Hemorrhoid Surgery

Facts About Hemorrhoids

  • Hemorrhoids are swollen veins. Each of us has veins around the anus that tend to stretch under pressure, somewhat like varicose veins in the legs. When these veins swell, they are called hemorrhoids.
  • Constipation is the main cause of hemorrhoids.
  • Symptoms of hemorrhoids include aching after a bowel movement; anal or rectal itching; bright red blood on toilet tissue or in toilet bowl; appearance of anal tissue pads or sensitive lumps.
  • There are four degrees of hemorrhoids and options for treatment for each degree.
    1. First degree: No prolapse (hemorrhoids do not protrude outside the anus).
    2. Second degree: Prolapse occurs during bowel movement and spontaneously returns when straining ceases.
    3. Third degree: Prolapse is manually reducible.
    4. Fourth degree: Prolapse is irreducible.
  • According to the American Society of Colon and Rectal Surgeons:
    1. Hemorrhoids are one of the most common ailments known in both men and women.
    2. More than half the population will develop hemorrhoids, usually after age.
  • Millions of Americans currently suffer from hemorrhoids, but most do not seek treatment beyond over-the-counter remedies. The average person suffers in silence for a long period before seeking medical care.
  • More than 525,000 patients are treated annually for symptomatic hemorrhoids. Of these, approximately 10–20 percent will require surgical treatment of the condition.
  • According to the National Digestive Diseases Information Clearinghouse, about half of the U.S. population will have hemorrhoids by age 50.
  • Often lifestyle changes, topical medications, and good hygiene are all that is needed to reduce the symptoms of hemorrhoids. Most painful hemorrhoids stop hurting on their own in one to two weeks3I. However, in a certain percentage of cases, surgical procedures are necessary to provide satisfactory, long-term relief.
  • The Procedure for Prolapse and Hemorrhoids (PPH) is a new, less painful procedure for advanced hemorrhoids (second to fourth degree). With the PPH procedure, patients experience less pain, and recover faster than patients who undergo the conventional hemorrhoidectomy procedure.
  • The PPH procedure was first introduced in the United States in October 2001.

Introduction

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Hemorrhoids, one of the most common ailments known in both men and women affect more than half the population at some point in their lives. Onset commonly occurs after the age of 30, but hemorrhoids are reported in people of all ages. More than 525,000 patients in the United States are treated annually for symptomatic hemorrhoids. Of these, approximately 10–20 percent will require surgical treatment for their condition.

Hemorrhoids are swollen veins. Each of us has veins around the anus that tend to stretch under pressure, somewhat like varicose veins in the legs. It is believed these veins exist to protect and cushion the anal canal. When these veins swell, they are called “hemorrhoids.” One set of veins is inside the rectum (internal hemorrhoids) and another is under the skin around the anus (external hemorrhoids).

A person may be more likely to get hemorrhoids as they age or if their parents had them. Pregnant women often get hemorrhoids because of the strain from carrying the baby and from giving birth. For most women, such hemorrhoids are a temporary problem. Being over weight, straining to move your bowels, sitting too long on the toilet, or standing or lifting too much can make hemorrhoids worse. Constipation is the main cause of hemorrhoids.

The following are tips for hemorrhoid prevention:

  • Include more fiber in your diet. Fresh fruits, leafy vegetables, and whole-grain breads and cereals are good sources of fiber.
  • Drink plenty of fluids (except alcohol). Eight glasses of water each day is ideal.
  • Do not read on the toilet. Sitting and straining too long encourages swelling.
  • Exercise regularly.
  • Avoid laxatives, except bulk-forming laxatives, such as Fiberall, Metamucil, etc. Other types of laxatives can lead to diarrhea, which can worsen hemorrhoids.
  • When you feel the need to have a bowel movement, don’t wait for long periods before using the bathroom.
  • Following are tips to reduce the pain caused by hemorrhoids:
  • Take warm soaks three or four times a day.
  • Clean your anus after each bowel movement by patting gently with moist toilet paper or moistened pads, such as baby wipes.
  • Use ice packs to relieve swelling.
  • Use acetaminophen (Tylenol®), ibuprofen (Motrin®), or aspirin to help relieve pain.
  • Apply a cream that contains witch hazel to the area or use a numbing ointment. Creams that contain hydrocortisone can be used for itching or pain.

Internal Hemorrhoids

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Internal hemorrhoids usually are not painful, but may bleed. Sometimes, an internal hemorrhoid may stretch until it bulges outside the anus. This is called a prolapsed hemorrhoid. A prolapsed hemorrhoid can go back inside the rectum on its own, or it can be gently pushed back inside. If the prolapsed hemorrhoid cannot be pushed back inside, consultation with a physician about surgical treatment options is necessary.

External Hemorrhoids

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External hemorrhoids involve the veins outside the anus. They can be itchy or painful and can sometimes crack and bleed. If a blood clot forms, one may feel a tender lump on the edge of the anus, and see bright red blood on toilet paper or in the toilet after a bowel movement.

Symptoms of hemorrhoids, both external and internal, include aching after a bowel movement; anal or rectal itching; bright red blood on toilet tissue or in toilet bowl; appearance of anal tissue pads or sensitive lumps. When any of these symptoms are present, it is important to see a doctor to make sure the cause of the discomfort is hemorrhoids and not some other problem. When the patient visits a doctor for anorectal complaints, the evaluation should include observation, palpation, and anoscopic examination.

Treatment

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Often lifestyle changes, topical medications, and good hygiene are all that is needed to reduce the symptoms of hemorrhoids. Most painful hemorrhoids stop hurting on their own in one to two weeks. If the pain persists, it is time to talk to a physician about other treatment options.

In a certain percentage of cases, surgical procedures are necessary to provide satisfactory, long-term relief. The newest procedure for advanced hemorrhoids is called the Procedure for Prolapse and Hemorrhoids (PPH). PPH is a technique developed in the early 90’s that reduces the prolapse (enlargement) of hemorrhoidal tissue. With the PPH procedure, patients experience less pain and recover faster than patients who undergo the conventional hemorrhoidectomy procedure.

PPH reduces the prolapse of hemorrhoidal tissue by cutting out a band of the prolapsed anal mucosal membrane with the use of a circular stapling device. The PPH procedure essentially “lifts up” or repositions the mucosal, or anal canal tissue, and restores the hemorrhoidal tissue back to its original anatomical position. This reduces blood flow to the internal hemorrhoids. These internal hemorrhoids, then, typically shrink within four to six weeks after the procedure. The PPH procedure results in less pain than traditional procedures because it is performed above the “pain” line, or dentate line, inside the anal canal. The advantage is this method affects few nerve endings, while traditional procedures are performed below the dentate line, affecting many sensitive nerve endings.

For patients with a lesser degree of prolapse (internal hemorrhoids that have fallen outside the anus), rubber band ligation is widely used for the treatment of internal hemorrhoids. In this procedure, the hemorrhoidal tissue is pulled into a double-sleeved cylinder to allow the placement of latex/rubber bands around the tissue. Over time, the tissue below the bands dies-off and is eliminated during a bowel movement. Rubber band ligation can be performed in a doctor’s office and requires little preparation. Often, however, there is the need for more than one procedure to resolve a patient’s condition.

In cases involving a greater degree of prolapse, a variety of operative techniques are employed to address the problem. In traditional hemorrhoidectomy, surgery is used to remove the hemorrhoids. A hemorrhoidectomy removes excessive tissue that causes the bleeding or protrusion. It is done under anesthesia and may require hospitalization and a period of inactivity. Laser hemorrhoidectomies do not offer any advantage over standard operative techniques. They also are quite expensive, and contrary to popular belief, are no less painful.

Other treatments include cryotherapy, BICAP coagulation, and direct current. Cryotherapy, popular 20 years ago, consists of freezing hemorrhoidal tissue. It is not recommended for hemorrhoids because it is very painful. BICAP, also known as bipolar diathermy coagulation, and direct current, which is low current electric stimulation, are techniques that shrink the hemorrhoids and cause the hemorrhoidal tissue to die. None of these treatments has gained widespread acceptance.

Although anorectal conditions are benign and easily treated, patients may delay seeking medical advice because of embarrassment of hemorrhoids or fear of cancer. As a result, many patients first see their physician when the problem is advanced, requiring extensive treatment, and causing greater patient distress than if the conditions had been adequately diagnosed and managed at an earlier stage.

Procedure Animation

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Watch PPH Procedure Video (2.3Mb): - Macromedia® Flash Player is required to view this animation. Download it here.

Introduction to PPH

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According to the American Society for Colon and Rectal Surgeons, the average person with symptomatic hemorrhoids suffers in silence for a long period before seeking medical care. Embarrassment, fear of extreme pain and long recovery associated with traditional hemorrhoidectomy, and fear of cancer all play a role in the delay in seeking treatment.

Now there is a breakthrough, less painful procedure for advanced hemorrhoids called the Procedure for Prolapse and Hemorrhoids (PPH) that eliminates the need for traditional hemorrhoidectomy for many patients. PPH is a technique developed in the early 90’s that reduces the prolapse (enlargement) of hemorrhoidal tissue. With the PPH procedure, patients experience significantly less pain and recover faster than patients who undergo conventional hemorrhoidectomy procedures.

Results from PPH Clinical Trials

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Compared to traditional hemorrhoidectomy, several studies have demonstrated that patients undergoing the PPH procedure:
  • experienced significantly less pain
  • experienced a quicker return to normal activities, including work
  • spent less time in the hospital
  • experienced less post-operative pain
  • experienced less post-operative bleeding
  • experienced less post-operative itching
  • experienced less post-operative incontinence and constipation

How PPH Works

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Using a stapling device, the PPH procedure essentially “lifts up” or repositions the mucosa, or anal canal tissue, and reduces blood flow to the internal hemorrhoids. These internal hemorrhoids, then, typically shrink within four to six weeks after the procedure. The PPH procedure results in less pain than traditional procedures because it is performed above the “pain” line, or dentate line inside the anal canal. The advantage is that this method affects few nerve endings, while traditional procedures are performed below the dentate line, affecting many sensitive nerve endings.

PPH Indications

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PPH is indicated for patients with:
  • Second degree hemorrhoids after failure of multiple rubber band ligation
  • Third and fourth degree hemorrhoids
  • Rectal mucosal prolapse

PPH Surgeon Training

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Thousands of surgeons are currently performing PPH around the world and more than 200,000 procedures have been done in Europe to date. Ethicon Endo-Surgery makes available an instrument set for use in performing the procedure, the Proximate® HCS Procedure for Prolapse and Hemorrhoid Set. Ethicon Endo-Surgery provides training to physicians prior to being able to use the product.

The PPH procedure was first introduced in Italy in 1997 and in the last four years has become very popular all over the world. In Dec. 1998, the procedure was launched in other European countries. The procedure was first introduced in the United States in Oct. 2001.