Management of Hemorrhoidal disease : Surgical Approach

Hemorrhoidal diseases can be treated surgically in a number of ways. Patients with advanced grade III or grade IV hemorrhoids, the presence of concurrent disorders, the inability to treat the patient's condition with conservative management, and patient preference form some of the main grounds for surgery. Following thorough consideration of both patient-related considerations and the available surgical competence, a surgical procedure is selected from the list of options. (1) In this review, we enumerate some of the main surgical and minimally invasive options:

Open hemorrhoidectomy (Milligan-Morgan method) (2)

This is widely considered the most effective surgical technique for treating hemorrhoids. Open hemorrhoidectomy is safe, simple, and cost-effective. It is the procedure of choice for third- and fourth-degree hemorrhoids. The underlying principle of open hemorrhoidectomy is the preservation of skin bridges between the excised hemorrhoids to prevent stricturing. It remains the same regardless of the instruments of excision, like diathermy, laser, ligature, and harmonic scalpel. Wounds are left to heal by secondary intention. (2)

The surgical technique: A V-shaped incision in the skin around the base of the hemorrhoid is followed by dissection to strip the entire hemorrhoid from its bed. The pedicle is ligated, and then the distal part is excised. The wound is left open, and a hemostatic gauze pad is left in the anal canal. The common complications are postoperative pain, acute urine retention, and bleeding. (2)

Closed hemorrhoidectomy (Ferguson's Ferguson's technique) (2)

This is a modification of the Milligan-Morgan method, where the incisions are closed with an absorbable running suture following surgical excision of the hemorrhoids. This method has no advantage in wound healing because of the high rate of suture breakage at bowel movements. There are several modifications to this method.

Submucosal hemorrhoidectomy (Parks procedure) (2)

It was designed to reduce postoperative pain and avoid anal and rectal stenosis. It is indicated for second to fourth-degree hemorrhoids.

Technique: A small diamond of anal epithelium is excised around the hemostat. The base of the tissue is suture-ligated and divided. The incision is continued cranially, creating two mucosal flaps on each side. Submucosal dissection is commenced to remove the hemorrhoidal plexus from the underlying internal sphincter muscle and overlying mucosa. The mucosal flaps are then allowed to flop back into position. No suture or any intra-anal dressing is used.

Pile 'suture' method (2)

This method uses three interrupted sutures to secure the hemorrhoids without excision. Recurrence is a common postoperative complication of this procedure.

Stapled hemorrhoidectomy (2,3)

This procedure is also known as circumferential mucosectomy or' or' procedure for prolapse and hemorrhoids'' (PPH). Common indications are third and fourth-degree hemorrhoids. Here the stapled resection of a complete circular strip of the mucosa above the dentate line is done. In PPH, the prolapsed tissue is pulled into a circular stapler, and excess tissue is removed while the remaining hemorrhoidal tissue is stapled. The staple line should be maintained at a distance of 3-3.5 cm from the anal verge to avoid postoperative rectal stenosis and pain.

While in general, stapled hemorrhoidectomy is believed to be much less painful than open hemorrhoidectomy and allows a quicker return to work compared to conventional procedures, some patients who undergo stapled hemorrhoidectomy may fall vulnerable to many serious complications including strictures, severe pain, and severe bleeding in some cases.

Radiofrequency ablation and suture fixation of hemorrhoids (2)

It is an innovative procedure designed for hemorrhoids of grades III and IV. Radiofrequency waves ablate tissue by converting radio waves into heat. The alternating current generates changes in the direction of ions within the tissue fluid. This creates ionic agitation and frictional heating, leading to coagulative tissue necrosis. After that, the hemorrhoids are plicated using strong, absorbable sutures. It gives better postoperative pain and bleeding results than stapled hemorrhoidectomy and Doppler-guided hemorrhoidal artery ligation.

LASER hemorrhoidectomy (2)

The hemorrhoid is vaporized or excised using Diode LASER. The smaller LASER beam allows for precision and accuracy; and, usually, rapid, unimpaired healing. It is painless. LASER therapy may be used alone or in combination with other modalities.

Doppler-guided hemorrhoidal artery ligation (DGHAL)

This is a promising newer technique. The specially designed proctoscope contained a Doppler transducer and a window through which the surgeon could identify and ligate the hemorrhoidal arteries by placing a suture around them. All the hemorrhoidal arteries are ligated in this procedure. It is a daycare procedure suitable for first-, second-, and some selected third-degree hemorrhoids. There is little or no bleeding postoperatively. DGHAL disrupts the arterial inflow and tethers the mucosa, causing the hemorrhoidal mass to shrink and retract. The procedure is a safe and effective alternative to hemorrhoidectomy. Pure external hemorrhoids would not respond to this procedure.

Postoperative complications of hemorrhoidectomy (2); Early postoperative complications include severe postoperative pain that lasts for two to three weeks, wound infection, bleeding, edema of the skin bridges, significant short-term incontinence, difficult urination or urinary retention, and delayed hemorrhage, which typically occurs seven to sixteen days after surgery and is likely caused by infection or the sloughing of vascular pedicles. There have also been reports of late problems, including anal stenosis, skin tag formation, and recurrence.

In most patients, the prolapse is not severe enough to call for surgery or an outpatient procedure (such as rubber band ligation [RBL] or sclerotherapy). Therefore conservative management also forms an essential choice in the management of hemorrhoids. This includes changing one's diet and lifestyle to consume more fiber and fluids, exercising more, and avoiding constipation and straining when defecating. Hemorrhoids may be treated topically with creams that contain anesthetics, corticosteroids, and anti-inflammatory medications. (4)

Further, studies have demonstrated the clinical effectiveness of numerous venoactive medications in treating hemorrhoids. The MPFF, which contains micronized diosmin (90%) and other active flavonoids (hesperidin, diosmetin, linarin, and isorhoifolin; 10%), has demonstrated clinical efficacy in the treatment of hemorrhoids and is proven to be more potent than pure diosmin. Studies have also proven MPFF's effectiveness in reducing bleeding and the primary side effects experienced by patients after hemorrhoidectomy. (4)

Since MPFF is well tolerated in all grades of hemorrhoids, it can be used as a first-line therapy in conjunction with dietary changes or as an adjunct in patients recovering from a hemorrhoidectomy. (4)

CONCLUSION

Hemorrhoids can be treated surgically in a variety of ways. Most surgical procedures used to treat hemorrhoids are based on ligation and excision techniques; however, more recent procedures attempt to minimise tissue dissection to lessen postoperative pain and bleeding. The very fact that many procedures are available shows that nothing is ideal. A surgeon should be well versed with different procedures and technologies as their use in a specific patient depends, to a large extent on the demands of the case.

Intelligent use of gadgets and technics for individual cases is the right approach

This World Piles Day, Let's Vouch To Strike the Core of Hemorrhoidal Disease. To get more information about Piles/ Hemorrhoids, from Diagnosis to Management, click on the link below.

https://medicaldialogues.in/world-piles-day

References:

1. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009-2017. doi:10.3748/wjg.v18.i17.2009

2. Agbo SP. Surgical Management of Hemorrhoids. J Surg Tech Case Rep. 2011;3(2):68–75.

3. Hardy A, Chan CLH, Cohen CRG. The Surgical Management of Hemorrhoids – A Review. Dig Surg. 2005;22(1–2):26–33.

4. Godeberge P, Sheikh P, Lohsiriwat V, Jalife A, Shelygin Y. Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease. J Comp Eff Res. 2021;10(10):801-813. doi:10.2217/cer-2021-0038