SURGERY INDICATION OF HAEMORRHOID

Dr. Muryanto,Msi Med, Sp.B

Outline
 Definition
 Brief history
 Epidemiology
 Anatomi
 Etiology/Risk factor
 Pathogenesis
 Pathology
 Classification
 Indications
 Clinical feature
 Management
 Complications
Definition
Pathological presentation of hemorroidal venous cushions characterized by
distention and sliding down of anal cushions containing varicose veins.
Brief history

 The Egyptian papyrus date 1700 BC

 Hippocrates in 460 – 375 BC
 Celcus 25 BC – AD 14
 Galen AD 131 – 141
 13 th Century
 EPIDEMIOLOGY
most
frequently 13.3%
between ages
45 and 65

4,4%

60% of haemorrhoid patients are male

more frequently in those of higher socioeconomic status than those of lower
status
Source :
1. Yamana T. Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids. Journal of the anus, rectum and colon. 2017 Jul 27;1(3):89-99.
2. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study. Gastroenterology. 1990 Feb 28; 98(2): 380-6.
 Anatomi

The
anal
canal

The The
surgical anatomi
anal anal
canal canal
Anal column
Anal valves (of Ball)
Pectinate / dentate
line
- sentinal
pile Anal
papillae
Anal sinuses
Anal glands
11 O’clock

3 O’clock
7 O’clock
Etiology and Risk factors
anorectal
deformity,
Local
Constipation
hypotonic
sphincter

Prolonged
straining lavatory
sitting
abdominal ascites

gravid
uterus,
Risk of
factors uterine
pelvic
hereditary etiology Trauma neoplasm,

ovarian
Pregnancy
neoplasm

Portal
Lack of fibre
hypertension
Ageing
rich diet paraplegia,
Neurological
Diarrhoea multiple
sclerosis
Pathogenesis
Weakening of the anal cushion and spasm of the internal sphinter

Pathology
 severe inflammatory reaction
 Mucose ulceration
 Ischemicia and thrombosis
 Abnormal Venous dilatation
and distortion

*: Marked dilatation of hemorrhoidal venous plexus; #: Fragmented anal

subepithelial muscle (the Treitz’s muscle or mucosal suspensory ligament)
Classified according to origin of
haemorrhoid

Above or
below the
Pecinate
line?

EXTERNAL OR INTERNAL
 Gr I Gr II Gr III Gr IV
not prolapse returns manually returned remains prolapsed
spontaneously

Grading of haemorrhoids (on history)

INDICATION
 Symptomatic Grade III , Grade IV , Or Mixed Internal and
External Haemorrhoid
 Strangulated Internal Haemorrhoids and some thrombosed
external Haemorrhoids
CLINICAL FEATURE
MANAGEMENT
Conventional Techniques
1. White Head ( 1882)
2. Morgan Milligen ( 1937 )
3. Park (1950) Submucous hemorrhoidectomy
4. Hill Ferguson ( 1952 )
New Techniques
1. HAL – RAR ( 1995 )
2. Stapled Hemorrhoidopexy ( 1996 )
3. Electrocautery device
4. Ultrasonic scalpel
5. Vessel sealing system
6. lasers
MANAGEMENT

TREATMENT GRADE III GRADE IV TROMBOSIT +

STRANGULATED
( Complicated)
Dietary + lifestyle   
modification
Medication ( Drug Terapi )   

Surgical Prosedur
1. Hemoroidectomy   
2. Stapled Hemorroidopexy   
3. HAL – RAR   

Source : World J Gastronterol 2015 , August 21 : 21(31): 9245-9252

COMPLICATION

1. Stenosis
2. Bleeding ( 0 – 3,5 % )
3. Infection
4. Recurence
 Non Surgical = 10 – 50 %
 Surgical = 5 %
5. Non Healing wound
6. Fistula
7. Retensio Urin