What are hemorrhoids?
Hemorrhoids are either internal or external, depending on the location. Internal hemorrhoids are covered with a lining called mucosa that is resistant to touch, pain, stretch or temperature, whereas external hemorrhoids are covered by very sensitive skin.
Hemorrhoids may be graded as follows:
- Grade I (primary): These slide below the toothed line or jagged line present above the anal canal (dentate line) while straining but pull back while relaxing. Treatment includes increasing fiber intake.
- Grade II (secondary): These protrude below the anal opening but reduce instantly. Treatments include sclerotherapy and rubber band ligation.
- Grade III (tertiary): These protrude below the anal opening and need to be reduced manually; Treatments include sclerotherapy, rubber band ligation or surgery.
- Grade IV (quaternary):These protrude below the anal opening and are not reducible. Surgical removal of hemorrhoids (hemorrhoidectomy) is indicated.
Why is hemorrhoid surgery done?
Surgery (hemorrhoidectomy) is indicated when all other approaches fail and in specific conditions such as:
- Hemorrhoids with significant bleeding
- Larger external hemorrhoids
- Protruding internal hemorrhoids
Hemorrhoids can be managed either medically or with surgery, depending on the severity of the symptoms. For grade I and II hemorrhoids, dietary changes and medical treatment are indicated as the first-line treatments.
For grade I, II and III hemorrhoids unmanageable by medical treatment, the office-based procedure will be indicated. Office-based procedures include the following:
- Rubber band ligation: It involves placing rubber bands on the hemorrhoids.
- Infrared photocoagulation: Heat produced by the infrared light cuts of the blood supply to the hemorrhoids.
- Electrocoagulation: Electric currents cuts of the blood supply to the hemorrhoids.
- Sclerotherapy: Injecting a chemical solution into the area around the hemorrhoids.
- Cryotherapy: Involves freezing the hemorrhoids.
What is the best procedure to remove hemorrhoids?
Hemorrhoid surgery (hemorrhoidectomy) is the most effective way to remove hemorrhoids. Excisional hemorrhoidectomy is the gold standard in the treatment of hemorrhoids. Apart from excisional hemorrhoidectomy, other surgical procedures involve:
- Transanal hemorrhoidal artery ligation (HAL)
- Stapled hemorrhoidopexy
Open vs. closed excisional hemorrhoidectomy
Hemorrhoidectomy involves complete removal of the layers (mucosa and submucosa) of hemorrhoids, without injuring the underlying muscle (sphincter muscle). Excisional hemorrhoidectomy can be open or closed. In the end, if the mucosa is closed with stitches, the procedure is known as closed hemorrhoidectomy; if the mucosa is left open, the procedure is known as open hemorrhoidectomy.
Transanal hemorrhoidal artery ligation
Transanal hemorrhoidal artery ligation is a procedure that involves inserting a Doppler sensor in the anus to detect the arteries supplying blood to hemorrhoids. The hemorrhoidal arteries are identified and tied to cut the blood supply. The hemorrhoids shrink immediately and are unnoticeable within weeks.
This procedure uses a stapler-like device to relocate the hemorrhoids and cut their blood supply. Recovery is faster and there are fewer complications.
Is hemorrhoid surgery painful?
Apart from open and closed hemorrhoidectomy, other procedures are relatively painless. As with any surgery, hemorrhoidectomies also have few complications that include:
Complications of stapled hemorrhoidopexy are: