Surg Clin N Am 82 (2002) 1153–1167

Hemorrhoids
T. Cristina Sardinha, MD, Marvin L. Corman, MD*
Department of Surgery, North Shore-Long Island Jewish Medical Center,
New Hyde Park, NY 11040, USA

The exact definition of hemorrhoids has been difficult to formulate, if for

no other reason than that the pathophysiology of this condition remains elu-
sive. The word, hemorrhoid (haima ¼ blood; rhoos ¼ flowing), derives from
the Greek adjective, haimorrhoides [1]. As a disease entity, hemorrhoids
have been reported to plague the human race since the earliest history of
man. Data from the National Center for Health Statistics suggest that
approximately 10 million people in the United States suffer from hemor-
rhoids [2]. The exact prevalence of hemorrhoids is difficult to estimate, how-
ever, because patients presenting with any anorectal symptoms assume that
they are suffering from this condition. Therefore, the ultimate diagnosis and
management truly must rest with an experienced clinician.
This article provides an overview of hemorrhoid disease, with emphasis
on newer therapeutic modalities.

Anatomy
According to Thomson [3], the submucosa does not form a continuous
ring of thickened tissue in the anal canal, but rather a discontinuous, series
of vascular cushions. The three main cushions are found in the left lateral,
right anterior, and right posterior positions. The submucosal layer of these
cushions is rich in blood vessels and muscular fibers. These fibers (muscula-
ris submucosae ani) arise from the internal sphincter and the conjoined lon-
gitudinal muscle, and are responsible for maintaining adherence of mucosal
and submucosal tissues to the internal sphincter and blood vessels of the
submucosa. These vascular cushions may protect the anal canal from injury
by filling with blood during defecation.

* Department of Surgery North Shore/Long Island Jewish Medical Center, 269-11 76th
Avenue, Suite #FP 417, New Hyde Park, NY 11040.
E-mail address: mcorman@lij.edu (M.L. Corman).

0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 8 2 - 8
1154 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

The blood supply to the vascular cushions in the anal canal is provided
by the terminal branches of the superior hemorrhoidal artery, and by
branches of the middle hemorrhoidal arteries. Terminal branches of the
inferior hemorrhoidal arteries, which supply the lower portion of the anal
canal, also participate in the network of intercommunicating vessels of the
anal cushions. The venous drainage from the anal canal is established by
the superior, middle, and inferior hemorrhoidal veins [4].

Pathophysiology and etiology

The deterioration of supporting tissue to the vascular cushions in the anal
canal produces venous distension, erosion, bleeding, and thrombosis. Sev-
eral theories have been postulated regarding the cause of hemorrhoids; how-
ever, the precise etiology of hemorrhoids is still unknown. Among the many
attempts to explain hemorrhoids are: venous obstruction secondary to
congestion and hypertrophy of the anal cushions, prolapse or downward
displacement of the anal cushions, destruction of anchoring connective
tissue, and abnormal dilatation of the veins of the internal hemorrhoidal
plexus. Other factors, such as heredity, age, anal sphincter tone, diet, occu-
pation, constipation, and pregnancy, have also been implicated in the cause
of hemorrhoids [4].

Classification
Hemorrhoids are classified according to location and degree of prolapse.
The dentate line separates internal from external hemorrhoids. Internal
hemorrhoids arise proximal to the dentate line from the superior hemorrhoi-
dal plexus and are covered by mucosa. Conversely, external hemorrhoids
are located distal to the dentate line, arise from the inferior hemorrhoidal
plexus, and are covered by squamous epithelium. Mixed hemorrhoids (inter-
nal-external) are present above and below the dentate line and arise from the
superior and inferior hemorrhoidal plexus and their anastomotic communi-
cations.
Hemorrhoids are also graded according to the degree of prolapse as fol-
lows [4–6]:
First degree: Cushions located above the pectinate line that do not
descend upon straining. They are usually associated with bleeding at
the time of defecation.
Second degree: Cushions that protrude below the pectinate line during
straining but return spontaneously to within the anal canal once strain-
ing stops.
Third degree: Cushions that protrude to the exterior of the anal canal
during straining or defecation and require manual reduction back into
the anal canal.
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1155

Fourth degree: Cushions that are irreducible and remain constantly pro-
lapsed independent of straining or defecation.

Diagnosis
A detailed history is one of the cornerstones for establishing the diagnosis
of hemorrhoids. The color and character of anorectal bleeding and the relief
obtained from reduction of prolapsed hemorrhoids into the anal canal lead
the examiner to the diagnosis. One should always keep in mind other ano-
rectal pathologic conditions that may present with similar symptoms. These
include rectal prolapse, polyps, carcinoma, hypertrophied anal papilla, skin
tags, fissure, fistula, and perianal infections.
Patients with hemorrhoids often complain of bleeding during or after
defecation, frequently exacerbated by straining. Blood can be evident on
the toilet paper or within the toilet bowl, or both. Occasionally, blood loss
can cause severe anemia or even require blood transfusion. Bleeding is more
commonly associated with internal hemorrhoids. Kluiber and Wolff [7]
found that the incidence of anemia attributed to hemorrhoids was 0.5 per
100.000 people per year in Olmsted County, MN. Uncomplicated hemor-
rhoidal disease is usually painless. Thrombosis, ulceration, or gangrene of
the pile may cause significant pain and discomfort.
An adequate physical examination should include a careful inspection,
palpation, digital examination, anoscopy, and proctosigmoidoscoy. The use
of anorectal physiologic studies as a tool for the diagnosis of hemorrhoids
has yet to be determined. Preoperative manometric studies may be of value
in patients who are at risk for the development of postoperative inconti-
nence, however. A thorough inspection and palpation is required to differ-
entiate hemorrhoids from perianal Crohn’s disease. Inspection is also
important in the diagnosis of a concomitant anal fissure. Inspection and pal-
pation should readily differentiate a thrombosed hemorrhoid, a tumor, or an
abscess. Anoscopy and proctoscopy will demonstrate the internal vascular
cushions and may also show active bleeding. Evidence of hemorrhoid bleed-
ing does not exclude other causes of rectal bleeding, however. Therefore,
further investigation, such as colonoscopy or barium enema, may be war-
ranted in patients whose symptoms suggest proximal colon pathology.
Complete colonic evaluation should be performed at some point in those
who are at a risk based on family history, or are at an age for colonic screen-
ing evaluation.

Treatment
Numerous therapeutic modalities have been used to manage hemor-
rhoids. A good understanding of the pathophysiology of hemorrhoids helps
one to select the most appropriate technique for treatment. Traditionally,
1156 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

the management of hemorrhoids has been based on the degree of prolapse of

the vascular cushions and the severity and type of symptoms. Most of the
available options for treatment of hemorrhoids are performed as outpatient
procedures. Guidelines have been established by the Standards Task Force
of the American Society of Colon and Rectal Surgeons to describe practice
parameters for the management of ambulatory anorectal surgery, including
hemorrhoidal disease [8].

Nonoperative management and minor surgical procedures

Conservative medical management of hemorrhoids can be accomplished
in the majority of patients. These nonsurgical options vary from advice with
respect to defecation habits, local hygiene, and dietary manipulations, to
minor procedures such as injection or rubber band ligation. Neglecting the
first urge to defecate, spending a prolonged time at the toilet, and straining
are common defecation errors. Hemorrhoidal disease, particularly third and
fourth degree, are often associated with mucous staining and itching. These
symptoms often require advice about anal hygiene to prevent perianal der-
matitis and to ameliorate symptoms. A high-fiber diet is associated with an
improvement in bowel habits and reduction in constipation. Furthermore,
the addition of bulk-forming agents to a normal diet can minimize the
amount of trauma to the anal canal epithelium caused by hardened stools,
therefore reducing the likelihood of ulceration and bleeding [9]. The use of
sitz baths and warm soaks to ameliorate symptomatic hemorrhoids, espe-
cially thrombosis, is also commonly recommended. Ice packs to decrease
swelling shortly after it becomes evident have also been recommended.
A large variety of topical agents, such as creams, lotions, suppositories,
and local anesthetics, have been employed with the purpose of improving
hemorrhoidal symptoms. These commercial preparations, including Anusol,
Tucks, Balneol, and Preparation H, among others, are common self-medica-
tions that have become ubiquitous in the Western population [4,5]. The effi-
cacy of such products has yet to be proved. However, anecdotal evidence
suggests some symptomatic relief of hemorrhoidal disease can be achieved
with the use of topical medications. Topical nitric oxide has been reported
as an alternative for managing strangulated internal hemorrhoid by decreas-
ing internal anal sphincter tone [10]. Even though topical agents may
improve symptoms, it is unlikely that they will eliminate and ultimately cure
the hemorrhoids.
Manual dilatation of the anal canal, described by Lord in 1968, was
based on the hypothesis that hemorrhoids were a consequence of narrowing
of the anal canal due to a ‘‘pecten band’’ [4–6]. This procedure has fallen
into disrepute because of concerns about anal incontinence. Konsten and
Beaten reported a 17-year follow-up of patients who underwent Lord’s pro-
cedure for the treatment of second and third degree hemorrhoids [11]. They
documented that 52% of these patients developed anal incontinence. Based
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1157

on these findings, the authors concluded that the use of anal dilatation for
the treatment of hemorrhoids should be abandoned.
Injection of sclerosing agents causes fibrosis of the vascular cushions, and
therefore obliterates the hemorrhoids. This approach is usually applied to
the treatment of first and second degree hemorrhoids. However, sclerother-
apy is contraindicated in the management of external hemorrhoids, throm-
bosed, or ulcerated internal hemorrhoids, as well as in the presence of
inflammatory or gangrenous piles. John Morgan first attempted sclerother-
apy to obliterate hemorrhoids as early as 1869 by using iron persulphate [4].
From 1871, this technique was advertised in the United States as a ‘‘painless
cure for piles without surgery.’’ Unfortunately, inappropriate technique of
injection and toxic chemical agents were linked to serious complications,
including death [4]. Improved techniques and appropriate dosing of scleros-
ing agents, however, afford good results in properly selected patients. Chem-
ical agents used for sclerotherapy include phenol (5%) in vegetable oil,
quinine and urea hydrochloride, sodium morrhuate, and sodium tetradecyl
sulfate. Despite its relative usefulness, few reports have been published in
English language journals in recent years [12,13]. This technique should
be limited to symptomatic first and second degree hemorrhoids in those
patients for whom rubber band ligation cannot be tolerated (see later).
Injection sclerotherapy may also be advisable for patients with coagulation
disorders.
The principle of cryotherapy is based on cellular destruction through rap-
id freezing followed by rapid thawing. This freezing temperature achieved
with nitrous oxide at
60°C to
80°C or liquid nitrogen at
196°C can
eliminate hemorrhoids by necrosing the vascular cushions [6]. This proce-
dure is associated with profuse foul-smelling discharge and irritation. In
addition to pain and slow healing, the inappropriate use of cryotherapy can
cause necrosis of the internal anal sphincter, resulting in anal stenosis and
incontinence. Therefore, because this procedure does not offer any advant-
age compared with other forms of treating hemorrhoids and is associated
with high morbidity, it is now generally believed that cryosurgery should
be eliminated from the therapeutic armamentarium in the management of
hemorrhoid disease.
The use of infrared coagulation was first described by Neiger in 1979 [14].
Infrared light penetrates the tissue and is converted to heat, which causes
tissue destruction. The use of a 1.5s pulse generates a tissue temperature
of 100°C, which results in a 3 mm depth of coagulated protein [15]. As with
injection, the primary benefit is in individuals with smaller hemorrhoids and
in those whose symptoms (especially bleeding) are not amenable to rubber
band ligation.
Rubber band ligation has become one of the most frequently applied
methods for the treatment internal hemorrhoids. The instrument for rubber
band ligation was originally described by Blaisdell in 1954 and later modi-
fied by Barron [4]. Since then, the results obtained by this technique have
1158 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

been so gratifying that this approach has replaced surgical hemorrhoidec-

tomy for approximately 80% of patients.
Rubber band ligation is a simple, inexpensive, office-based procedure that
can be applied to most individuals with bleeding and or prolapsed hemor-
rhoids. It is ideal for the treatment of second and third degree hemorrhoids.
The rubber rings should be placed on an insensitive area at or just above the
dentate line. The use of an anesthetic is unnecessary. Following a cleansing
enema, a proctosigmoidoscopy and anoscopy are performed. Multiple liga-
tions at three to four week intervals may be required, depending on the
number of piles that must be banded and the individual’s response to ther-
apy. Controversies exist about the number of piles that can be banded in any
one session. Generally, we believe that the placement of two or more rubber
rings in the first treatment session should be avoided, because multiple
bandings may lead to excessive discomfort and the potential for greater
complication. Although Law and Chou [16] reported triple rubber band
ligation in a single session as safe and cost-effective, postligation pain
occurred in up to 37% of patients. A high-fiber diet with bulking agents and
stool softeners is usually recommended following banding.
Rubber band ligation is associated with a low complication rate (\2%).
Complications include a vaso-vagal response to anoscopy and the placement
of the bands, anal pain, and, rarely, pelvic sepsis. Secondary thrombosis of
the external component may also be seen and occurs in from 2% to 11% of
patients following banding [17]. The management of this condition is similar
to that of spontaneous thrombosis of external hemorrhoids. Delayed bleed-
ing after banding usually occurs 7 to 10 days postprocedure as the banded
bundle sloughs. Hemorrhage is rare (0.5%), as has been reported by Roth-
berg and others [18,19].
Rubber band ligation offers excellent results in the treatment of internal
hemorrhoids. Patient satisfaction has been well documented—80% to 90%.
Sixty to 70% are cured with a single treatment session. If symptoms persist
after two or more banding sessions, however, surgical hemorrhoidectomy
should be considered [17,20]. A meta-analysis of treatment modalities for
hemorrhoidal disease demonstrated that rubber band ligation was the pro-
cedure of choice for the management of first through third degree hemor-
rhoids [21].

Operative treatment
Lateral internal sphincterotomy alone for the treatment of hemorrhoids is
based on the principle that patients selected for it have high resting anal canal
pressures [22]. A study conducted by Leong and colleagues, however, reported
no advantage in combining internal sphincterotomy with hemorrhoidectomy
[23]. Although lateral internal sphincterotomy may be recommended in
selected patients with concomitant hemorrhoids and anal fissure, this tech-
nique should be abandoned as the sole treatment for hemorrhoidal disease.
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1159

Surgical hemorrhoidectomy should be considered in the presence of an

external component, ulceration, gangrene, extensive thrombosis, hypertro-
phied papillae, associated fissure, or failure of rubber band ligation to alleviate
symptoms. In the United States, most surgical hemorrhoidectomies are per-
formed as an outpatient procedure. The choices of anesthesia and patient posi-
tioning are individualized and are generally based on patient condition and
surgeon preference. Most hemorrhoidectomies are performed by using a local
anesthetic combined with mild sedation. We prefer to place the patient in the
prone jackknife position with the buttocks taped apart. This position offers
good exposure of the anus and provides greater comfort for the assistant.
Many alternative techniques have been described to surgically extirpate
hemorrhoids, but today the primary variable is whether the surgical wound
is closed or left open. The closed technique (the so-called Ferguson hemor-
rhoidectomy) is the method adopted by most surgeons. After infiltrating the
anus with a local anesthetic (eg, 0.5% bupivacaine in 1:200,000 epinephrine
solution), a Hill-Ferguson retractor is placed into the anal canal to reveal
the extent of hemorrhoids. The next step is the placement of a clamp, incor-
porating any skin tag as well as the vascular cushion to be excised. Excision
is accomplished with a scalpel, scissors, or electrocautery. The laser has also
been used as a cutting tool for this purpose, but has no advantage and is
expensive. The incision should be carried beyond the anal verge, removing
the external hemorrhoidal plexus, and proximally into the anal canal. The
internal sphincter is carefully dropped away from the plane of dissection.
After complete dissection and mobilization of the hemorrhoid pedicle, a
suture ligature is placed using absorbable material, and the hemorrhoid is
excised. Hemostasis is achieved with electrocautery or with the suture. The
wound is completely closed with a continuous suture, using the same stitch
employed to ligate the pedicle. A small dressing is applied following cleans-
ing of the wound. Bulky pressure dressings or packing are not indicated
because they produce more pain. Excision of three or more pile sites has
been the traditionally favored surgical approach. However, the Ferguson
Clinic group has suggested a limited hemorrhoidectomy, with excision of
only one or two pedicles, to treat symptomatic hemorrhoids [24]. With this
approach, fewer than 2% of patients required further therapy. Moreover,
the incidence of complications was significantly lower with this limited hem-
orrhoidectomy.
A sutureless, closed hemorrhoidectomy was recently reported by Sayfan
and coworkers to be a safe and rapid procedure for the treatment of third
and fourth degree hemorrhoids, as well as that of associated skin tags
[25]. This method was also associated with fewer complications and a
shorter convalescence when compared with the open procedure. Prospec-
tive randomized trials and long-term follow-up are imperative if one is to
properly evaluate any new therapy.
Open hemorrhoidectomy is an option when the wound cannot be com-
pletely closed, even with a narrow retractor in place, or in the presence of
1160 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

gangrene or circumferential hemorrhoids. The procedure is identical to the

technique previously described for the Ferguson operation, except that the
procedure ends after ligation of the pedicle. The mucosa and perianal skin
are left open and hemostasis is established with electrocautery. Alterna-
tively, a semiclosed procedure can be performed, closing the anal canal
mucosa and leaving the perianal skin open. Both open and closed hemor-
rhoidectomies are acceptable options in the treatment of hemorrhoids.
The closed method is generally felt to be associated with earlier wound
healing. Postoperative pain is probably similar to that with the open tech-
nique [26].
Complications following surgical hemorrhoidectomy are frequently
related to surgical technique and to issues of postoperative management.
Fear of pain is the most important reason why patients avoid hemorrhoidec-
tomy. Many alternatives have been directed to minimizing postoperative
pain, most recently stapled hemorrhoidopexy (see later). Currently, posthe-
morrhoidectomy pain is managed with analgesics and nonsteroidal anti-
inflammatory agents, stool softeners, and fiber.
Urinary retention is the most frequently seen complication. The incidence
varies from 10% to 32% [17]. Bleday and colleagues reported a 20% inci-
dence of postoperative urinary complications [27]. A number of contributing
factors have been implicated as leading to urinary retention. These include
the use of spinal anesthesia, fluid overload, rectal packing, rectal pain and
spasm, and bulky dressings [4]. Urinary tract infection is usually a result
of catheterization for urinary retention.
Bleeding is frequently related to inadequate hemostasis or mass ligation
of the hemorrhoid pedicle instead of suture ligature. Returning the patient
to the operating room is usually required. The incidence of postoperative
bleeding varies from 2% to 4%. Only 0.8% to 1.3% require reoperation, how-
ever [17]. Delayed hemorrhage (ie, 7 to 14 days postoperatively) is probably
a result of sepsis within the pedicle. This occurs following approximately 2%
of hemorrhoidectomies. Delayed bleeding is usually not a preventable com-
plication. The management of bleeding includes injection with epinephrine
solution, direct pressure with or without topical epinephrine, and suture
ligation. Other less frequent early complications include wound infection
(\I%), fecal impaction, and external vein thrombosis.
Late complications can be found in up to 6% of hemorrhoidectomies.
Anal fissure is the most common, accounting for 1% to 2.6%, followed by
anal stenosis (1%) [17]. Other concerns include incontinence (0.4%), anal fis-
tula (0.5%), recurrent hemorrhoids (\l%), skin tags, ectropion, and mucosal
prolapse [4,17].
Most recently, a modified circular stapling approach has been advocated
for the surgical management of hemorrhoids. The so-called Procedure for
Prolapsed Hemorrhoids (PPH) was described initially by Longo in 1998
[28]. The reported success and growing acceptance of this technique by
European and Asian surgeons has stimulated the desire for a prospective
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1161

randomized trial in the United States. The rationale for stapled hemorrhoi-
dopexy (not ‘‘hemorrhoidectomy’’) is based on the concept that interruption
of the superior and middle hemorrhoidal vessels, and the upward lifting of
the prolapsed anorectal mucosa and repositioning of the vascular cushions
back into the anal canal cause the hemorrhoidal tissue to atrophy. This tech-
nique addresses the theoretical concept that hemorrhoids represent down-
ward sliding of the anal canal lining, which results in elongation and
kinking of the upper and middle hemorrhoidal vessels [3]. Stapled hemor-
rhoidopexy has been mainly advocated for third and fourth degree internal
hemorrhoids. Conversely, external hemorrhoids are not appropriately
treated by this means, but the tags and external component can be concom-
itantly excised if indicated. Residual external hemorrhoids may actually be
partially or completely drawn into the anal canal with the PPH, or may
atrophy and become asymptomatic [29]. Even though stapled hemorrhoido-
pexy has been advocated for the treatment of second degree hemorrhoids
[30], in the absence of a prospective, randomized trial we believe that these
hemorrhoids are better treated by rubber band ligation.

Technique of Stapled Hemorrhoidopexy

A modified 33 mm circular stapler is used to perform the stapled hemor-
rhoidopexy [31]. This operation is facilitated by the use of the PPH pro-
cedural set (Ethicon Endo-Surgery, Inc., Cincinnati, OH), consisting of a
circular stapler (HCS33), a suture threader (ST100), a circular anal dilator
(CAD33), and a purse-string suture anoscope (PSA33) (Fig. 1). The tech-
nique for PPH involves the placement of a purse string suture, using non-
absorbable monofilament material, approximately 2 cm to 4 cm cephalad to
the dentate line (Fig. 2). The suture is placed into the mucosa and submu-
cosa of the lower rectum, avoiding the muscular layer and vagina. Care must
be taken to place the purse string sufficiently high so that when fired it does
not incorporate the anal mucosa and underlying internal anal sphincter. If
this were to occur, severe pain might ensue, in addition to the risk of stric-
ture and mucosal ectroprion [32,33]. These complications should be avoid-
able if the purse string is placed at least 2 cm above the dentate line [28,34].
The single greatest advantage of stapled hemorrhoidopexy is the reduc-
tion in postoperative pain. This has been demonstrated in several prospec-
tive trials that compared this approach with that of Milligan-Morgan
hemorrhoidectomy. The pain after PPH has been described as vague, dull,
and analogous to tenesmus, but differing from the severe, sharp, anal pain
associated with conventional hemorrhoid surgery [33]. Mehigan and cow-
orkers prospectively randomized 40 patients to undergo PPH hemorrhoi-
dopexy versus Milligan-Morgan hemorrhoidectomy [35]. The average
postoperative pain score from postoperative day zero to day ten was signifi-
cantly lower in the PPH group compared with the Milligan-Morgan hemor-
rhoidectomy group. By using two 10 cm linear analogue scales, the authors
1162 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

Fig. 1. PPH set of instruments.

also evaluated the degree of pain related to what the patient expected. This
was also lower in the PPH group. Similar results were reported by Rowsell
and colleagues in 22 randomized patients [36]. Larger controlled trials also
demonstrated that PPH hemorrhoidopexy diminished postoperative pain
when compared with conventional hemorrhoidectomy [29,30,37,38]. More-
over, stapled hemorrhoidopexy was also associated with a shorter hospital
stay and a faster return to full activity [39].
The reported complication rates of hemorrhoidopexy have been similar
to those of conventional hemorrhoidectomy (Table 1). One case report of
severe pelvic sepsis was noted [39], however, as was the development of a
recto-vaginal fistula [40]. The latter complication should be avoided by per-
forming a digital vaginal examination before firing the stapler, to confirm
that the vaginal mucosa has not been incorporated into the stapler. Short-
term results of stapled hemorrhoidopexy are very encouraging, especially
for third and fourth degree hemorrhoids. Long-term follow-up is required
before one feels comfortable, especially with respect to recurrence. Cer-
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1163

Fig. 2. Purse string placement.

tainly, one downside is the cost of the equipment. It is expensive when

compared with the paucity of special requirements associated with conven-
tional surgical hemorrhoidectomy. Moreover, the vast majority of hemor-
rhoidectomies in the United States are performed on an outpatient basis.
Comparing the European and Asian inpatient approach for conventional
surgery is, therefore, inappropriate.
This new technique of stapled hemorrhoidopexy is an exciting develop-
ment in the search for a relatively painless procedure to treat hemorrhoidal
disease, and it has been greeted with a mixture of skepticism, interest, and
enthusiasm. Multicenter, prospective, randomized trials with long-term fol-
low-up are awaited.

Special considerations
Thrombosed external hemorrhoids usually present as a painful, tender
mass in the anus, frequently following an episode of constipation or diar-
rhea. This manifestation is also associated with excessive straining or spend-
ing a prolonged time on the toilet. If the patient presents with severe pain,
ulceration, rupture, or onset of the condition within 48 hours, excision is the
preferred treatment. Conversely, if the discomfort is mild or if the problem
is present for greater than two or three days, and the discomfort seems to
be dissipating, sitz baths, stool softeners, and analgesics may be the best
 1164

Table 1
Postoperative complications after stapled hemorrhoidopexy
Mean Mean
follow-up hospital Urinary
Author Patients (months) stay (days) Bleeding % retention % Incontience % Stenosis % Thrombosis% Skin tags %
Ho [29] 57 4.8 2.1 8.8 1.8 NA NA 1.8 3.5
Boccasanta [37] 40 20 2.0 12.5 10.0 2.5 7.5 15.0 5.0
Shalaby [30] 100 12 1.1 1.0 7.0 0.0 2.0 3.0 4.0
Arnaud [32] 140 18 1.5 5.0 1.4 NA 3.5 1.4 1.4
Ganio [38] 50 16 1.0 6.0 6.0 0.0 NA NA NA
Mehigan [35] 20 11 1.0 5.0 5.0 5.0 0.0 NA 20
NA, non applicable.
T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1165

therapeutic options. The use of topical nifedipine is suggested by Perroti

and colleagues [41].
Thrombosed internal hemorrhoids are often attributed to prolapse of the
internal component with inadequate reduction, resulting in venous stasis
and thrombosis of the vascular cushion. In addition, all the previously men-
tioned factors that may cause thrombosis of external hemorrhoids are also
responsible for thrombosis of internal piles. The management of acute
thrombosed internal hemorrhoid is usually nonoperative, because pain is
not a frequent complaint. Sitz baths, stool softener, and mild analgesics are
recommended. Brief and coworkers suggest topical isosorbide dinitrate oint-
ment as an effective alternative to treat acute strangulated prolapsed internal
hemorrhoids [10]. They follow this with rubber band ligation after resolu-
tion of the symptoms. Surgical treatment is advisable in the presence of
concurrent extensive hemorrhoids, skin tags, and anal fissure. Even though
conservative treatment of strangulated hemorrhoids is employed in most
instances, the continued discomfort, prolonged disability, and financial bur-
den may warrant urgent operation for all such individuals.
The presence of gangrene, prolapsed, and edematous hemorrhoids usu-
ally causes severe pain, swelling, bleeding, foul-smelling discharge, and
difficulty evacuating. The treatment of this condition consists of careful
reduction of the hemorrhoids into the anal canal under local anesthesia with
sedation, followed by pressure dressing and taping the buttocks together.
Ideally, the patient should be admitted to the hospital and a hemorrhoidec-
tomy performed on the following day. This approach allows for the swelling
to decrease and for avoiding excessive removal of anal canal mucosa, there-
by minimizing the risk of anal stricture.
Hemorrhoidal disease in patients with human immunodeficiency virus
(HIV) can be safely managed as in noninfected patients in the early stage
of disease [42]. Patients with acquired immunodeficiency syndrome (AIDS),
however, are at high risk for complications (ie, infection, nonhealing
wounds), and probably should not undergo surgery except under well-con-
trolled circumstances. Scaglia and associates treated 22 AIDS patients with
bleeding second to fourth degree hemorrhoids using sclerotherapy, without
reported complications [43]. Nineteen patients improved after the first injec-
tion and 3 required subsequent sessions.
Hemorrhoids are a very common complaint in women at all stages of
pregnancy. Surgical hemorrhoidectomy should be relegated to patients suf-
fering from complications only. Symptoms usually resolve after delivery; so
conservative management is generally preferred [17].
Hemorrhoidal disease in patients with inflammatory bowel disease often
leads to diagnostic and therapeutic dilemmas. Hemorrhoidal symptoms are
usually exacerbated by bowel frequency. If indicated, hemorrhoidectomy
can be relatively safely performed in patients if the ulcerative colitis is in
remission, but should be avoided in patients with Crohn’s disease [44].
Definitive or extensive surgical treatment of any anorectal condition in
1166 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

patients with inflammatory bowel disease may result in delayed healing or

nonhealing of the wound, causing greater disability to the patient than
before the operation.

References
[1] Hulme-Moir M, Bartolo DC. Disorders of the anorectum. Gastroenterol Clin North Am
2001;30(1):183–97.
[2] Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An
epidemiologic study. Gastroenterology 1990;98:380.
[3] Thomson WBF. The nature of haemorrhoids. Br J Surg 1975;62:542.
[4] Corman ML. Hemorrhoids. In: Corman ML, editor. Colon and rectal surgery. 4th edition.
Philadelphia: Lippincott-Raven; 1998. p. 147–205.
[5] Keighley MRB, Williams NS. Haemorrhoidal disease. In: Keighley MRB, Williams NS,
editors. Surgery of the anus, rectum, and colon. 2nd edition. London: W.B. Saunders Co.;
1999. p. 351–427.
[6] Nivatvongs S. Hemorrhoids. In: Gordon PH, Nivatvongs S, editors. Principles and practice
of surgery for the colon, rectum, and anus. 2nd edition. St. Louis: Quality Medical
Publishing Inc.; 1999. p. 193–215.
[7] Kluiber RM, Wolff BG. Evaluation of anemia caused by hemorrhoidal bleeding. Dis Colon
Rectum 1994;37:1006.
[8] Standards Task Force. American Society of Colon and Rectal Surgeons. Practice
parameters for the treatment of hemorrhoids. Dis Colon Rectum 1993;36:1118.
[9] Moesgaard F, Nielsen ML, Hansen JB, et al. High-fiber diet reduces bleeding and pain in
patients with hemorrhoids. Dis Colon Rectum 1982;25:454.
[10] Brief JW, Zimmerman DD, Schouten WR. Treatment of acute strangulated internal
hemorrhoid by topical application of isosorbide dinitrate ointment. Int J Colorectal Dis
2000;15(4):253–4.
[11] Konsten J, Beaten CGMI. Hemorrhoidectomy vs. Lord’s method: 17-year. follow-up of a
prospective, randomized trial. Dis Colon Rectum 2000;43:503–6.
[12] Khoury GA, Lake SP, Lewis MCA, et al. A randomized trial to compare single with
multiple phenol injection treatment for haemorrhoids. Br J Surg 1985;72:741–2.
[13] Senapati A, Nicholls RJ. A randomized trial to compare the results of injection
sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids. Int
J Colorectal Dis 1988;3:124–6.
[14] Neiger A. Hemorrhoids in everyday practice. Proctology 1979;2:22.
[15] Reis Neto JA, Quilici FA, Cordeiro F, et al. Ambulatory treatment of hemorrhoids: a
prospective random trial. Coloproctology 1992;6:342–7.
[16] Law W-I, Chu K-W. Triple rubber band ligation for hemorrhoids: prospective, randomized
trial of use of local anesthetic injection. Dis Colon Rectum 1999;42:363–6.
[17] Beck DE. Hemorrhoidal disease. In: Beck DE, Wexner SD, editors. Fundamentals of
anorectal surgery. 2nd editon. London: W.B. Saunders Co.; 1998. p. 237–53.
[18] Corman ML, Veidenheimer MC. The new hemorrhoidectomy. Sur Clin North Am 1973;
53:417–22.
[19] Rotheberg R, Rubin RJ, Eisenstat T, et al. Rubber band ligation hemorrhoidectomy: long-
term results. Am Surg 1983;49:167.
[20] Wrobleski DE, Corman ML, Veideheiner MC, et al. Long-term evaluation of rubber ling
ligation in hemorrhoidal disease. Dis Colon Rectum 1980;23:478–82.
[21] MacRae HM, McLoad RS. Comparison of hemorrhoidal treatment modalities: a meta-
analysis. Dis Colon Rectum 1995;38:687–94.
[22] Schouten WR, van Vroonhoven TJ. Lateral internal sphincterotomy in the treatment of
hemorrhoids: a clinical and manometric study. Dis Colon Rectum 1986;29:869–72.
 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167 1167

[23] Leong AFP, Hussain MJ, Seow-Chen F, et al. Performing internal sphincterotmy with
other anorectal procedures. Dis Colon Rectum 1994;37:1130–2.
[24] Hayssen TK, Luchtefeld MA, Senagore AJ. Limited hemorrhoidectomy: results and long-
term follow up. Dis Colon Rectum 1999;42:909–15.
[25] Sayfon J, Becker A, Koltun L. Sutureless closed hemorrhoidectomy: a new technique. Ann
Surg 2001;234(l):21–4.
[26] Arbman G, Krook H, Haapaniemi S. Closed vs. open hemorroidectomy - is there any
difference? Dis Colon Rectum 2000;43:311–34.
[27] Bleday R, Pena JP, Rothenberger DA, et al. Symptomatic hemorrhoids: current incidence
and complications of operative therapy. Dis Colon Rectum 1992;35:477.
[28] Longo A. Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal
prolapse with circular suturing device: a new procedure. In: Mundozzi, editor. 6th World
Congress of Endoscopic Surgery. Rome, June 3–6, 1998. p. 777–84.
[29] Ho YH, Cheong WK, Tsang C, et al. Stapled hemorrhoidectomy - cost and effectiveness.
Randomized, controlled trial including incontinence scoring, anorectal manometry,
and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 2000;
43:1666–75.
[30] Shalaby R, Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan
haemorrhoidectomy. Br J Surg 2001;88:1049–53.
[31] Wexner SID. The quest for painless surgical treatment of hemorrhoids continues. J Am
Coll Surg 2001;193(2):174–8.
[32] Arnaud J-P, Pessaux P, Huten N, et al. Treatment of hemorrhoids with circular stapler, a
new alternative to conventional methods: a prospective study of 140 patients. J Am Coll
Surg 2001;193:161–5.
[33] Seow-Choen F. Stapled hemorrhoidectomy: pain or gain. Br J Surg 2001;88:1–3.
[34] Milito G, Cortese F, Casciani CU. Surgical treatment of mucosal prolapse and
haemorrhoids by stapler. In: Proceedings of the 6th World Congress of Endoscopic
Surgery. Rome, June 3–6, 1998.
[35] Mehigan BJ, Monson JRT, Hartley JE. Stapling procedure for haemorrhoids versus
Milligan-Morgan haemorrhoidectomy: randomized controlled trial. Lancet 2000;355:782–5.
[36] Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemor-
rhoidectomy) versus conventional haemorrhoidectomy: randomized controlled trial.
Lancet 2000;355:779–81.
[37] Boccasanta P, Capretti PG, Venturi M, et al. Randomised controlled trial between stapled
circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced
hemorrhoids with external mucosal prolapse. Am J Surg 2001;182(l):64–8.
[38] Ganio E, Altornare DF, Gabrielli F, et al. Prospective randomized multicentre trial
comparing stapled with open haemorrhoidectomy. Br J Surg 2001;88:669–74.
[39] Molloy RG, Kingsmore D. Life threatening pelvic sepsis after stapled hemorrhoidectomy.
Lancet 2000;355:810.
[40] Pescatori M. Stapled rectal prolapsectomy. Dis Colon Rectum 2000;43:876–7.
[41] Perroti P, Antropoli C, Molino D, et al. Conservative treatment of acute thrombosed
external hemorrhoids with topical nifedipine. Dis Colon Rectum 2001;44:405–409.
[42] Wexner SD. AIDS: what the colorectal. surgeon needs to know. Prespect Colorect Surg
1990;2:19–54.
[43] Scaglia M, Delaini GG, Destafano 1, et al. Injection treatment of hemorrhoids in patients
with acquired immunodeficiency syndrome. Dis Colon Rectum 2001;44:401–4.
[44] Mazier WB. Hemorrhoids. In: Mazier WB, Levin DH, Luchtefeld MA, et al, editors.
Surgery of the colon, rectum and anus. Philadelphia: W.B. Saunders Co.; 1995. p. 229–54.