SURGERY OF ANUS AND ANAL

CANAL (3)
Dr Emad Geddoa
Associate Professor of Surgery
FICS.MD.MRCS
May 2022
 Objectives:

Haemorrhoids
HAEMORRHOIDS
 HAEMORRHOIDS
Haemorrhoids also known as piles,
Tend to occur more commonly in men.
Represents excessive dilatation of the venous plexus at the
lower ends of the anal mucosal columns.
Pathology:
- First degree: bleed only, no prolapse.

- Second degree: prolapsed but will reduce spontaneously,

or can be reduced digitally and will remain reduced.

- Third degree: continuously remain prolapsed.

Internal haemorrhoids:
Are located above the dentate line and covered with columnar
epithelium, these are dilated veins of the superior and
middle rectal plexuses.

External haemorrhoids:
Lie below the dentate line and are covered with squamous
epithelium and involve the dilated inferior rectal veins.
Internal haemorrhoids are usually seen in three groups (as
seen in lithotomy position of the patient) of primary
haemorrhoids:-

a- left lateral ( 3 o’clock ).

b- right anterior ( 11 o’clock ).

c- right posterior ( 7 o’clock ).

The primary haemorrhoid can be further divided into
three parts:

1- pedicle: at the anorectal ring covered with pale pink

mucosa.

2- internal haemorrhoid: which commences just below

the anorectal ring and is bright red or purple,
occasionally,a branch of the superior rectal artery may
enter the pedicle ”arterial piles”.

3- associated external haemorrhoid which lies between

the dentate line and anal margin and is covered with skin
 Aetiology
1- Hereditary: familial congenital weakness of veins wall.

2- Morphological: high venous pressure in the veins of the

lower rectum due to upright posture.

3- Anatomical: tributaries of superior haemorrhoidal vein lie

unsupported in loose connective tissue and pass through
the muscular tissue and can be constricted during
defecation & these veins have no valves.

4- Exacerbating factors: straining accompanying constipation

or that induced by over purgative or diarrhoea of enteritis
or colitis.
Haemorrhoids may be symptomatic of other
conditions:
1- Carcinoma of rectum: by compressing or causing
thrombosis of superior rectal vein.

2- Pregnancy : due to pressure by gravid uterus and

progesterone induced relaxation of the smooth muscle in
the walls of the veins, plus an increased pelvic circulating
volume.

3- Straining: at micturation due to urethral stricture or an

enlarged prostate.

4- From chronic constipation.

 Clinical features
1- Bleeding: painless, fresh rectal bleeding.

2- Prolapse: late symptom, occurs during defecation.

3- Discharge: mucoid discharge of prolapsed haemorrhoids

& pruritus due to discharge.

4- Pain: is absent unless complication occur.

5- Anaemia: may present due to chronic blood loss.

 Diagnosis
* Inspection: proplased haemorrhoids or skin tags may be
seen.

* Per-rectal examination: must be done to rule out other

causes of bleeding per- rectum.
Uncomplicated internal haemorrhoids are not palpable.

* Proctoscopy: internal haemorrhoids bulge into the lumen of

the scope.

* Sigmoidoscopy: should be done in all cases to rule out

coexisting colorectal carcinoma
 Complications:
1- Profuse haemorrhage.
2- Strangulation with onset of severe pain.
3- Thrombosis: the haemorrhoid appears dark purple or black
and feels solid.
4- Ulceration of prolapsed haemorrhoid.
5- Gangrene may occurs if strangulation is tight enough to
constrict the arterial supply.
6- Fibrosis may follow thrombosis.
7- Suppuration may occurs due to infection in a thrombosed
haemrrhoid.
8- Pylephlebitis ( portal pyaemia ) : infected haemrrhoids may
lead to portal pyaemia & liver abscesses.
 Treatment:
a- Conservative treatment: indicated in early cases:

* High fibre diet.

* Small dose of laxative.

* Avoidance of straining at defecation.

* Suppositories or cream that contain decongestants.

* Correct anaemia.
b- Surgical treatment:
1- Sclerotherapy:
for the 1st degree & early 2nd degree haemorrhoid :
Submucosal injection of 5% phenol in almond oil into the apex
of the haemorrhoid to cause a septic fibrosis and scarring
and subsequent atrophy.

2- Banding treatment:
for 2nd degree haemorrhoids :
By slipping tight elastic bands on the pedicle of each
haemorrhoid with a special instrument.
The band cause ischemic necrosis of the piles which slough
off within a few days.
3- Cryosurgery:

Tissue destruction by freezing ( -196C ) with liquid nitrogen.

Its application cause coagulation necrosis of the piles which
subsequently separated and dropped.
[ this technique cause mucous discharge & pain & now not used ].

4- Photocoagulation:

The application of infrared coagulation by a special instrument.

For the treatment of haemorrhoids that do not prolapse.
5- Haemorrhoidectomy: indications are:
1- third degree haemorrhoids.

2- second degree haemorrhoids which not cured by non-

operative treatments.

3- fibrosed haemorrhoids.

4- intero-external haemorrhoids when the external

haemorrhoids is well defined.

Technique: either open or closed technique;

The individual haemorrhoid is dissected, transfixed & excised.
 Complications of haemorrhoidectomy:

a- Early:
1- Pain.
2- Acute retention of urine.
3- Reactionary haemorrhage.

b- Late:
1- Secondary haemorrhage.
2- Anal stricture.
3- Anal fissure.
4- Incontinence.
 Thrombosed External Haemorrhoid
(Perianal Haematoma)
This is a very painful condition due to rupture of dilated anal
vein secondary to straining at defecation or coughing or
lifting a heavy weight.

It leads to haemorrhage in loose subcutaneous connective

tissue usually in the lateral position.

Clinical features:
Appears suddenly and is very painful & on examination a
tense, tender swelling that resemble a semiripe black
currant is seen.
 Treatment:

If untreated: it may resolve, suppurate, fibrosed and give rise

to a cutaneous tag or burst and extrude the clot.

If seen within 36 hours:

under local anaesthesia the haemorrhoid is bisected and the
two halves are excised .

The relief of pain is immediate and a permanent cure is

certain.
THANKS