Colorectal Surgery

High fibre diet
Fibre supplement such as Metamucil, Normacol or Fybogel
Must not ignore the urge to open bowel.

Rubber Band Ligation
*Putting rubber bands over the hemorrhoids to cut off their blood supply. This lead to the shrinkage of the hemorrhoids and dropped off from the bowel wall. Maximum 3 haemorrhoids ligated at any one time.

• Effective for small haemorrhoids
• Risks: <1% of bleeding
  Usually dull ache for 24-48 hours
  Severe pain is uncommon
  Severe infection is rare

Sclerotherapy

• Injecting 5% Phenol in Almond Oil into hemorrhoids
• Good for small hemorrhoids
• It has been shown to be less effective than rubber band ligation in some studies.

1. Open Haemorrhoidectomy (conventional)

• Necessary for large or complicated haemorrhoids
• This procedure is performed under anaesthetic in a hospital or Day Surgery Centre
• It involves the cutting out of the haemorrhoids. A maximum of 3 haemorrhoids can be removed at any one time with careful preservation of the mucosal bridges (to prevent anal stenosis) and the identification and preservation of internal anal sphincters (to prevent faecal incontinence).
• Disadvantages:
  Main disadvantage is significant anal pain for at least 2 weeks despite laxatives, analgesia, oral Metronidazole and warm bath. It may also need to be performed in 2 stages if the haemorrhoids are large and circumferential
• Risks: <5% risk of bleeding requiring hospitalization or intervention, delayed wound healing acting like an anal fissure, faecal incontinence (uncommon) and rare anal stenosis

2. Ligasure Haemorrhoidectomy

• Similar to open haemorrhoidectomy in that the haemorrhoid is excised. However, the excision is carried out using Ligasure Small Jaw rather than standard diathermy. This instrument reduces postoperative pain and operating time.
• It is suitable for patients who have large external haemorrhoids and large skin tags (4th degree haemorrhoids)

3. Stapled Haemorrhoidectomy

What is stapled haemorrhoidectomy?
An operation designed by Dr Antonio Longo in the late 1990s. This operation involves the use of a stapled gun inserted through the anus to cut the internal hemorrhoids out. There is no external wound.

What are the benefits of stapled haemorrhoidectomy?
It gives minimal pain after the operation. It does not need to be performed in stages. It also allows patients to return to work or normal activity in a significantly shorter time compared to open haemorrhoidectomy.

What are the disadvantages?
It removes internal haemorrhoids very well but it does not remove the external haemorrhoids or anal skin tags. Therefore, it is not suitable for patients with fourth degree haemorrhoids or in patients who would like to have their skin tags removed. The literature also indicates a higher recurrence rate especially for prolapse.

What are the risks?

4. Transanal Haemorrhoid Dearterialisation (THD)

In the search for a painless surgical treatment for haemorrhoid, transanal haemorrhoid dearterialisation (also known as Doppler-guided haemorrhoid artery ligation or haemorrhoid artery ligation and rectoanal repair – HAL RAR), is a relatively new innovation based on a different principle from conventional open haemorrhoidectomy. Since it was first reported by Morinaga and colleagues in 1995, it has gradually gained in popularity among surgeons.

The operation involves the use of a specifically designed proctoscope together with a Doppler transducer. With the rotation of the proctoscope, the Doppler probe allows for the accurate localization of the terminal branches of haemorrhoidal arteries which are then ligated with sutures. The reduced blood flow should lead to the shrinkage of haemorrhoids. The haemorrhoids were also reduced into the anal canal via a continuous stitch to compress the haemorrhoids tightly. In fact, the compression actually makes the haemorrhoids ischaemic and therefore the internal haemorrhoids are removed by making them “die inside”. The external haemorrhoids were reduced into the anal canal to a certain extent via the pulling action by the same stitch.

The postoperative pain from this operation is minimal because the technique avoids suturing the sensitive anoderm below the dentate line. It also avoids any external wound. Therefore, the main advantages are minimal postoperative pain, minimal analgesic use, no need to use warm/Sitz bath, a safe operation and quicker recovery (compared to open haemorrhoidectomy). The disadvantages are that it is not suitable for fourth degree haemorrhoids or in patients who would like to have their skin tags removed. Perhaps a combination of THD and excision of certain skin tags may be carried out for those with prolapsed haemorrhoids and large skin tags to minimize their postoperative pain.

In a systematic review published in Diseases of the Colon & Rectum in 2009 (DCR 52 (9): 1665-71), the overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding and 4.7% for pain at defaecation. The recurrence rate at one year or more was 10.8% for prolapse, 9.7% for bleeding and 8.7% for pain at defecation. The operative risks are bleeding and anal pain (especially if the suture is too close to dentate line).

In summary, I believe THD is effective in controlling symptoms of PR bleeding and prolapse with minimal morbidities. Personally, I perform THD for second and third degree haemorrhoids. In my opinion, Ligasure haemorrhoidectomy is a better option for fourth degree haemorrhoids. However, this instrument is not readily available in many hospitals due to the cost of the instrument. Finally, there is an alternative to painful haemorrhoidectomy and it is important to be able to provide different modality of treatment for different types and sizes of haemorrhoids.