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 hemorrhoids during
 Hemorrhoidectomy has
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, perianal
 Hemorrhoidectomy is associated with
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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