Hemorrhoidal pathology is one of the most frequent causes of consultation in Coloproctology clinics. Hemorrhoids are physiological plexuses of the anal canal made up of arteriovenous complexes. Their main function is the sealing of the anal canal in the control of defecation. Most symptoms are caused by internal hemorrhoids. The most frequent symptom is bleeding. In addition to prolapse, because they are mucosally lined, they can cause soiling, perianal irritation and anal itching. Hemorrhoids rarely hurt, unless they prolapse, incarcerate or thrombose.
Treatment of hemorrhoids
There are a wide variety of therapeutic options for this pathology including hygienic-dietary measures, rubber band ligation, sclerotherapy, infrared coagulation, and surgical treatment.
For the surgical treatment of hemorrhoids, new procedures are emerging with the main objective of reducing the pain of conventional hemorrhoidectomy, trying to achieve similar results in terms of efficacy and safety. Among the new techniques we find hemorrhoidectomy with special sealants such as the advanced bipolar electroscalpel or ultrasonic device, circular hemorrhoidopexy with stapler and doppler-guided hemorrhoidal dearterialization and mucopexy (THD/HAL).
Conventional hemorrhoidectomy includes the Milligan-Morgan and Ferguson techniques, and consists of excision of the hemorrhoids. It is still considered the “gold standard” for obtaining the best long-term results, but its main complication continues to be significant postoperative pain.
Hemorrhoidectomy with special sealants consists of performing hemorrhoid excision with an instrument that performs bipolar or ultrasound electrothermal sealing. This technique presents comparable results to conventional techniques with less postoperative pain, since this instrument uses a high-frequency current and an active feedback system to control the energy released, which limits thermal propagation and reduces local damage.
Circular stapler hemorrhoidopexy (PPH) is a less painful alternative for the treatment of hemorrhoids that consists of stapling the hemorrhoids WITHOUT removing them. This technique is indicated in grade III hemorrhoids (hemorrhoids that prolapse with defecation and are manually reduced), and that present a circumferential prolapse. Since this stapling is performed at the rectal level and does not leave wounds in the anal canal, it causes less postoperative pain. The mechanism of this technique consists of reintroducing 2-3cm of hemorrhoidal plexus by circumferentially resecting a bundle of rectal mucosa and submucosa that is in excess in the area close to the hemorrhoidal tissue. The defect is simultaneously closed by the stapler and the hemorrhoidal area is fixed higher. This causes a reduction of the prolapse and an interruption of the arterial flow to the hemorrhoids, solving the main symptoms caused by grade III hemorrhoids, which are prolapse, bleeding and pain.
Another of the new techniques for the treatment of hemorrhoids WITHOUT removing them, which also produces less postoperative pain, is Doppler-guided hemorrhoidal dearterialization and mucopexy (THD/HAL). The main objective of this technique is also the treatment of hemorrhoid symptoms such as bleeding, pain and prolapse. The technique consists of ligating the maximum point of arterial flow that reaches the hemorrhoid, using a very sensitive Doppler. Subsequently, in the same operation, the prolapsed mucosa is raised to its original position by means of stitches in the rectal mucosa.
Advantages of the new hemorrhoid surgery techniques
The main advantage offered by the techniques that do not perform hemorrhoid excision over those that do is less postoperative pain, since no surgical aggressions are performed in the anal canal. This reduction in postoperative pain allows a significant reduction in the consumption of analgesics and an earlier return to work or normal daily activities than with conventional surgical techniques.