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DEPARTMENT OF SURGERY

SACRED HEART HOSPITAL- CEBU CITY MEDICALCENTER CONSORTIUM

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Hemorrhoidal venouscushions Arecomposed of 

submucosal tissuecontaining venules,arterioles, andsmooth-muscle

fibers that arelocated in the analcanal

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The major drainage of the hemorrhoidal

plexus is through the superior hemorrhoidal vein, which drains into theinferior mesenteric vein and the portalsystem

Hemorrhoidal veins have no valves Valveless veins exert maximal pressure at

the lowest point

Most common locations are:

right anterolateral, right posterolateral, andleft lateral

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Internal hemorrhoids have 3 main cushions, which are situatedin the left lateral, right posterior (most common), and right

anterior areas of the anal canal. However, this combination is

found in only 19% of patients; hemorrhoids can be found at

any position within the rectum

Found at the 3,

7 and 11 o'clock

positions in theanalcanal

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Are thought to function as part of thecontinence mechanism and aid in completeclosure of the anal canal at rest

Are a normal part of anorectal anatomy

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Usually swollen and inflamed due toprecipitating factors

Excessive straining, increased abdominalpressure, and hard stools increase venousengorgement of the hemorrhoidal plexus andcause prolapse of hemorrhoidal tissue.

Bleeding, thrombosis, and symptomatichemorrhoidal prolapse may result

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Decreased venous return  Straining and constipation

Pregnancy

Portal hypertension and anorectal varices 

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Lack of erect posture Familial tendency

Higher socioeconomic status

Chronic diarrhea

Colon malignancy Hepatic disease

Obesity

Elevated anal resting pressure

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Spinal cord injury

Loss of rectal muscle tone

Rectal surgery Episiotomy

Anal intercourse

Inflammatory bowel disease, includingulcerative colitis, and Crohn disease

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Abnormal swelling of the anal cushions causes

dilatation and engorgement of thearteriovenous plexuses.

This leads to stretching of the suspensorymuscles and eventual prolapse of rectal tissuethrough the anal canal.

The engorged anal mucosa is easilytraumatized - 

Leading to Rectal prolapseleads to soiling and mucus discharge

(triggering pruritus) and predisposes toincarceration and strangulation

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External hemorrhoids  are located distal to the

dentate line and arecovered with anoderm.

the anoderm is richlyinnervated, thrombosis

of an externalhemorrhoid may causesignificant pain.

External hemorrhoidal veins are found

circumferentially under the anoderm

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Internal hemorrhoids are located proximal to the dentate line and

covered by insensate anorectal mucosa.

They may prolapse or bleed, but rarelybecome painful unless they developthrombosis and necrosis (usually related to

severe prolapse, incarceration, and/orstrangulation)

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Internal hemorrhoids are graded according tothe extent of prolapse.

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1st

Degree:

bulge into the analcanal and may prolapse

beyond the dentate lineon straining

Bleeding occurs

Does not prolapseoutside the anal canal

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2nd Degree:

prolapse throughthe anus butreducespontaneously

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3rd Degree:

Require manual reduction afterprolapse

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4 th degree hemorrhoids 

prolapse but cannot be reduced and

are at risk for strangulation A surgical emergency

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Combined internal and externalhemorrhoids 

A straddle in the dentate line and have

characteristics of both internal and externalhemorrhoids

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The most significant symptom is rectalbleeding

Usually bright red

Internal hemorrhoids are not painful Bleeding can be significant because of an

arteriovenous fistula formation in plexus

Other symptoms are prolapse, pruritis, and

perianal edema

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Thrombosed External Hemorrhoids Thrombosed hemorrhoids are an acute and

very painful problem that develops rapidly

Typically a perianal mass develops which ispainful to palpate (and look at)

The lesion is due to sudden clot formation inone of the subcutaneous or submucosal veins

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visual inspection of the rectum digital rectal examination

anoscopy or proctosigmoidoscopy

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TREATMENT OF HEMORRHOIDS:

SURGICAL APPROACH

NON-SURGICAL

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Hemorrhoidectomy is often the treatmentof choice, especiallyif the patient has had

chronic hemorrhoidalsymptoms

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Is a procedurerequired forpatients who do

not respond toother forms of therapy.

All are based on decreasing blood flow to the

hemorrhoidal plexuses and excising redundant

anoderm and mucosa.

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Parks or Ferguson hemorrhoidectomyinvolves resection of hemorrhoidal tissueand closure of the wounds with absorbablesuture

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AKA:

the Milligan and Morgan

Hemorrhoidectomy

follows the same principles of excisiondescribed in SubmucosalHemorrhoidectomy, but the wounds areleft open and allowed to heal by secondary

intention

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Whitehead's hemorrhoidectomy involvescircumferential excision of the hemorrhoidalcushions just proximal to the dentate line.

Has a risk of ectropion (Whitehead's deformity ).

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Hemorrhoidal tissues are sharplyexcised starting just beyond theexternal component and workingproximally, finishing with resection ofthe internal component. B, Thesphincter muscles are preserved bydissecting only the tissues superficialto them. C, The pedicle is transfixed andthe defect closed with a running

absorbable suture 

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Treats circumferential prolapsed andbleeding hemorrhoids

Circumferential portion of the lower rectaland upper anal canal mucosa andsubmucosa and performs a reanastomosiswith a circular stapling device

The prolapsed anal cushions are retractedinto their normal anatomic positions withinthe anal canal

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Grade 4 hemorrhoid before reduction. B,

Placement of stapling device obturator. 

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Stapling device with circumferential excision of anal canal and hemorrhoid mucosa

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an alternative surgical approach

It has replaced stapled hemorrhoidectomy

It fixes the redundant mucosa above thedentate line. PPH removes a shortcircumferential segment of rectal mucosaproximal to the dentate line using a circularstapler

has an equivalent risk of postoperativecomplications when compared to traditional

hemorrhoidectomy

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Urinary retention – 10-50 % Fecal impaction

Bleeding- small or massive

- may also occur 7 to 10 days afterhemorrhoidectomy when the necroticmucosa overlying the vascular pediclesloughs

InfectionsLong term sequelae:

Incontinence, anal stenosis, ectropion(whitehead’s deformity) 

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For persistent bleeding from first, second,and selected third-degree hemorrhoids

Mucosa located 1 to 2 cm proximal to thedentate line is grasped and pulled into a

rubber band applier

the rubber band strangulates the underlyingtissue, causing scarring and preventingfurther bleeding or prolapse

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After firing the ligator, the rubber bandstrangulates the underlying tissue, causingscarring and preventing further bleeding orprolapse

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urinary retention 

 infection   bleeding  

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uses a device that creates an intense beamof infrared light.

Heat created by the infrared light causesscar tissue, which cuts off the blood supplyto the hemorrhoid

The scar tissue holds nearby veins in placeso they don't bulge into the anal canal.

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Medical management is the initial treatmentof choice for grade I internal andnonthrombosed external hemorrhoids

Consist of:

warm baths a high-fiber diet

adequate fluid intake

stool softeners

topical and systemic analgesics

proper anal hygiene

course of topical steroid cream

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Topical nitroglycerineand nifedipine havealso been used torelieve symptoms

associated with analsphincter spasm

Stool softener

Ointments

FACTU

Dafron

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Hemorrhoids generally do not resolve butusually worsens through time

Incarcerated and Strangulated hemorrhoidsare surgical emergencies

1st and 2nd Degree Internal hemorrhoid doesnot require surgical intervention

Hemorrhoidectomy is done for symptomatic

cases and not for aesthetic purposes.

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