HEMORRHOIDS

dr. Erwin Syarifuddin Sp.B-KBD

DEFINITION
 Hemorrhoids are clusters of
 vascular tissues
 Smooth muscles
 connective tissues
That lie along the anal canal in three columns
 left lateral (3 o’clock)
 right anterior (11 o’clock)
 right posterior positions. (7 o’clock)

Because some do not contain muscular walls, these clusters may be considered
sinusoids instead of arteries or veins
HEMORRHOIDS??

Nonetheles “Hemorrhoids” commonly invoked to characterize the

pathologic process of symptomatic hemorrhoid disease instead of
the normal anatomic structure.

Hemorrhoids defined as the symptomatic enlargement and/or distal

displacement of anal cushions, which are prominences of anal mucosa
formed by loose connective tissue, smooth muscle, arterial and
venous vessels
CLASSIFICATION OF A HEMORRHOID =
DENTATE LINE
Internal hemorrhoids lie above the dentate line and are derived from
endoderm.
Covered by columnar epithelium
Innervated by visceral nerve fibers and thus cannot cause pain.
Vascular outflows of internal hemorrhoids include the middle and superior
rectal
veins, which subsequently drain into the internal iliac vessels.
CLASSIFICATION OF A HEMORRHOID =
DENTATE LINE
External hemorrhoids are located below the dentate line and
develop from ectoderm embryonically.
Covered with anoderm, composed of squamous epithelium
Innervated by somatic nerves supplying the perianal skin and thus producing
pain.
Vascular outflows of external hemorrhoids are via the inferior rectal veins
into the pudendal vessels and then into the internal iliac veins

While no taxonomy of external hemorrhoids is used clinically (Banov L Jr, Knoepp LF Jr)
PATHOPHYSIOLOGY
There are two current theories that could be associated in the genesis of the
pathology : (Lohsiriwat 2012).
The vascular theory in which arteriovenous shunts with increased blood
flow lead to anal cushions enlargement that could in turn cause mucosal
edema, thrombosis, and bleeding.
The mechanical theory is based on the deterioration of the anal
cushions’ supporting tissue leading to a sliding anal mucosa with
subsequent mucosal ulceration and bleeding
GRADES OF HEMORRHOID
Internal hemorrhoids are further stratified by the severity of prolapse.
 1st degree: Internal hemorrhoids do not prolapse out of the canal but are
characterized by prominent vascularity.
 2nd degree : Hemorrhoids prolapse outside of the canal during bowel
movements or straining, but reduce spontaneously.
 3rd degree : Hemorrhoids prolapse out of the canal and require manual
reduction.
 4th degree : Hemorrhoids are irreducible even with manipulation.
SIMPTOMPS
 Anal bleeding
 Hematochezia
 Pain
 Pruritus
 Wet anus
 Constipation
DIAGNOSIS
 History : Anal bleeding,
Hematochezia, Pain
 Anal & Digital Rectal Examination
(exclude others causes)
 Endoscopy
MANAGEMENT
 First-line therapy : prevention and minimally interventional therapy
particularly in the community setting.
 Diet and lifestyle play an important role in haemorrhoid management.
 Fibre has traditionally been thought to both prevent and treat
haemorrhoidal symptoms.
 Further advice to increase oral fluids, exercise regularly, avoid straining
and constipation-inducing medications makes logical sense but there is
unfortunately little evidence.
DRUG THERAPY
 Preparatory creams and suppositories. These combinations of :
 Steroids
 Anaesthetics
 Antiseptics
 Barrier Creams
May be effective in temporarily relieving the acute symptoms of haemorrhoidal disease.

 Venotonic therapies : Oral flavonoid

 Increase vascular tone
 reduce venous capacity
 decrease capillary permeability
 Facilitate lymphatic drainage and have anti-inflammatory effects.
A large meta-analysis showed that venotonics have significant beneficial effects on bleeding,
pruritus, discharge and overall symptom improvement
SITZ BATH
The main goal of medical treatment is to control acute
symptoms of hemorrhoids rather than to cure the underlying
hemorrhoids.
(Varut Lohsiriwat 2016)

Surgery is the treatment of choice for hemorrhoids that have

failed to respond to conservative measures. (Faucheron, 2018)
SURGICAL PROCEDURE
HEMORRHOIDECTOMY
 Hemorrhoidectomy by excision
of the three main pedicles
arranged in the classic 3, 7, and
11 o’clock position with ligation
of vascular pedicle and the raw
area of dissection to be closed
by secondary intention (Milligan et al.
1937).

 Ferguson et al. proposed a

variation of the technique, by
closing the wound with the aim
to decrease the postoperative
pain and soiling (Ferguson et al. 1971).
 Gold standard for excision hemorrhoidectomy
HEMORRHOIDECTOMY
been the only surgical treatment for
 Hemorrhoidectomy has
hemorrhoids during nearly 50 years and is still considered as the
main option if recurrence is the main consideration for the patient
HEMORRHOIDECTOMY -
COMPLICATION
 However, anal cushions contribute to maintaining anal continence during
coughing, straining, and sneezing (Aigner et al. 2009).
 Anal cushions protect the underlying anal sphincters during defecation and
play a key role in differentiating gas, liquid, and solid and the
subsequent decision to evacuate(Sneider and Maykel 2010; Yeo and
Tan 2014).
significant postoperative pain,
 Hemorrhoidectomy is associated with
perianal discharge, irritation, and late complications such as
anal incontinence and stenosis
MODERN SURGERY FOR
HEMORRHOID
To decrease postoperative complications, several procedures have been
proposed;
These new techniques have emerged in the end of the twentieth century
and can be considered as modern surgical approach to hemorrhoids.
1. Thermofusion hemorrhoidectomy
2. Doppler-guided hemorrhoidal artery ligation
3. Stapled hemorrhoidopexy
4. Embolization
(Critical Aspects of Modern SurgicalApproach to Hemorrhoids; Jean-Luc Faucheron, Bertrand Trilling, and Pierre-Yves Sage;2018)
THERMOFUSION
HEMORRHOIDECTOMY
The energized vessel sealing system allows sealing of blood vessels up to 7
mm in diameter with minimal thermal spread.
Very high frequency current and provides hemostasis by denaturing collagen
and elastin from the vessel wall (Nienhuijs and de Hingh 2009).
Retraction of the hemorrhoidal tissue that is dissected off the internal anal
sphincter using the device; the pedicles are secured by thermofusion and
the wound left open to heal with adequate skin bridges.
Significantly shorter operative time, shorter theater room occupancy, earlier
return to normal activity and work, (Gentile et al. 2011).
Expensive (relative)
- LIGASURE
- HARMONIC
SCALPEL
- THUNDERBEAT
DOPPLER-GUIDED
HEMORRHOIDAL ARTERY
LIGATION
Proctoscope called the Moricorn and a Doppler guidance to localize the
arteries and then suture ligate them selectively.
Based on the theory that hemorrhoids occur when there is an imbalance in
the blood flow of the hemorrhoidal plexus, either caused by increased inflow
or decreased venous outflow (Festen et al. 2009).
By arterial ligation the inflow is reduced, causing the plexus to diminish and
the hemorrhoids to shrink (Faucheron and Gangner 2008).
Does not deal with large prolapse (Giordano et al. 2009).

Severe prolapsed piles, addition to Doppler-guided hemorrhoidal artery

ligation + the mucopexy (Forrest et al. 2010; Gupta et al. 2011)  HAL – RAR (Recto
Anoplasty Repair)
 Gambar HAL
STAPLED
HEMORRHOIDOPEXY
Reduction of mucosa and hemorrhoidal prolapse
with a circular suturing device as an alternative to
hemorrhoidectomy (Longo 1998).
Technique aims in interrupting the submucous
hemorrhoidal vessels and restore the
hemorrhoidal tissue back into their anatomic
position.
Excision above the dentate line, less pain than
the conventional Hemorrhoidectomy, avoiding a
wound in the somatically innervated anoderm.
Clever procedure targeted towards both the
mechanical hypothesis and the vascular
hypothesis can be considered as a modern
surgical approach to hemorrhoids
POST STAPLED HEMORRHOIDECTOMY
EMBOLIZATION
New technique, responding to the theory of the arterial vascularization of
the hemorrhoids.
The principle is to embolize the main feeding arteries of the piles, in order to
permanently reduce the blood flow in the hemorrhoids (Moussa et al. 2017).
Procedure : Performing super selective microcoil embolization (pushable 2–3
mm fiber coils) of the distal branches of the superior rectal arteries with a
microcatheter, via a right femoral approach, under local anesthesia.
COMPLICATIONS
 Postoperative pain
 Bleeding
 Anal sepsis
 Anal incontinence
 Anal stenosis
WHICH SURGICAL OPTIONS FOR WHICH
PATIENTS AND WHICH
HEMORRHOIDS. . .??
 Modern surgical approach to hemorrhoids should not be on the basis of
“one size fits all.” Many factors have to be taken into account.
 The ideal operation should be effective on the symptoms with as low as
possible rate of recurrence, minimal postoperative pain and discomfort to
allow early return to normal and/or usual activities, and safe with minimal
mortality and morbidity
 Excisional surgery is still considered as the gold standard for the operative
treatment of hemorrhoids because of its low recurrence rate
MODERN SURGICAL APPROACH
TO HEMORRHOIDS
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