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.

An internal hemorrhoid is caused by the rectal cushion enlargers, and bulges into the rectal canal.  In some cases it even pulls down a portion of the rectum above, loses its normal anchoring, and can protrude from the anus.  This is referred to as a prolapsing internal hemorrhoid.  Internal hemorrhoids are exposed to passing stools in the rectal canal.  The trauma of passing a stool, particularly a hard stool, can cause bleeding and pain.  The rectal lining that has been pulled down secretes a mucus, and moistens the anus and surrounding areas.  Sometimes stool can also leak out onto the anus skin.  Constant moisture and the presence of stool can cause rectal itchiness.  However, rectal itchiness is not a common symptom of hemorrhoids.  After a bowel movement, a prolapsing hemorrhoid usually returns back into the rectal canal, or can be pushed back in with a finger.  It will normally prolapse again on the next bowel movement.

Sometimes the hemorrhoid will protrude from the rectal canal and cannot be pushed back inside.  This condition is known as an incarceration of the hemorrhoid.  Incarcerated hemorrhoids can lose their blood supply from the squeezing of the anus sphincter.  This can cause the blood vessels and cushions to die, a conditon referred to as gangrene.  Gangrene requires immediate medical treatment.

Physicians have come up with a grading system for describing the severity of internal hemorrhoids.

• First Degree Hemorrhoids-Hemorrhoids that bleed without prolapsing.
• Second Degree Hemorrhoids-Hemorrhoids that prolapse and retract by themselves (bleeding may or may not be present).
• Third Degree Hemorrhoids-Prolapsed hemorrhoids that must be pushed back in by a finger.
• Fourth Degree Hemorrhoids-Prolapsed hemorrhoids that cannot be pushed back in. (Fourth Degree Hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the rectal lining through the anus)

External Hemorrhoids

Generally, the symptoms of external hemorrhoids differ from internal hemorrhoids.  External hemorrhoids can generally be felt as bulges at the anus.  They usually do not cause many of the symptoms that are typical of internal hemorrhoids.  This is because they are low in the anal canal and don’t really have an effect on the function of the anus or anal sphincter.  Many external hemorrhoids cause problems when clots form inside of them.  This is called thrombosis.  Thrombosis of an external hemorrhoid can be very painful and often require medical attention.  External hemorrhoids are supplied by somatic nerves, which makes them painful, as opposed to internal hemorrhoids.  Thrombosed hemorrhoids may heal with scarring and leave a tag of skin protruding from the anus.  When the tag is large, it can make anal hygiene difficult or irritate the anus.

Some of theses theories include an inadequate intake of fiber, prolonged sitting on the toilet, and chronic constipation.  There is not very much experimental support to back up any of these theories.  Pregnancy is a common cause of enlarged hemorrhoids, though the actual reason is not known.  Another cause can be enlarged tumors in the pelvis.  These tumors can cut off the veins draining the anal canal and cause enlarged hemorrhoids.

Another theory takes into consideration the pulling force of passing a stool.  This would particularly be the case with a hard stool passing through the rectal canal that drags the hemorrhoidal cushions downward.  This relates to having an inadequate fiber intake.

Hemorrhoids are known to be more prevalent in the 45 to 65 age group.  Another theory suggests that with age, or an aggravating condition, the supporting tissues that are responsible for tying the hemorrhoids to the underlying muscle deteriorates.  Over time this allows the hemorrhoidal tissue to slide down into the rectal canal.

It is a physiological fact that enlarged hemorrhoids are associated with elevated pressure in the rectal sphincter, the muscle surrounding the rectal canal, and the hemorrhoids.  The rectal sphincter is the muscle area that allows us to control our bowel movements.  We don’t know if the elevated pressure precedes the enlarged hemorrhoids, or if the enlarged hemorrhoids causes the elevated pressure.  If it precedes the hemorrhoids, perhaps increased pressure during a bowel movement in the rectal canal is the cause.  This would greatly increase the pulling force of the stool as the theory states above.

Some also believe that there is a genetic predisposition for hemorrhoids.  This predisposition could be weak rectal vein walls or valves.  Others also believe that humans are more prone to hemorrhoids simply because of our erect posture.  This naturally sends more blood to the rectal area making it easier for them to form.

Hemorrhoids are masses of tissue within the anal canal that contain blood vessels.  They also contain the supporting tissues made up of muscle fibers.  The anal canal is classified as the last four centimeters between the rectum and the anus.  The anus is the opening of the anal canal.

Hemorrhoids are not abnormal, though most people think this.  They are present in everyone, but the problem occurs when these hemorrhoidal cushions enlarge.  When these hemorrhoidal cushions enlarge, the can cause problems and are then considered abnormal or a disease.

Hemorrhoids become a problem in 4% of the general population.  They are not partial to men or women, and normally prevale between 45 and 65 years of age.

Anatomy of Hemorrhoids

The blood vessels that supply blood to the anal canal descend from the rectum.  The rectum is above the anal canal.  This area contains a network of arteries that make the conditions perfect for hemorrhoids.  This is also the reason that blood from hemorrhoids is a bright red, because it is fresh arterial blood rather than venous blood.  This also is why bleeding from hemorrhoids can be very severe.  The blood vessels that supply blood to the hemorrhoidal vessels pass through the tissue around the hemorrhoidal cushions.

The anal veins drain blood away from the canal and hemorrhoids.  The veins drain in two directions; one drains upwards into the rectum, and the other downward through the skin surrounding the anus.  The dentate line differentiates the transition from anoderm (anal skin) to the rectum lining.

Formation of Hemorrhoids

If the hemorrhoid forms at the top of the anal canal, or inside the anus, it is considered an internal hemorrhoid.  If it originates near the anus in the anal canal, it is considered an external hemorrhoid.  Technically, the difference between an internal and external hemorrhoid is if it is above or below the dentate line.

During the formation of internal hemorrhoids, the vessels of the hemorrhoidal cushions swell along with the supporting tissues.  When these bulging cushions protrude into the anal canal, problems arise.  No one knows exactly how external hemorrhoids form.

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