Jason F. Hall

Introduction

Complaints attributable to hemorrhoidal disease are common in both primary care and specialty settings. The vast majority of hemorrhoidal presentations can be managed with nonsurgical treatments, although procedural intervention is required in some circumstances. A firm grasp of anorectal anatomy is essential for choosing the appropriate method of treatment.

Anatomy of Hemorrhoids

Hemorrhoids are specialized, nonpathologic, vascular cushions found within the anal canal. They are typically organized into three anatomically distinct cushions located in the left lateral, right anterolateral, and right posterolateral anal canal (Fig. 26-1, A). Hemorrhoids are found in the submucosal layer and are considered sinusoids because they typically have no muscular wall. They are suspended in the anal canal by the muscle of Treitz, which is a submucosal extension of the conjoined longitudinal ligament.

Hemorrhoids are classified as internal or external. Internal hemorrhoids are located proximal to the dentate line and have visceral innervation; therefore the most common presentation is painless bleeding. Because they are close to the anal transitional zone (ATZ), internal hemorrhoids can be covered by columnar, squamous, or basaloid cells. External hemorrhoids are located in the distal third of the anal canal and are covered by anoderm (squamous epithelium). Because of the somatic innervation of external hemorrhoids, patients who have these are more likely to be seen with pain (Fig. 26-1, B).

Hemorrhoids are thought to enhance anal continence and may contribute 15% to 20% of resting anal canal pressure. They also provide complete closure of the anus, enhancing control of defecation. In addition to making important contributions to the maintenance of continence through pressure phenomena, hemorrhoids also relay important sensory data regarding the composition (gas, liquid, stool) of intrarectal contents.

The central causative pathway for the development of hemorrhoidal pathology is an associated increase in intraabdominal pressure. This increase may be secondary to straining, constipation, or obesity. Other etiologic factors can include diarrhea, pregnancy, and ascites. Aging is also associated with dysfunction of the supporting smooth muscle tissue, resulting in prolapse of hemorrhoidal tissues.

Hemorrhoids are normal structures and thus are treated only if they become symptomatic. Common complaints include bleeding, pain, and swelling. After nonoperative measures have failed, treatment is largely applied on the basis of size and symptomatology. Hemorrhoids classically are categorized into grade 1, with enlargement, but no prolapse outside the anal canal; grade 2, with prolapse through the anal canal on straining, but with spontaneous reduction; grade 3, manual reduction required; and grade 4, hemorrhoids cannot be reduced into the anal canal.

First-degree hemorrhoidal disease can usually be treated with nonsurgical measures. The primary goal is to decrease straining with bowel movements and thus reduce the intraabdominal pressure transmitted to the hemorrhoidal vessels. The mainstay of nonoperative hemorrhoidal treatment is increased fiber and water consumption.

Patients with 2nd-degree hemorrhoids can be offered a trial of nonsurgical management, although a number of these measures will fail and require procedural intervention. The 3rd- and 4th-degree hemorrhoids generally require surgery.

Office Procedures

Common office procedures in the management of patients with symptomatic hemorrhoids include rubber band ligation, infrared coagulation, bipolar diathermy, sclerotherapy, and cryotherapy. All these techniques rely on some form of tissue destruction, which then results in fixation of the remaining hemorrhoidal tissues.

Rubber band ligation is the most frequently used procedure used in the United States. This technique is most often used to address 1st- and 2nd-degree hemorrhoids, although 3rd-degree hemorrhoids can occasionally be treated with this technique as well (Fig. 26-2, A). The rubber band necroses the intervening tissue over the course of 7 to 10 days and is passed in the patient’s stool. The most common of the many implements available for application of the rubber bands is a suction ligator, which allows the surgeon to draw in the hemorrhoidal tissue and apply the rubber band with one hand. Other devices require that the operator grasp the hemorrhoidal pile with a long forceps and apply the rubber band with the other hand (Fig. 26-2, B).

Hemorrhoidal banding controls bleeding in more than 90% of cases. Complications are rare but include vasovagal response, pain, bleeding, and pelvic sepsis. Most complications can be avoided by ensuring that the rubber band is placed well above the dentate line, close to the base of the hemorrhoidal pile (Fig. 26-2, C). Pelvic sepsis may result from incorporation of the distal rectal wall into the band. The combination of pain, urinary retention, and fever after banding should raise suspicion of pelvic sepsis.

Operative Hemorrhoidectomy

Patients for whom medical or nonsurgical therapies are not successful are candidates for operative hemorrhoidectomy. Typically, these patients have 3rd- or 4th-degree hemorrhoids. Fortunately, postsurgical recurrence is rare. The most common procedures are the Ferguson and Milligan-Morgan hemorrhoidectomy. Both techniques involve elliptical excision of the internal and external hemorrhoidal complex (Fig. 26-3, A).

An operating anoscope is placed in the anal canal. An ellipse of anoderm is raised and dissected back toward the anal canal. The hemorrhoids are then raised off the anal sphincters. The layer of connective tissue that is present can be left on the sphincters, although some surgeons directly expose the sphincters. During this dissection it is important to separate the hemorrhoidal tissue from the internal sphincter without damaging the latter. After completion, the procedure is repeated on any further hemorrhoid columns that require removal.

The Ferguson technique is frequently used in the United States. After removal of the hemorrhoidal tissues, the base of the hemorrhoid is suture-ligated, and the anal mucosa/anoderm are reapproximated using a running absorbable stitch.

The Milligan-Morgan technique is used primarily in the United Kingdom. The defect is left open and allowed to granulate inward over 4 to 8 weeks.

Stapled Hemorrhoidopexy

Stapled hemorrhoidopexy was described as an alternative to traditional excisional hemorrhoidectomy because of the pain associated with the latter technique. The procedure involves placement of a mucosal purse-string suture 2 to 3 cm above the dentate line. A specially designed surgical hemorrhoidal stapler is used to resect the mucosa and submucosa associated with the hemorrhoid and to close the resultant defect.

This technique is associated with less pain and analgesic use and higher rates of recurrence and residual prolapse. The most common complication of stapled hemorrhoidopexy is bleeding from the staple line. This is easily controlled with suture ligature or electrocautery. Other, rare complications include rectal perforation, pelvic sepsis, and chronic pain syndrome.

Strangulated Hemorrhoids

Strangulated (or incarcerated) hemorrhoids are 3rd- or 4th-degree hemorrhoids that become thrombosed because of chronic prolapse and resultant swelling. Patients typically have severe anal pain and sometimes urinary retention. Physical examination typically reveals thrombosis of the internal and external hemorrhoids, with or without evidence of necrosis (Fig. 26-3, B).

Patients can usually be managed with emergent excisional hemorrhoidectomy. If there is evidence of tissue necrosis, all nonviable tissue should be excised and the incision left open. In poor candidates for surgical intervention, the anoderm can be infiltrated with local anesthesia. The anesthesia causes the internal sphincter to relax, and the internal hemorrhoids can be reduced with gentle massage. External thrombectomies and multiple rubber band ligations of the internal hemorrhoids can be performed as an alternative to excisional hemorrhoidectomy.

Suggested Readings