Piles Treatment: Overview of Surgical Options

piles treatmentPiles treatment is essential especially when it is causing distressing symptoms.  While there are a number of home remedies and medical treatment options available, sometimes these unfortunately just do not work.

In such cases, surgical treatments are offered to patients. In this article, we shall take a closer look at the different options that are available to patients when it comes to surgical management of piles.

1. Hemorrhoidectomy

Literally defined, hemorrhoidectomy refers to surgical removal of piles. It is an effective form of piles treatment that is reserved for patients who do not respond to medical treatment.

a. Indications to perform a hemorrhoidectomy

There are two main kinds of piles – external (which are visible around the anus) and internal (which are within the rectal cavity). Sometimes, external piles can get thrombosed – meaning the blood within the veins can clot.

Removing these thrombosed piles using surgery usually has a good outcome for patients.

On the other hand, internal piles are usually treated with medical treatments. If this fails, surgery can be offered, especially if the hemorrhoids are affecting the patient’s quality of life.

b. Types of Hemorrhoidectomy

There are two main types of hemorrhoidectomies – open and closed. They are classified as such because of the way the procedure itself is performed. The common factor between the two methods is that in both the cases the piles are completely excised.

c. The Procedure

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  • Preparation of the patient

Prior to performing the procedure, patients are advised to take a couple of enemas to help clear out the bowels completely. This allows the surgeon to get a clear view of the piles.

  • Anaesthesia

The procedure is performed under moderate sedation, though in some cases a general anaesthetic agent may need to be given. The anal area is number using local anaesthetic such as lignocaine 1%.

The nerve supplying the anal area called the pudendal nerve is also blocked using the anaesthetic agent.

  • Positioning of the patient

The commonest position patients are placed in when performing piles surgery is called ‘prone jack knife’ position. Here the patient is placed on their chest and some form of support is placed under the groin area so as to elevate the buttocks.

This allows the surgeon to get a clear view of the anal area and easy access to perform the procedure. In some cases, patients are placed in the lithotomy position, which is the same position women assume when giving birth.

  • Closed Technique

Once the patient is place in position, the buttocks are retracted using adhesive tape so that the anal area is clearly visualized.

Local anesthetic agent (lignocaine 1%) is injected into the skin and also the nerve that supplies the anal area and the rectum, called the pudendal nerve. This helps numb the entire area making this a painless procedure.

Once the anesthetic has been administered, the doctor will take a closer look at where exactly the piles are by opening up the anal canal using a retractor device. Once the positions are all confirmed, each of the piles is grasped using a clamp.

A suture is applied at the base of the pile so as to prevent any major blood loss. This also helps to mark out an area where the incision needs to be made.

An incision is then strategically made to remove the pile. Once this is done, and leaking tiny blood vessels are cauterized to stop any bleeding. Each of the areas that are incised is then closed shut using a suture, which is why this technique is called ‘closed’.

Care is taken to ensure there is no damage to the underlying muscle and that there is no narrowing of the anal canal after the procedure.

  • Open Technique

This is very similar to the closed technique. The only difference is that following the removal and excision of the piles, the wound is not sutured shut, but is in fact left ‘open’ and just covered with a dressing.

  • After The Procedure

Following the procedure the patient is observed for a short period of time and then discharged home with advice on how to look after the wound. Dressing can be changed as required.

Patients may be given laxative and stool softeners that help allow for easy bowel movements and no stress on the wounds. Pain killers may help relieve the pain, but sometimes warm baths can have the same effect.

Most patients who have undergone hemorrhoidectomy are seen in the outpatient department for review a month to 6 weeks later.

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2. Stapled Haemorrhoidopexy for Piles Treatment

This is a relatively newer surgical procedure using a special stapler. It does not involve making an incision in the lining of the anal cavity to remove the piles.

Preparation and positioning the patient are similar to what has been previously described. In most cases, patients are placed under general anaesthetic, though local anaesthesia may also be used.

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  • The Procedure

As is the case with conventional hemorrhoidectomy, the hemorrhoids are visualized using an anal dilator. The lining of the anal cavity is secured using sutures and the position of the sutures is confirmed by the surgeon using their finger.

The sutures help to lift the piles up. The stapler is then introduced to a level above the sutures and the piles are stapled back into place. While the procedure is a lot more complicated than has been briefly described here, it does achieve similar results to other types of piles surgery.

The advantage of this kind of surgery is that the amount of bleeding that can occur is a lot less than conventional surgery.

However, recent studies have now shown that the effects are not necessarily long lasting and patients may require repeat procedures in the future.

  • After The Surgery

Gauze is applied to the area to keep it covered. Pain killers are given to help reduce any pain. Laxatives may be prescribed to reduce straining during bowel movement.

Routine follow up is carried out in a month to 6 weeks following the procedure.

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3. Haemorrhoid Artery Ligation

This is a relatively new technique also called Doppler guided hemorrhoidal artery ligation. The main purpose of this procedure is to close the arteries that supply the hemorrhoids. In other words, by cutting off the blood supply to the hemorrhoids, the eventually shrink and falloff.

While this may seem similar to procedures such as sclerotherapy, this technique of piles treatment is a lot more accurate as the actual blood vessels supplying the piles is accurately located and closed.

The preparation and consent procedure is similar to any other surgical treatments for hemorrhoids. This includes clearing out the patient’s bowels using a stool softener or laxative.

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  • The procedure

The patient is placed in a lithotomy or jack knife position to gain good access and visualisation of the piles. Local anaesthetic is injected and the rectal cavity is visualized using an anal retractor.

Once the piles are identified, a Doppler device is inserted into the rectum and placed against each of the piles.The Doppler device emits an ultrasound wave which can locate the artery or blood vessel that supplies the piles.

By accurately locating the blood vessel, it can be ligated using a suture and complete closure of the blood vessel can be confirmed using the Doppler again.

Successful closure is indicated by the lack of blood flow through the artery into the piles as detected by the Doppler.

Sometimes following the procedure, there may be small bits of hemorrhoidal tissue still remaining which can give rise to hemorrhoids in the future. In order to remove this, a staple hemorrhoidopexy may be performed as described above.

The procedure can be performed on all the piles in one sitting.

  • After the surgery

Following the procedure, the patient is observed for a brief period of time and then discharged home. As is the case with any piles surgery, patients may be prescribed laxatives or stool softeners to help ease bowel motions and reduce straining.

Painkillers may be prescribed for the first 2 to 3 days after the procedure as patients may experience pain. Routine follow-up is carried out in a month to 6 weeks following the procedure.

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Conclusion

The above discussion only describes in brief the common surgical procedures adopted in the surgical treatment of piles.

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