PPH was developed in the early 90’s to reduce the prolapse of hemorrhoidal tissue.  This is done by excising a band of prolapsed anus mucosa membrane with the use of a circular stapling device.  The prolapsed tissue is pulled into an instrument in PPH.  This allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled.  This should restore the tissue back to its normal anatomical position.

The main instrument used is called a circular anus dilator.  This dilator reduces the prolapse of the anus skin and parts of the anus mucous membrane.  After the obturator is removed, the prolapsed membrane falls into the dilator lumen.

Another instrument is then inserted through the dilator called a purse-string suture anoscope.  This instrument will push the prolapsed mucous back against the rectal wall 270 degrees around.  The mucous membrane that comes through the anoscope window can be contained in a suture that includes only mucous membrane.  By rotating the instrument it is possible to suture the entire anal circumference in a purse-string suture.

The hemorrhoidal circular stapler is then opened to its maximum position, and inserted through the dilator.  It is positioned proximal to the purse-string suture.  The ends of the suture are knotted externally.

With moderate traction on the suture, a simple maneuver draws the prolapsed membrane into the circular stapling instrument.  The instrument is tightened, and then staples the prolapse.  They will generally keep the instrument in the closed position for 30 seconds before firing, and 20 seconds after firing to act as a tamponade, which may help promote hemostasis.

When the stapler is fired, it releases a double staggered row of titanium staples into the tissue.  A circular knife then excises the extra tissue.  A circumferential column of mucosa is removed from the upper rectal canal.  Finally, the staples are examined through the anoscope to check for bleeding.  If bleeding occurs, additional absorbable sutures may sometimes be placed.

Milligan-Morgan Technique
This procedure was developed in the UK by Dr. Milligan and Dr. Morgan in 1937.  In this procedure the three major hemorrhoidal blood vessels are excised.  To avoid stenosis, three pear-shaped incisions are left open, separated by bridges of skin and mucosa.  This is the most popular hemorrhoid surgery procedure.  It is considered the gold standard that other hemorrhoid surgery techniques are compared against.

Ferguson Technique
This technique was developed in the United States by Dr. Ferguson in 1952.  It is a modified version of the Milligan-Morgan technique.  In this procedure the incisions are totally or partially closed with an absorbable running suture.  A retractor is used to expose the hemorrhoidal tissue, which is removed surgically.  The remaining tissue is sutured or sealed through coagulation.

The Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain. or postoperative morbidity because of a high suture breakage rate.

This is not typically an out-patient surgery like a hemorrhoidectomy.  Normally an in-patient stay is required because of the high level of pain experienced after the procedure.  This stay is normally about 3 days.

1. Incisions are made around the hemorrhoid.  The hemorrhoid is removed and the swollen vein inside is tied off to prevent bleeding.  The surgical area can be stitched back together or left open.
2. There is another procedure that uses a circular stapling device.  This device does not require any incisions.  The hemorrhoid is just lifted up, and then the device staples underneath it.

Surgery can be done with a scalpel, cautery pencil, or laser.

When is Surgery Used?

Hemorrhoidectomy is used when you have:

• Large internal hemorrhoids
• Recurring internal hemorrhoids
• Large external hemorrhoids that are very painful
• Exhausted all other means of hemorrhoid removal

Complications

• Pain
• Bleeding from the rectal area
• Inability to urinate
• Hematoma (blood collecting in surgical area)
• Icontinence (uncontrollable bowel or bladder)
• Infection
• Fecal impaction (feces trapped in rectal canal) Late Complications
• Narrowing rectal canal
• Additional hemorrhoids
• Abnormal passage that forms between the rectal or rectal canal and other areas
• Rectal Prolapse

Recovery

You will experience some pain after the surgery.  If your doctor provides a prescription for pain killers, take them as prescribed.  Ask your doctor what over the counter medication is ok for you to take.  Some bleeding is normal, but if you experience excessive bleeding, seek medical attention.  Numbing medicines can be applied before and after bowel movements to help with pain.  Ice packs applied to the rectal area can help with swelling and pain.  Frequent soaks in warm water (sitz bath) are recommended to help with pain and muscle spasms.  Some doctors may prescribe an antibiotic to reduce the chance of infection.  Stool softeners are recommended to help keep bowel movements smooth.  Straining during bowel movements may cause recurrence of hemorrhoids.  Expect a follow-up exam with the surgeon 2 to 3 weeks after the surgery.

What to Consider

It is imperative that you make changes in daily habits to help reduce strain in bowel movements.  Hemorrhoidectomies may provide better long term results than other hemorrhoid treatments.  However, surgery is more costly and comes with a greater risk of complications and pain.

Most internal hemorrhoids can either be treated with home treatments and remedies, or fixative procedures.  Fixative procedures involve less risk, less pain, and require less time away from work when compared with surgery.

The modern variation of these treatments is infrared coagulation.  This procedure uses an infrared beam to coagulate and destroy the affected tissue.  This treatment is very reliable, simple, and can be controlled accurately.

Advantages

1. The depth of tissue destruction can be easily controlled by length of exposure time
2. Short coagulation time (1 second) which allows for easy outpatient procedure
3. Finely focused beam, allowing other endoscopic procedures to be conducted alongside the infrared procedure
4. No non-contact coagulation
5. Does not cause interference with electromagnetic devices (pacemakers)
6. Used for 1 to 3 grade hemorrhoids
7. Can treat an infinite amount of hemorrhoids in one procedure
8. Less painful than other procedures (sclerotherapy and rubber band ligation)

Disadvantages

1. Expensive tools and necessary skill limit the choice of doctor that can perform this procedure
2. May require more than one treatment
3. Follow-up treatments after a year are normally required
4. Not as effective as rubber band ligation in the long term
5. Minor bleeding for 7 to 14 days after the treatment

Procedure and Recovery

A complete medical history and physical examination should be performed before a doctor considers you for this procedure.

That patient will lie down on his/her side with knees drawn up to the chest.  A proctoscope and infrared coagulator will be inserted into the anus.  The patient will feel a sharp prick or burning sensation when the coagulator is used.  The coagulator is applied to the base of the hemorrhoids and shoots bursts of infrared for 1 to 1.5 seconds.  A white spot marks the point of coagulation.  Blood vessels of the hemorrhoids are destroyed, which in turn decreases blood flow to the hemorrhoid.  Sometimes this whill immediately reduce bleeding.  Over the next week scar tissure forms, and the healing process will be completed.

Who Should Get It?
Doctors recommend sclerotherapy with:

• Small hemorrhoids that don’t react to home treatment
• Internal hemorrhoids that aren’t big enough for rubber band ligation
• Persistent bleeding from hemorrhoids
• People age 70 and older who are in poor health and could not receive more invasive surgery

Does it Work?
Sclerotherapy is comparable to rubber band ligation for small hemorrhoids.  That is about 60 to 80 percent effective.  However, sclerotherapy is not as effective as rubber band ligation for larger hemorrhoids.  Hemorrhoids often reoccur after sclerotherapy, but the procedure can be repeated.

Complications
Complications include:

• Painful burning if the injection is too close to the anus
• Allergic reaction
• Possible shedding of mucosa (rectal lining)
• Infection in the sphincter area
• Uncontrollable bowels or bladder
• Prostatitis (infection of the prostate)
• Bleeding

Post Procedure and Recovery

Bleeding from the anus can occur for 7 to 10 days after the procedure, especially when the hemorrhoid falls off.  Bleeding should be light and stop on its own, otherwise seek medical attention.  Over the counter pain relievers and shallow baths for 15 minutes at a time are fine.  To help reduce the risk of bleeding, don’t take nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 to 5 days before and after the procedure.  Doctors recommend taking stool softeners to help ensure smooth bowel movements.  Straining during bowel movements increase the risk of hemorrhoids recurring.

For Your Consideration
Sclerotherapy is not an everyday procedure and is not as common as other fixative procedures.  The doctor’s expertise plays a large roll in the effectiveness of the procedure.  It is important to find an experienced doctor in this field.  It is also important to make changes in your daily diet to encourage smooth bowel movements.  If hemorrhoids persist, sclerotherapy can be repeated.  Other surgical treatments can also be tried.

• Hemorrhoids that continually bleed
• Prolapsed hemorrhoids
• Thrombosed hemorrhoids
• Very painful hemorrhoids.

• Rubber band ligation
• Sclerotherapy
• Infrared coagulation
• Hemorrhoidectomy