Surgical Treatment of the Hemoroidal Pathology

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Surgical Treatment of the Hemoroidal
Pathology Belgorod 0ctober 2011
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Physiology
The Haemorrhoidal plexus is a physiological
structure of large vascular spaces and
atero-venous shunts so-called corpus cavernosum
recti (CCR). The CCR is described as an
atero-venous cavernous network without the
interposition of a capillary system. Selzner et
al. 1962 Staubesand et al. 1963 Thulesius et al
1973
The superior rectal artery (SRA) contributes
exclusively to the blood supply of the CCR and it
is a functional blood supply that fills this
cavernous network. Widmer 1955 Thomson 1975
Patricio et al 1988 Sun et al.1992 Shafik 1996
Aigner et al 2004
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Physiology
Arteriovenous anastomoses within the submucosa
are thought to contribute to the increase in
volume of the anal cushions, sealing the anal
canal. The cushions contribute approximately
1520 of the resting anal pressure. Perhaps
more importantly, they serve as a conformable
plug to ensure complete closure of the anal
canal. Stieve 1928 Widmer 1955, Selzner 1962
Thomson 1975 Gibbons et al. 1986, Lestar et al.
1989 Selzner 1992
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The development of haemorrhoidal disease begins,
from dilatation within the cavernous bodies of
the anal cushions, caused by multi-factorial
mechanisms such as Defects in regulation of
arterovenous shunts Increased arterial blood
flow Decreased venous drainage
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Classification (Goligher)
IV DEGREE the nodules and vascular masses become
very painful and cannot be reinserted. A
considerable swelling prevents the blood from
flowing back, a condition which could result in
haemorrhoidial thrombosis, prolapse and ulcers.
III DEGREE the piles lose their retractility and
have to be manually reinserted into the anus.
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Aetiopathogenesis
The pathogenesis of haemorrhoids is not yet
finally elucidated Holzheimer 2004
The pathogenesis of the enlarged, prolapsing
cushions is unknown. American
Gastroenterological Association Technical
Review on the Diagnosis and Treatment of
Haemorrhoids Gastroenterology 2004
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Aetiology
Genetic links
(association between haemorrhoids, hernia and
genitourinary prolapse or varicose
vein) (Selzner 1962, Burkitt 1975 Loder et al
1994)
Environmental factors
CONSTIPATION STRAINING (Stern 1964 Burkitt 1974
Hyams 1970 Thomson 1975, Haas et al.
1984) Low-fiber diet Obesity Sedentary lifestyle
DETERIORATION OF CONNECTIVE SUPPORTIVE TISSUE (Gas
s-Adams 1955, Thomson 1975, Haas et al.
1980. Loder et al.1994) Pregnancy Associated
disease
Other Conditions
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Aetiopathogenesis
Sphincter Hyper tone Hancok 1977 Teramoto et al.
1981 Lane 1982
Abnormally high anal pressure
Anal cushions Hypertension Sun et al.1990
Increased straining during defecation
Deterioration of connective supportive
tissue Gass-Adams 1955 Thomson 1975 Haas et al.
1980 Loder et al.1994
Venous drainage impairment increased cushions
pressure Stress on supporting connective mesh
Increased congestion and slippage of the anal
cushions
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HISTORY From ancient Greece to the modern age
Hippocrates (V B.C.) Cauterisation Excision
Ligature 'One may cut, resect, suture or burn
hemorrhoids. These measures seem to be terrible
but they don't cause any damage' Celsus (30
A.D.) Ligature Excision (not more than 3
cushions at the same time) Galenus (138-201
A.D.) Ligature Ibn-Sina(981-1038 A.D.)
Ligature Guglielmo da Saliceto (1210-1280)
Excision cauterisation
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Haemorrhoidal surgical techniques
More invasive
Traditional excisional surgery MM
Stapled anopexy (PPH)
Minimally invasive Surgery
Transanal Haemorrhoidal Dearterialization
Less invasive
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Longo Stapled Hemorrhoidopexy or Tranversal
Mucosectomy

• Advantages
• Highly effective in some conditions (mucosal
  prolapse)
• Immediate esthetical result
• Reduction of post-op pain
• Reduction of hospitalisation

• Disadvantages
• Expensive disposable device
• Moderate complication rate
• Techniques associated with increased risks

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Associated risks LONGO
Learning curve at least 50 Cases before safe
results Realisation of the pursetring boursa is
mandatorty and it is quite complicated to
integrate all hemoroids in it when you have
external protusion. Helicoidal pustring
suturing to integrate only one side,quite
difficult to have a correct vision of the
procedure due to the introducer Evaluation of
the distance from the dentate line Danger to
integrate in the purstring some rectovaginal
tissue (see anatomy of the pelvic
floor) Stenosis
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Stapled versus conventional surgery for
hemorrhoids. Jayaraman S, Colquhoun PH, Malthaner
RA. Source University of Western Ontario,
Department of Surgery, 339 Windermere Rd. Rm
C8-114, London, Ontario, Canada. sjayaram_at_uwo.ca
Stapled hemorrhoidopexy is associated with a
higher long-term risk of hemorrhoid recurrence
and the symptom of prolapse. It is also likely to
be associated with a higher likelihood of
long-term symptom recurrence and the need for
additional operations compared to conventional
excisional hemorrhoid surgeries. Patients should
be informed of these risks when being offered the
stapled hemorrhoidopexy as surgical therapy. If
hemorrhoid recurrence and prolapse are the most
important clinical outcomes, then conventional
excisional surgery remains the "gold standard" in
the surgical treatment of internal hemorrhoids.
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A review of 1107 patients treated with SH from
twelve Italian coloproctological centers has
revealed a 15 (164/1107) complication rate.
(first week) were severe pain in 5.0 of all
patients, bleeding (4.2), thrombosis (2.3),
urinary retention (1.5), anastomotic dehiscence
(0.5), fissure (0.2), perineal intramural
hematoma (0.1), and submucosal abscess (0.1).
Bleeding was treated surgically in 24, with
Foley insertion 15 and by epinephrine
infiltration in 2 53 of patients with bleeding
received no treatment and 6 needed transfusion.
One patient with anastomotic dehiscence needed
pelvic drainage and colostomy formation. The most
common complication after 1 week was recurrence
of hemorrhoids in 2.3 of patients, severe pain
(1.7), stenosis (0.8), fissure (0.6), bleeding
(0.5), skin tag (0.5), thrombosis (0.4),
papillary hypertrophy (0.3) fecal urency (0.2),
staples problems (0.2), gas flatus and fecal
incontinence (0.2), intramural abscess, partial
dehiscence, mucosal septum and intussusception
(each lt0.1). Recurrent hemorrhoids were treated
by ligation in 40 and by Milligan-Morgan
procedure in 32. All hemorrhoidal thromboses
were excised. Anal stenoses were treated by
dilatation in 55 and by anoplasty in 45.
Fissure was treated by dilatation in 57. Most
complications (65) occurred after the surgeon
had more than 25 case experiences of stapled
hemorrhoidectomy. The most common complication in
the first 25 cases of the surgeon's experience
was bleeding (48)
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Longo Technique without introducer
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Non Excisional Surgery
Doppler-Guided Transanal Haemorrhoidal Dearterial
ization
No Post-Op pain No Post-Op complications Resolutiv
e No need for general anaesthesia No need for
hospitalisation Can be Repeated
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Non Excisional Surgery
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THD Surgical Approach

• Exact location of the terminal branches of the
  SRA.
• Precise needle rotation
• Exact needle penetration
• Selective ligature of the arteries

SRA
Ligation
Doppler signal
2-3 cm to Dentate line
Doppler probe
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THD Surgical Approach
After ligature, the arterial inflow to the piles
decreases and the piles collapse . The decreased
tension facilitates the shrinkage of
haemorrhoids and reduction of the prolapse.
The sutures create a mucosal fixation and
lifting of the haemorrhoidal cushions.
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Localisation of the principal artery branches
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Stich Technique
Location of the terminal branches of the superior
rectal artery in lithotomy position
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Technique Modified technique for prolapsed piles
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RAR (Doppler Guided Recto Anal Repair
Proctoplasty).
AMI Gmbh HAL RAR Technique
The light source and the proctoscope is quite big
and not easy to manipulate
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RAR (Doppler Guided Recto Anal Repair
Proctoplasty).
AMI Gmbh HAL RAR Technique
Circular anchoring point in the proctoscope
inducing instability of the needle holder
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Angiodin Procto Cannula

• The horizontal diameter is slightly wider,
  allowing the needle to rotate freely inside the
  dearterializer, without any impediment, around a
  fixed point constituted by a slot where the tip
  of the needle holder is inserted. (Fig 1.)
• The slot is positioned in a slightly off central
  position at the tip of the cannula. This way, the
  results is ergonomically by far superior to the
  HAL indeed in these the needle has to follow a
  groove to rotate and, frequently slips out of
  this groove making it very difficult to complete
  the rotation.

Rotational pattern of the needle
Slot for the tip of the needle-holder_________
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The slit for the needle to perform the ligature
of the Haemorrhoidal Artery branches, is wider
but shorter longitudinally (8 mm), such to
constitute an impediment to the mucosal prolapse
inside the proctoscope. (Fig.2)
Slit for ligating the Superior Haemorrhoidal
Artery branches
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• All of the above, together with a thickness of
  the proctoscope wall much smaller than the HAL
  and the flat-top shape of our proctoscope allows
  for the needle to reach a depth, outside of the
  ligation slit by more than 6 mm, much more than
  the HAL (2,5 m).
• This guarantees that the arterial branch lies
  inside the needle rotation and is, therefore,
  ligated.

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What is the real depth of the S.R.A? Do we realy
match the right signal?
8 MHz Continious 3to7mm
8 MHz Continious 3to8mm
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What is the real depth of the S.R.A? Do we realy
match the right signal?
With Angiodin Procto we can evaluate the exact
depth of the Artery ,the size of it and we can
safely evaluate the ligation of the artery due to
the fact that some arteries are deeper than 8mm
especially in the posterior wall of the anal
canal
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What is the real depth of the S.R.A? Do we realy
match the right signal? Discussion....
After 70 measurements during total anesthesia in
Healthy voluntary patient undergoing cystoscopy
we discovered that the depth of the posterior
artery located at 5,7 where not running right
under the mucosa measured depth was between 0,9cm
to 1,6 cm
ANT
We also discover that the relapse piles where
mostly occuring posteriorly 5,7 PM
Post
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Tips and Triks
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Tips and Triks
Do not allow heamatoma to occur in the
proctoscope !
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Tips and Triks
Work with a curved needle holder to facilitate
rotation and allows access with two instruments..
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Disadvantage
Advantage
PROCEDURE
NOT ALWAYS INDICATED NOT ALWAYS EFFECTIVE USUALLY
NOT RESOLUTIVE
NO NEED OF HOSPITALIZATION CAN BE
REPEATED LESS PAINFUL
OUTPATIENT TREATMENTS (PARASURGICAL PROCEDURES)
SEVERE POST.OP. PAIN NEED OF HOSPITALIZATION RARE
BUT SEVERE COMPLICATIONS
HAEMORRHOIDAL TISSUE EXCISION (
TRADITIONAL SURGICAL PROCEDURES)
HIGHLY EFFECTIVE RARE RELAPSES
MODERATE COMPLICATIONS RATE TECHNIQUE ASSOCIATED
RISKS (BLEEDING, PERFORATION, SPHINCTER LESIONS)
HIGHLY EFFECTIVE IN SOME CONDITIONS (MUCOSAL
PROLAPSE) REDUCTION OF POST-OP PAIN REDUCTION OF
HOSPITALISATION
STAPLED HAEMORRHOIDOPEXY
CAN BE EFFECTIVE IN GRADES 2 3 OF
HAEMORRHOIDS NO POST-OP PAIN NO POST-OP
COMPLICATION RESOLUTIVE NO NEED OF GENERAL
ANESTHESIA NO NEED FOR HOSPITALISATION IMMEDIATE
RETURN TO NORMAL ACTIVITY CAN BE REPEATED
Doppler Guided Haemorrhoidopexy
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Preoperative
Postoperative
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Preoperative
Postoperative
3 weeks later
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Preoperative
Postoperative
3 weeks later
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Transanal Haemorrhoidal Dearterialization
Aim To assess the efficacy and safety of
Doppler-guided THD for the treatment of
symptomatic haemorrhoids
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Patients
With symptomatic haemorrhoids
Jan 2005
Sep 2009
From to
All patients had failed conservative treatment
and rubber banding
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Patients
Mean age 53 yrs (range 24-82)
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Surgical technique
After November 2000, always 6 ligatures
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Technique (location of terminal branches) The
terminal branches of the superior rectal are
generally located at 1 oclock, 3 oclock, 5
oclock,7 oclock, 9 oclock and 11 oclock, if
observed in lithotomy position
THD must be rotated until the pulsating Doppler
signal, corresponding to the arterial pulsation,
is audible. When the artery is located it is
possible to proceed to perform a ligature of it.
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Postoperative management
No regular laxatives No antibiotics
Analgesia Ketoralac 10mg orally as required
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Follow up
1 Week
1 Month
6 Months thereafter
(post-op pain and any complications recorded
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Postoperative management
Mean 1.35
(Ketoralac 10 mg TDS)
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Complications
BLEEDING immediate 2
delayed 1 SUBMUCOSAL HAEMATOMA 3 ANAL
FISSURE 2 (VASgt8) THROMBOSED PILE 3
(VASgt8) URINARY RETENTION 1 DELAYED
DISCHARGE 3 READMISSION 1
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Symptomatic outcome Mean follow-up 48 months
(21-78)
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Symptomatic outcome Mean follow-up 48 months
(21-78)
RELAPSE RATE RELATED TO GOLIGHER GRADE   II
7 (Bleeding) III 4,8 lt2002 (6)
(before anupexis) gt2002 (3,7) (after
anupexis) IV 26,6 lt2002 (50) (before
anupexis) gt2002 (11,1) (after anupexis)
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Conclusions
THD IS A SAFE AND EFFECTIVE TECHNIQUE FOR THE
TREATMENT OF II AND III DEGREE HAEMORRHOIDS. ITS
ROLE FOR IV DEGREE HAEMORRHOIDS SHOULD BE FURTHER
ASSESSED.

NEGLIGIBLE TISSUE TRAUMA
REDUCED POSTOP. PAIN
NO MAJOR COMPLICATIONS
DAY SURGERY IN LOCAL ANAESTHESIA
WIDE INDICATIONS