Depending on the severity of the symptoms and the grade of the hemorrhoids, patients may be treated

through nonoperative measures, office-based procedures, or operative therapy.

Nonoperative Management

As constipation and excessive straining during defecation are often the underlying causes of

hemorrhoids, symptoms can be reduced or eliminated in many patients by altering their dietary intake

and lifestyle. This goal is often achieved in patients with grade 1 or 2 hemorrhoids by increasing fluid

and fiber in the diet, increasing physical exercise, and adding supplemental fiber. Fiber helps to add

moisture to the stool to decrease constipation, and the addition of fiber has been shown in a doubleblind, placebo controlled trial to be effective in reducing hemorrhoidal bleeding.3 Warm sitz baths,

suppositories, and topical creams or ointments may also help to alleviate symptoms, however they often

do not provide a long-term solution.

2 In patients with first-, second-, or third-degree internal hemorrhoids with no symptomatic external

disease who fail conservative therapy, office-based therapies such as rubber band ligation,

sclerotherapy, or photocoagulation may be an option. Rubber band ligation can be performed through

an anoscope in the office without the use of anesthesia. The band is placed around the hemorrhoid

above the dentate line, causing localized ischemia of the intervening tissue (Fig. 70-11). More than one

hemorrhoid may be banded at one time, however multiple synchronous bands may lead to increased

pain. A portion of the hemorrhoid and the rubber band are passed during defecation 48 to 72 hours

following application. Fibrosis that occurs at the site of the banding causes fixation of the remaining

hemorrhoidal tissue, which helps to prevent further prolapse and bleeding. Relief of symptoms may be

achieved in up to 80% of patients who undergo banding, however recurrence rates as high as 30% have

been reported.4 Complications of hemorrhoidal banding include severe pain requiring removal of the

band, increased bleeding, and thrombosis of the hemorrhoids. Severe perianal sepsis is a rare

complication, and should be suspected in any patient who develops worsening pain, fever, or the

inability to void.

Figure 70-11. Rubber band ligation of an internal hemorrhoid.

Sclerotherapy involves the injection of a sclerosing agent into the submucosa that leads to fibrosis of

the surrounding tissue. Many different injection agents have been described, however phenol is most

commonly used. Injection is performed through an anoscope, and may be an option for symptomatic

hemorrhoids that are too small to band. It is important not to inject the sclerosant directly into the

hemorrhoids or thrombosis may ensue. Infrared photocoagulation causes thrombosis and tissue

destruction within the anal canal. The probe is applied just proximal to the internal hemorrhoids

through an anoscope. Results with both sclerotherapy and photocoagulation are varied and tend to be

temporary only.

Operative Treatment

3 Excisional hemorrhoidectomy should be considered in patients who fail conservative or office-based

procedures, who have combined internal and external hemorrhoids, who have hemorrhoids that require

manual reduction (grade 3), or who have associated pathology such as ulceration, fissures, or fistulas.

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Hemorrhoidectomy is typically an outpatient procedure, and in most cases local or regional (spinal)

anesthesia may be used, however general anesthesia may also be employed. The patient is placed in the

prone jack-knife position with the buttocks taped apart. An elliptical incision is made, beginning on the

anoderm to remove any external component of the hemorrhoid, and is continued to the base of the

hemorrhoid above the dentate line (Fig. 70-12). It is critical to preserve the underlying IAS muscle, as

damage to the IAS may lead to postoperative incontinence. One, two, or three hemorrhoidal bundles

may be excised at once, however it is also critical to ensure that normal anoderm is left between the

excision sites; failure to preserve this anoderm may lead to postoperative anal stenosis. The dissection

may be undertaken with the use of a scalpel, scissors, electrocautery, or controlled electrical energy

such as ultrasonic shears or a bipolar vessel sealing device. The wound may be left open or, more

commonly, may be closed with absorbable suture.

Excisional hemorrhoidectomy is superior to office-based therapies in achieving complete remission of

hemorrhoidal symptoms, however complications including stenosis and hemorrhage are more common.5

Patients who undergo hemorrhoidectomy are also less likely to require multiple treatments. Surgical

treatment of hemorrhoids can unfortunately also result in significant postoperative pain, and patients

often require narcotic pain medication and may require up to 2 to 4 weeks to recover.

Stapled hemorrhoidopexy, while initially described as a treatment of mucosal prolapse, is also an

option for prolapsing and bleeding hemorrhoids. Also known as the Procedure for Prolapse and

Hemorrhoids (or PPH), this technique involves the removal of a circumferential sleeve of mucosa and

submucosa of the distal rectum and anus. A circular stapler creates an anastomosis which elevates the

anal canal and fixes the anal cushions into their normal anatomic positions. Because the resection is

performed above the level of the dentate line, this technique is advantageous as it may result in less

postoperative pain. It has no effect on external hemorrhoids, and therefore its use is somewhat limited.

Stapled hemorrhoidopexy is begun by placing a purse string suture in the mucosa and submucosa

approximately 4 cm above the dentate line, incorporating all the redundant tissue circumferentially

(Fig. 70-13). Correct placement of this suture is critical to prevent placement of the stapler too close to

the dentate line, which can result in chronic pain. The anvil of a specialized circular stapler is then

passed above the purse string, and the suture is used to pull the mucosa and submucosa into the stapler

head. The stapler is then fired, which excises the sleeve of tissue and creates the anastomosis.

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Figure 70-12. Technique of internal closed hemorrhoidectomy. A: Exposure of hemorrhoid with elliptic excision starting at

perianal skin and extending to anorectal ring. B: Submucosal hemorrhoidal plexus dissected from the internal sphincter, anoderm,

and mucosa. C: Wound closed with a running suture.

A meta-analysis of prospective randomized studies demonstrated that when compared with excisional

hemorrhoidectomy, stapled hemorrhoidopexy offers some short-term benefits including less

postoperative pain and earlier return to normal activity.6 In long-term follow-up, however, stapled

hemorrhoidopexy has been associated with a higher rate of recurrent symptoms. Although PPH has been

associated with several unique complications (rectovaginal fistula, staple line bleeding, and chronic

pain), the overall rates of postoperative complications did not differ between the procedures.

Doppler-guided transanal hemorrhoid devascularization involves suture ligation of each hemorrhoidal

column with resection of the hemorrhoid. A specific anoscope that includes a Doppler probe is used to

identify the signal of the vessel feeding each hemorrhoidal column, typically above or just at the top of

the column. Once the vessel is identified, it is then ligated with a suture and the Doppler probe is again

used to confirm the disappearance of the signal. Typically the hemorrhoidal column is then also

oversewn with this suture. The purported benefit of this procedure is that because the ligation occurs

above the dentate line, postoperative pain should be significantly lower than with an excisional

hemorrhoidectomy. Long-term results with this procedure are limited, however some authors have

reported effectiveness in 90%.7

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Figure 70-13. Stapled circular hemorrhoidectomy or procedure for prolapsing hemorrhoids. A: A purse-string suture is placed in

the rectal mucosa proximal to hemorrhoids. B: The stapler anvil is placed proximal to the purse string, and the purse string is tied

down to draw hemorrhoidal tissue into the staple line. C: The stapler is fired and removed, excising a sleeve of distal rectal tissue

and creating a stapled anastomosis.

Figure 70-14. A, B: Excision of the entire thrombosed hemorrhoid.

Special Hemorrhoid Situations

Thrombosed External Hemorrhoids. Thrombosed external hemorrhoids are a relatively common

complication of hemorrhoidal disease. The exact etiology is unknown, however their presence is often

associated with physical exertion or straining (heavy exercise, moving or lifting furniture) or a bout of

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