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Haemorrhoids: Study and Surgical Management

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1. Anatomy and Pathophysiology

Normal Anal Cushions

• Arteriovenous communications (branches of the superior rectal artery)
• Smooth muscle (Treitz muscle) and connective tissue that anchors cushions to the internal sphincter
• Overlying mucosa/anoderm

Venous Drainage Significance

• Above dentate line → superior rectal vein → portal system
• Below dentate line → inferior rectal veins → systemic (pudendal → IVC)

• Internal haemorrhoids (above dentate line): visceral innervation — painless unless strangulated
• External haemorrhoids (below dentate line): somatic innervation — painful

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2. Classification

By Anatomical Origin

Degree Classification of Internal Haemorrhoids (Goligher's System)

Strangulated haemorrhoids are a subtype of 4th degree where prolapsed tissue has its blood supply cut off — a surgical emergency.

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3. Aetiology and Risk Factors

• Chronic constipation / straining at stool
• Low-fibre diet
• Prolonged sitting (especially on the toilet)
• Pregnancy and puerperium (raised intra-abdominal pressure)
• Portal hypertension (cavernous haemorrhoids — special consideration)
• Chronic diarrhoea / IBS
• Hereditary connective tissue weakness
• Obesity
• Aging (progressive connective tissue degeneration)

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4. Clinical Features

Symptoms

• Painless bright red rectal bleeding (BRBPR) — hallmark; blood on paper, coating stool, or dripping into pan
• Prolapse — sensation of lump/tissue per anum
• Mucus discharge and perianal soiling
• Pruritus ani
• Discomfort/heaviness — not true pain unless complicated
• Pain — only with:
  • Strangulation
  • Thrombosed external haemorrhoid
  • Co-existing fissure

Signs on Examination

• Confirms internal haemorrhoids
• Identifies position, degree, and active bleeding points
• Performed at rest and with straining

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5. Investigations

Mandatory

Indicated (to exclude other pathology)

Important: Rectal bleeding must NEVER be attributed to haemorrhoids without excluding colorectal malignancy, especially in patients >40 years or with red-flag features.

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6. Differential Diagnosis

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7. Management

Step-up Approach

Conservative → Office Procedures → Surgery

A. Conservative Management (1st–2nd degree, mild)

• Dietary modification: High-fibre diet (25–35 g/day), adequate hydration
• Stool softeners / bulking agents (ispaghula husk, lactulose)
• Sitz baths (warm water, 10–15 min, 2–3x/day) — symptomatic relief
• Topical preparations (hydrocortisone + lidocaine): short-term symptom relief only; no evidence of cure
• Lifestyle: Avoid prolonged straining, regular exercise, normalise weight

B. Office (Outpatient / Non-operative) Procedures

Rubber band ligation is the gold-standard outpatient procedure — most cost-effective with lowest recurrence rates for 2nd–3rd degree haemorrhoids.

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C. Surgical Management

Indications (Bailey & Love's, p. 1452)

• 3rd- and 4th-degree haemorrhoids
• 2nd-degree haemorrhoids failing non-operative treatments
• Mixed haemorrhoids with a well-defined external component
• Bleeding causing anaemia
• Strangulated haemorrhoids (urgent)
• Patient preference after counselling

Pre-operative Preparation

• Full history and examination, proctoscopy
• FBC, clotting, group & save
• Bowel preparation (phosphate enema on morning of surgery OR mechanical bowel prep)
• Consent (covering: bleeding, infection, anal stenosis, incontinence, recurrence, fistula)
• DVT prophylaxis (LMWH + TED stockings)
• Positioning: lithotomy (commonest) or jack-knife (prone)
• Anaesthesia: GA ± caudal/spinal block; local infiltration with adrenaline reduces bleeding

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Operative Techniques

1. Milligan-Morgan Haemorrhoidectomy (Open) — Gold Standard

• Technique: Three haemorrhoidal pedicles excised with scissors/diathermy. The pedicle is transfixed and ligated at its base, then excised. Wounds are left open (heal by secondary intention).
• Crucial: Preserve skin bridges between excision sites (mucocutaneous bridges) to prevent anal stenosis.
• Advantages: Low recurrence, well-studied
• Disadvantages: Painful post-op (7–10 days), slow wound healing (4–6 weeks)

2. Ferguson Haemorrhoidectomy (Closed)

• Same excision as Milligan-Morgan, but wounds are closed with absorbable sutures
• More common in USA
• Less post-operative pain, faster healing but higher wound dehiscence risk

3. Stapled Haemorrhoidopexy (Procedure for Prolapse and Haemorrhoids — PPH)

• Technique: A circular stapling device (PPH-01 gun) is used to excise a doughnut of rectal mucosa/submucosa above the haemorrhoids. This:
  • Interrupts arterial supply
  • Repositions prolapsed cushions back into the anal canal (mucopexy)
• Advantages: Less post-operative pain, faster return to work, short op time
• Disadvantages:
  • Cannot treat external haemorrhoids
  • Higher recurrence and re-intervention rates long-term
  • Risk of rare but serious complications: rectovaginal fistula, rectal perforation, staple line bleeding, pelvic sepsis
• NICE guidance: Acceptable alternative for 2nd–3rd degree; patients must be informed of higher long-term recurrence

4. Transanal Haemorrhoidal Dearterialisation (THD) / Haemorrhoidal Artery Ligation (HAL)

• Doppler-guided ligation of 6 terminal branches of the superior rectal artery
• Often combined with mucopexy (RAR — Recto-Anal Repair) to reduce prolapse
• Less painful than conventional haemorrhoidectomy
• Suitable for 2nd–4th degree
• Increasing evidence base; recurrence rates comparable to RBL in some studies

5. LigaSure / Harmonic Scalpel / Diathermy-Assisted Haemorrhoidectomy

• Modifications of Milligan-Morgan using vessel-sealing devices
• Reduced operative time, less blood loss, comparable pain and recurrence

6. Whitehead's Haemorrhoidectomy

• Circumferential excision of haemorrhoidal tissue
• Largely abandoned due to high complication rate: Whitehead's deformity (ectropion of rectal mucosa through anal canal → wet anus, mucus discharge, stenosis)

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Post-operative Care

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8. Complications

Early Complications

Late Complications

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9. Special Situations

Strangulated (Gangrenous) Haemorrhoids

• Emergency: Fourth-degree prolapse with oedema and vascular compromise
• Conservative: Ice packs, analgesia, reduction if possible — may allow semi-elective surgery in 6–8 weeks
• Emergency haemorrhoidectomy: Increased risk but acceptable; traditionally avoided due to oedema
• Thrombectomy for thrombosed external haemorrhoid within 72 hours gives best symptom relief

Thrombosed External Haemorrhoid

• <72 hours: Surgical excision under LA (not just incision — excise the whole haemorrhoid to prevent re-thrombosis) → rapid relief
• >72 hours: Conservative management (analgesia, sitz baths, laxatives) — spontaneous resolution over 2–4 weeks

Haemorrhoids in Pregnancy

• Conservative management throughout pregnancy
• Avoid surgery during pregnancy
• Most resolve post-partum
• If necessary, RBL can be performed in 2nd trimester

Portal Hypertension / Cirrhosis

• Anorectal varices (not true haemorrhoids) — can bleed massively
• Avoid conventional haemorrhoidectomy — catastrophic haemorrhage risk
• Treat the underlying portal hypertension (TIPSS, portosystemic shunt)
• Conservative measures only for true haemorrhoids in this context

Immunocompromised / HIV Patients

• Increased infection and poor wound healing risk
• Avoid surgery if possible; office procedures preferred
• If surgery necessary, cover with prophylactic antibiotics

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10. Prognosis

• Conservative management: Effective for 1st–2nd degree in most patients; recurrence common if lifestyle not modified
• Rubber band ligation: 80–90% success for 2nd–3rd degree; may require repeat sessions
• Haemorrhoidectomy: Most definitive treatment; recurrence rates 2–5% at 5 years for open technique
• Stapled PPH: Higher symptomatic recurrence (up to 30% requiring re-intervention at 5 years in some trials — ETHOS trial, UK)

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Summary Algorithm

Symptomatic Haemorrhoids
        ↓
Clinical Assessment + Proctoscopy (exclude malignancy)
        ↓
   ┌────────────────┬──────────────────┬─────────────────┐
1st Degree       2nd Degree         3rd Degree        4th Degree
   ↓                ↓                  ↓                  ↓
Conservative    Conservative       Conservative        Surgery
+ Injection    → RBL / Injection  → RBL (try first) → Haemorrhoidectomy
Sclerotherapy  → Surgery if fails  → Surgery if fails    (Milligan-Morgan
                                                          / THD / Stapled)

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• Bailey & Love's Short Practice of Surgery, 28th Edition, p. 1452
• NICE Guideline IPG473 — Stapled haemorrhoidopexy
• ACPGBI (Association of Coloproctology of Great Britain and Ireland) — Haemorrhoids guidelines
• Goligher JC — Surgery of the Anus, Rectum and Colon (grading system)
• Thomson WH (1975) — The nature of haemorrhoids (sliding anal lining theory)