we found that the age at presentation was more than a decade earlier

than the age at presentation seen in the study.

The male: female ratio in our study was also found to be much higher than in the

study by

Arbman et.al.

68
 2) Post-procedure complication

Table 10

Post-procedure complication

Complication Open Haemorrhoidectomy Closed Haemorrhoidectomy

Present You.S.Y.et.al24 Present You.S.Y.et.al24

study study

Pain (in %) 76 45 50 15

Compared to a study by You. S.Y et.al, pain was seen in a higher percentage of

patients in our study for both the procedures. But the pain following open

Haemorrhoidectomy was seen in a larger percent of patients than those undergoing

closed Haemorrhoidectomy. This is comparable to the results of You.S.Y.el.al.

3) Follow-up at 3 Weeks

Table 11

Follow-up at 3 Weeks

Open Haemorrhoidectomy Closed Haemorrhoidectomy

Present study Arbman et. al. Present study Arbman et. al.

Pain (in %) 60 54 33 46

Soiling(in %) 53 78 33 27

Pain and soiling following both the procedures was assessed after 3 weeks and

compared with the study by Arbman et.al. In our study, we saw that a higher

percentage of people complained of pain and soiling at 3 weeks following open

haemorrhoidectomy than those undergoing closed Haemorrhoidectomy which was

comparable to the results of the above mentioned study.

69
 4) Healing after 3 Weeks

Table 12

Healing after 3 Weeks

Open Haemorrhoidectomy Closed Haemorrhoidectomy

Present Arbman You.S.Y.et.al Present Arbman You.S.Y.
study et. al. study et. al. et.al
Healing(%) 43 18 18 73 86 75

Healing at 3 weeks was compared to studies by Arbman et.al. and You.et.al.

Compared to both the studies, a higher rate of healing was seen following open

haemorrhoidectomy in our study while, healing rates following closed

haemorrhoidectomy was comparable to that seen in both the studies. As with the other

two studies, a higher rate of healing was seen in closed as compared to open

haemorrhoidectomy.

5) Follow up at 6 Weeks

Table 13

Follow up at 6 Weeks

Open Haemorrhoidectomy Closed Haemorrhoidectomy

Present study Arbman et. al. Present study Arbman et. al.

Pain (in %) 33 24 10 19

Soiling(in %) 36 52 20 28

Pain and soiling following both the procedures was assessed after 6 weeks and

compared with the study by Arbman et.al. In our study, we saw that a higher

percentage of people complained of pain and soiling at 6 weeks following open

haemorrhoidectomy than those undergoing closed haemorrhoidectomy which was

comparable to the results of the above mentioned study.

70
 6) Healing after 6 weeks

Table 14

Healing after 6 weeks

Complication Open Haemorrhoidectomy Closed Haemorrhoidectomy

Present study Arroyo Present Arroyo.S.Y.et.al

et.al25 study

Healing(in %) 86 40 93 90

Healing at 6 weeks was compared with a study by Arroyo et.al. In our study, the

healing rates following both the procedures were almost comparable at 6 weeks,

whereas, in Arroyo’s study, healing was seen in only 40% of patients following open

hemarrhoidectomy but 90% patients had healed wounds after closed

hemarrhoidectomy.

71
 CONCLUSION

Hemorrhoids is one of the oldest diseases suffered by mankind causing significant

discomfort, and the most common clinical presentation being bleeding and mass per

rectum. Commonly done surgical procedure is open haemorrhoidectomy popularized

by Milligan – Morgan.

This study was done to compare the above procedure with closed haemorrhoidectomy

popularized by Ferguson, with respect to post operative pain, wound healing, post

operative course.

The results of the study concluded that post operative pain was less in closed

haemorrhoidectomy with early wound healing.

72
 SUMMARY

 In my study there are more number of cases seen below mean age of 35 yrs of

age both in males and females with male predominance.

 The most common presentation in haemorrhiods are bleeding per rectum 90%

of cases with mass and pain during defecation are 55% and 30% respectively

 In the study group open haemorrhoidectomy had more complications in regard

to pain (p< 0.05%), bleeding (p<0.05%) and serous discharge on 1st post

operative day.

 After 3 weeks follow up pain (p<0.05) is significantly seen open group.

 73% of cases in closed group were healed wounds at 3 weeks, in comparison

to 43% in open group.

 Pain (p<0.05%) and soiling was higher in open group compared to closed

group. The findings were statistically significant, as suggested by the p value.

 A comparable number of patients were found to be healed both in open and

closed haemorrhoidectomy at 6 weeks follow up.

 After 3 month follow up both the groups had no complications.

73
 BIBLIOGRAPHY

1. Keighley and Williams, Surgery of Anus, rectum and colon, Second

edition,Vol 1: Saunders Publications, Pg. 351-422.

2. Norman S. Williams. Anus and anal canal in Bailey and Love’s Short practice

of surgery, 24th edition, Arnold Publications; Pg. 1242-1263.

3. Williams and Warwick. Gray’s anatomy, 36th edition, Churchill Livingstone,

Ch. 8, Pg. 1358 - 1361.

4. Gag Decker, DJ du Plessis. Lee Mc Gregor’s - Synopsis of Surgical Anatomy,

Twelfth Edition, Bristol: John Wright and Sons; Pg. 61-68.

5. Chummy S. Sinnatamby. Last’s anatomy – Regional and applied, Tenth

edition, Churchill Livingstone, Pg. 305-308.

6. Thompson WHF. The nature of haemorrhoids. Br J Surg, 1975; 62: 542-52.

7. Thomson WH. Haemorrhoids. Chapter 20.1 in Oxford Textbook of

Surgery,edited by Morris PJ and Malt RA, New York, Oxford University

Press, 1994; Pg. 1125-1136.

8. Gibbons CP, Bannister JJ, Read NW, Role of constipation and anal hypertonia

in the pathogenesis of haemorrhoids. Br J Surg, 1988; 75; 656-660.

9. Gass and Adam. Haemorrhoids. Aetiology and Pathology, Am J Surg, 1950;

79:40-43.

74
10. Haas PA et al, The pathogenesis of haemorrhoids, Dis Colon Rectum, 1984;

27: 442-450.

11. Dodi G, Pirone E, Cavallari F. Sclerotherapy and elastic band ligation of

haemorrhoids. Annali Italian di Chururgia, 1995; 66 (6); 769-73.

12. White JE, Syphax B, Funderburk WW. A modification of the white head

haemorrhoidectomy. Surg Gynecol Obstet, 1972; 134: 103.

13. Hancock BD, Smith K. The internal sphincter and Lords procedure for

haemorrhoids. Br J Surg, 1975; 62: 833-6.

14. Milligan ETC. Haemorrhoids. BMJ, 1939; 2: 412.

15. Milligan ETC, Morgan C, Naughton Jones, Office RR. Surgical anatomy of

anal canal and the operative treatment of haemorrhoids. Lancet 1937; ii: 1119.

16. Abbasakoor et al. Anal endosonography in patients with anorectal symptoms

after haemorrhoidectomy. Br J Surg, 1998; 85: 1522-24.

17. Whitehead W. Surgical treatment of haemorrhoids. BMJ, 1882; 1: 149.

18. Boccasanta P et al. Circular haemorrhoidectomy in advanced haemorrhoidal

disease. Hepatogastroenterology, 1998; 45 (2): 969-72.

19. Dazois RR. Disorders of the anal canal. Section X, Chapter 32 in Sabiston

Textbook of Surgery, 15th edition, Saunders, Pg. 1036-37.

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20. Arabi Y, Gatehouse D, Alexander J. Williams, Keighley MRB. Rubber band

ligation or lateral subcutaneous sphincterotomy for treatment of haemorrhoids.

Br J Surg 1977; 64: 737-740.

21. Christina Sardinha, Marvin L. Corman. Haemorrhoids. Surg Clin N Am 2002;

82: 1153-1167.

22. Philip H. Gordon, Santhat Nivatvongs. Principles and practice of surgery for

colon, rectum and anus, 1st ed, Quality Medical Publishing Inc., 1992; 1: 10-

38, 2: 51-62; 8: 180-197.

23. Gunnar Arbman, Hans Krook, Staffan Haapaniemi. Closed vs. Open

hemarrhoidectomy- Is there any difference? Dis colon rectum, 2000, jan;43 (1)

:31-34

24. S. Y. You, S. H. Kim, C. S. Chung, D. K. Lee. Open vs. closed

hemarrhoidectomy. Dis colon rectum, 2005; 48:108-113.

25. A. Arroyo, F. Perez, E. Miranda, P. Serrano, F. Candela, J. Lacueva et al.

Open versus closed day-case haemorrhoidectomy: is there any difference? Int

J Colorectal Dis;2004: 19:370-373.

76
 PROFORMA

Name: IP No:

Age: SL No:

Sex Date of admission:

Occupation Date of haemorrhiodectomy

Religion Date of discharge:

PRESENTING COMPLAINTS

Bleeding Per Rectum: Yes/No/Duration Nature:

Mass Per Rectum: Yes/No/Duration Nature:

Straining at defecation Yes/No/Duration Nature

Painful defecation: Yes/No/Duration Nature:

Constipation: Yes/No/Duration Nature

Discharge Per Rectum Yes/No/Duration Nature

Anal irritation:

PAST HISTORY

Surgeries

Medical conditions: Diabetes/Hypertension/Tuberculosis/Asthma.

FAMILY HISTORY

77
PERSONAL HISTORY

Diet Sleep

Bowel/Bladder Smoker/Alcoholic

EXAMINATION

GPE:

Pallor Icterus

Cyanosis Clubbing

Lymphadenopathy

Vitals: Pulse rate: Blood pressure:

Systemic examination

Per abdomen

Cardiovascular System:

Respiratory System:

Central Nervous System:

Local Examination

Per rectal: Digital

Anoscopy

Diagnosis:

INVESTIGATIONS

Hb%: TC: DC: ESR: RBS: Blood urea:

Serum creatinine: BT: CT: Chest x-ray: ECG:

78
PREOPERATIVE PREPARATION

Overnight fasting; Injection TT; Shaving of relevant parts; soap water enema;

previous night and in the morning.

PROCEDURE

Anaesthesia: Position:

Haemorrhiodectomy Duration at each site:

Postop: Antibiotic: Analgesic:

COMPLICATIONS

Pain:

Discharge:

Bleeding:

Urinary retention:

Other:

FOLLOW UP

3 Day

3 Weeks

6 Weeks

3 months

IMPRESSION

79
 Presenting Type of complication Follow up
Complaints surgery

Grade of haemorrhoids

No of haemorrhoids

Open haemorrhoidectomy

Closed hamorrhiodectomy
Hb(gm/dl)

3 weeks

6 weeks
Painful defecation

Urinary retension
Serous discharge

3 days
Minor bleeding
SL NO

IP no Name Date of

Discharge P/R
Anal irritation
AGE

Bleeding P/R
SEX

Gm
Constipation

HB

%
Mass P/R

3 months
surgery

Pain

Healing

Healing
Soiling

Soiling

Soiling
Pain

Pain

Pain
1 64097 Sanoop 24 M 20/08/08 + + - - - - II 3 12 + + + + - + + - + + - - + NC

2 65817 Veketappa 60 M 10/09/08 + + - - - - III 2 11 + + + + - - + - + - - + - NC

3 66405 Thimaihh 50 M 19/09/08 + + - - - + III 2 13 + + + - - + + + + - + + - NC

4 67363 Nanjappa 50 M 01/10/08 - + - - - - II 3 11 + + - + - - + - + + - - + NC

5 68007 Naveen 23 M 10/10/08 + + - - - - II 2 13 + - + - - + - + - + + - + NC

6 67543 Munisham 80 M 22/10/08 + - - - - - III 3 10 + + - - + - + - + - - + - NC

apa

7 69996 Naveencha 46 M 5/11/08 + - + - + + II 3 11 + + + - - + - - - + - - + NC

ndra

8 69992 Rajanna 45 M 5/11/08 + + - + - - III 2 10 + + - - - + + + + + + - + NC

9 70409 Srinivas 39 M 10/11/08 + + - + - - II 3 12 + + - + + - - - - - - - - NC

80
10 76644 Ananth 37 M 12/11/08 + + + - - + II 2 11 + + + - - + - + - + + - + NC

11 72985 Goutam 27 M 10/12/08 + + - - - - II 2 10 + - + - - - - - - + - - + NC

12 73607 Rivana 40 M 17/12/08 + + - + - - II 3 10 + - - - - + - + - - - - - NC

13 74361 Ballapa 47 M 24/12/08 + - - - - - II 3 12 + + + + - + - + - - + - - NC

14 77297 Fazail ali 30 M 21/01/09 + + - - - + II 3 12 + + - - - + - + - - + - + NC

15 76582 Chikkapa 43 M 21/01/09 + + + - - - III 2 11 + - + - - - - - - + - - + NC

16 76673 Radhakrish 36 M 22/01/09 + + - - + - II 3 11 + - - + - - - - - - - - + NC

na

17 78600 Murugesh 26 M 12/02/09 - - + + + - II 3 12 + + + + - + + + + + + + + NC

18 79082 Savitha 22 F 18/02/09 + + - - - + II 3 10 + + - + - - - - - + - - + NC

19 74221 Krishnamur 41 M 19/02/09 + - + - - - II 3 12 + + + + - + + + + - + - + NC

thy

20 70723 Mare 40 M 26/02/09 + + + + - - II 2 13 + - - - - - - - - + - - + NC

gowda

21 80305 Narayanap 50 M 09/03/09 + + - - - + III 3 10 + - + - - + - + - + - - + NC

pa

22 81509 Sandhya 32 F 18/03/09 + + - - - - II 2 12 + - - + - - - - - + - - + NC

23 81670 Rammana 30 M 19/03/09 + - - + - + II 3 11 + - + - - + - + - + + - + NC

81
24 92409 Mallika 38 F 23/03/09 + + - - - - III 3 10 + + + - - - + - + + - + + NC

25 82788 Natraj 30 M 02/04/09 + - - - - + II 2 12 + + - + - - - - - - - - + NC

26 83380 Kashinath 42 M 08/04/09 + - + + + - II 3 12 + + + + - + + + + - + + + NC

27 84351 Veketappa 49 M 22/04/09 + - - - - - II 2 12 + + + + + + - + - - - - + NC

28 84477 Naranamm 38 F 24/04/09 + + - - - + II 2 12 + - - - - + - + - - - - + NC

a

29 89943 Jayashree 30 F 30/04/09 - + + - - - II 2 13 + + + + - + + + + + + - + NC

30 85499 Mamatha 22 F 07/05/09 + - - - - - II 2 11 + - - + - + - + - - - - + NC

31 86084 Shankar 43 M 14/05/09 + + - + - + II 3 11 + + + + - + + + + + - + + NC

32 87990 Srinivas 65 M 04/06/09 - + + - + - II 2 12 + - - - + - - - - + - - + NC

33 88546 Papamma 52 F 11/06/09 + - - + - + II 2 11 + + - + - + - + - + - - + NC

34 88542 Ramachan 29 M 11/06/09 - + - - - - III 3 10 + + + + - + + + + + + + + NC

d

35 89815 Amitraj 38 M 25/06/09 - + - - - + II 3 14 + + + - - - + - + + - + + NC

36 89475 Rudrappa 26 M 22/06/09 + - + + + - III 3 10 + + + + - + + + + - - + + NC

37 96182 Satya 25 F 29/06/09 + - + - + II 2 12 + + - - - - + - + + - + + NC

38 89990 Munivekek 39 M 29/06/09 + - - - - - II 2 10 + - + + - - - - - - - - + NC

tappa

82
39 90496 Satyarami 37 F 02/07/09 + - - - - + III 3 10 + + + + - + + + + + + + + NC

40 91451 Giriyappa 38 M 13/07/09 + - + - + - II 3 12 + + + + - - + - + - - + + NC

41 92036 Pranath 26 M 20/07/09 + + - + - + II 3 13 + - + - - + - + - + - - + NC

42 93364 Dharmaraj 35 M 03/08/09 + + - + - - II 2 12 + - + + - - - - - + - - + NC

43 10015 Lalith 29 M 28/10/09 + - + - + - III 2 10 + - - - - - - - - - - - + NC

6

44 10266 Avinash 17 M 25/11/09 - - - - + - II 3 12 + + + - - + + + + - - - + NC

2

45 10786 Nagesh 20 M 21/01/10 + - - - - - II 3 11 + - + + - - - - - - - - + NC

3

46 10852 Latha 25 F 21/01/10 + - + - - - II 2 14 + - - - - - - - - + - - + NC

7

47 10785 Ramappa 50 M 25/01/10 + - + - - - III 2 11 + - + + - - - - - + - - + NC

0

48 10981 Vanitha 26 F 28/01/10 + + - - + - III 3 12 + - + + - + - + - - - - + NC

8

49 10861 Keerthi 23 F 04/02/10 + + + - - - III 2 12 + - + - - + - + - - - - + NC

8

50 10641 Prakash 41 M 04/02/10 + - + + + - III 2 11 + + + - - - + - + + - + + NC

3

83
51 10802 Rajesh 31 M 14/02/10 + + - - - - II 3 11 + - + + - + - + - - - - + NC
9

52 10706 Gowramm 40 F 15/02/10 + - + - - - II 3 13 + - - + - - - - - + - - + NC

7 a

53 11009 Papanna 46 M 22/02/10 + + - - - - II 2 11 + - + - - + - + - - - - + NC

6

54 10785 Rangappa 50 M 25/02/10 + - - - + - III 2 15 + + + - - - + - + + - - + NC

0

55 11098 Pushpa 32 M 04/03/10 + + - - - - II 3 10 + - + - + + - + - - - - + NC

4

56 10927 Sampagi 35 M 04/03/10 + + - - - - II 3 11 + + - + - - + - + + - + + NC

1

57 11044 Someseker 45 M 11/03/10 + + - - + - II 2 12 + - - + - - - - - + - - + NC

2

58 10865 Ravi rao 45 M 15/03/10 + + + - - - III 3 13 + + + + - - + - + + - + + NC

7

59 11106 Rajesh 26 M 18/03/10 + + - - + - III 3 11 + + - - - - + - + + - + + NC

2

60 11254 Sumathi 26 F 25/03/10 + + - - - - II 2 12 + - + + - - - - - + - - + NC

8

NC – NO COMPLAINS

84