There are so many surgical and non-surgical procedures for the treatment of hemorrhoids that the list alone would be a compendium of the history of mankind itself, so I will only list the most common in the last 50 years. <\/p>\n\n\n\n
Sclerotherapy:<\/strong><\/p>\n\n\n\n It is an old method in which a sclerosing agent such as phenol 5%, sodium morrhuate, quinine in urea 5%, etc. is injected into the hemorrhoidal pedicle producing a submucosal necrosis and subsequent fixation. It was used for grade I or II hemorrhoids. The reasons why this technique has been abandoned are: the disadvantage of not being able to clearly calculate with the needle the submucosal space and the amount necessary for infiltration, the subsequent pain, the degree of necrosis, the bad odor secondary to tissue necrosis, the possibility of infiltration of the sphincteric space with consequent necrosis, the subsequent fibrosis and the possibility of residual anal stenosis. <\/p>\n\n\n\n Infrared photocoagulation:<\/strong> Cryotherapy:<\/strong> Electrocoagulation: Direct current and bipolar instruments have been designed to release this electrical energy for 10 minutes to the hemorrhoidal pedicle. Its use has not become popular due to its high cost compared to other much cheaper methods with the same results.<\/p>\n\n\n\n Laser:<\/strong> Of all the surgical methods designed for antihemorrhoidal treatment, the following three have been shown to have the best cost-benefit ratio with the best results and the least recurrence over time.<\/p>\n\n\n\n Hemorrhoidal ligation with elastic bands:<\/strong><\/p>\n\n\n\n Es el procedimiento que m\u00e1s com\u00fanmente se hace en el \u00e1mbito de un consultorio.\u00a0 Esta dise\u00f1ado para hemorroides internas grado I o II, en donde todo el paquete esta circunscrito al canal anal en donde no existen terminaciones nerviosas de dolor.\u00a0 Esta t\u00e9cnica esta contraindicada en hemorroides de mayor tama\u00f1o por dos razones, la primera es que el \u00e1rea de la base del paquete es demasiado amplia poder ser abarcada por la banda que es adonde se debe poner esta y la segunda raz\u00f3n es que este tipo de hemorroides ya tienen un car\u00e1cter mixto y por ende el anodermo esta involucrado en donde existen terminaciones nerviosas de dolor y el colocar estas bandas en esta zona causa un dolor insoportable que obliga al retiro de esta. <\/p>\n\n\n\n The procedure is very simple, it does not require special preparation apart from a sodium phosphate enema two hours before, if the patient wishes, some sedation can be given but in most cases no medication is required. The patient is placed in left lateral decubitus, an anoscope is inserted locating the hemorrhoidal bundle, the ligator is introduced with the band mounted and after pulling this by suction or with a forceps the band is triggered locating it at the base above the dentate line. This band causes ischemia, then necrosis and after 4 to 5 days this redundant tissue detaches with little bleeding leaving a small ulcer, which heals with fibrosis which fixes the mucosa to the muscular layer and therefore to the anal canal. It is not recommended to place more than three bands per session as this increases discomfort as well as the risk of stenosis. After the procedure the patient is instructed to resume his daily activities, the most frequent symptom of complaint is tenesmus that after 8 to 12 hours subsides and can be managed with acetaminophen. This is a safe, very effective procedure for the type of hemorrhoids mentioned and with very low morbidity as well as complications. The most feared is post-bandage sepsis where the patient complains of difficulty urinating, fever and pelvic pain. Delayed diagnosis and treatment can be fatal, and includes hospitalization, aggressive water-electrolyte resuscitation, band removal and coverage with broad-spectrum antibiotics. <\/p>\n\n\n\n Mixed Hemorrhoidectomy: This procedure can be performed under general, conductive or local anesthesia. In our environment we have done it with saddle spinal anesthesia and pudendal anesthetic block (see the technique in the chapter on local anesthesia in anorectal surgery) but lately we are doing it with local anesthesia assisted with propofol which is the intravenous induction anesthetic with the highest clearance rate which allows the anesthesiologist to sedate the patient in a transient but deep way preserving his capacity for spontaneous ventilation, As soon as its infusion is suspended, the patient recovers his state of consciousness with full mental lucidity and minimal nausea or vomiting.<\/p>\n\n\n\n The position (Sims or left lateral decubitus, Lloyd-Davies or modified lithotomy, or prone or sevillian knife) given to the patient depends on the preference of each surgeon. At the Military Hospital School, the position used is that of the Sevillian knife, which is the one used by the author in the majority of anorectal procedures because it is the one in which the anal canal is the most expeditious. After the patient is in this position, his buttocks are separated with adhesive tape to expose the anus. The pudendal block described above is performed, and the redundant hemorrhoidal bundles are located. A double elliptical incision is made from the anoderm to about two centimeters above the dentate line. For best cosmetic results the length of the incision should be three times the width. The dissection of the hemorrhoidal bundle is started through the virtual plane created between the internal anal sphincter and the hemorrhoidal plexus, the identification of this plane is fundamental to avoid the profuse bleeding that occurs when one of the hemorrhoidal vessels is incised and also to preserve the sphincter. Upon reaching the base or hemorrhoidal pedicle, 2-0 chrome Catgut transfixion stitches are placed, sectioning the pedicle and resecting the hemorrhoid. We proceed to close and fix the mucosa to the anal canal with continuous stitches until reaching the intersphincteric groove where this suture is knotted, leaving a small dog ear in the anoderm with two objectives: to allow any bleeding that occurs inside the hemorrhoidectomy to drain through this site and secondly to place stitches in the skin causes great pain, in addition to healing this skin defect is covered avoiding skin flaps. <\/p>\n\n\n\n No more than three hemorrhoidal bundles should be resected per procedure and often two can be involved (usually at 2 and 5 o'clock) in a single incision, and as a fundamental paradigm, healthy mucosal bridges should always be left between the incisions in order to avoid strictures.<\/p>\n\n\n\n This is a fairly safe and effective procedure for the definitive eradication of this problem, but the argument against it is the great pain it causes, especially between the fourth and fifth post-surgical day. It is not known why, since generally the person has had his first bowel movement in the first three days. What is clear is that what makes this procedure intensely painful is having to incise and resect the anoderm. For this reason a new procedure has been designed and will be described below. The postoperative medical management is based on ABA (Analgesics + Sitz baths with warm water + stool softeners), diet rich in fiber and plenty of fluids.<\/p>\n\n\n\n Procedure for Prolapsed Hemorrhoids (PPH): The initial approach in terms of patient position and local anesthesia assisted is the same as for traditional hemorrhoidectomy. After this, the obturator that reduces the hemorrhoidal prolapse and the core that shows the dentate line are introduced, both implements are included in the PPH kit, then a grooved anal separator is used and with it the pull-up is made involving mucosa and submucosa with a 2-0 polypropylene with a small round needle (RB1), four centimeters above the dentate line. When the gun is finished, the anvil is introduced with the anvil open, the head of the anvil is passed proximal to the anvil, the anvil is closed (in women a vaginal examination should be performed to rule out the involvement of the rectovaginal septum), the anvil is closed and the shot is fired after 30 seconds of pressure both before and after the shot to guarantee hemostasis. Postoperative management is the ABA already described. The main complaint of the patients is tenesmus which improves in most of them by the end of the first week.<\/p>\n\n\n\n Complications described in the literature are: Rectovaginal fistulas, pelvic sepsis, rectal obstruction, hematomas, Fournier's gangrene. The above can be avoided with a good training of surgeons, an adequate selection of patients, being strict in choosing those with circumferential Grade III or Grade IV hemorrhoids with little external component, taking special care in the rectovaginal septum, and only involving the mucosal and submucosal gastric mucosa.<\/p>\n\n\n\n There are at least 16 randomized studies and two multicenter studies in ambulatory patients that demonstrate that the PPH technique causes less postoperative pain, with less work incapacity and a marked reduction in the use of analgesics; with good symptom control and without the need for other antihemorrhoidal procedures after 1 year of follow-up compared to traditional hemorrhoidectomy.<\/p>","protected":false},"excerpt":{"rendered":" Existen tantos procedimientos quir\u00fargicos y no quir\u00fargicos para el tratamiento de las hemorroides que su solo listado seria un compendio de la misma historia de la humanidad, por lo que solo enunciare los m\u00e1s socorridos en los \u00faltimos 50 anos. Escleroterapia: Es un m\u00e9todo viejo en el cual se inyecta en el pediculo hemorroidal un […]<\/p>\n","protected":false},"author":1,"featured_media":1058,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"off","_et_pb_old_content":"","_et_gb_content_width":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1057","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts\/1057","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/comments?post=1057"}],"version-history":[{"count":2,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts\/1057\/revisions"}],"predecessor-version":[{"id":1103,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts\/1057\/revisions\/1103"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/media\/1058"}],"wp:attachment":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/media?parent=1057"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/categories?post=1057"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/tags?post=1057"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
It is used by releasing several applications of infrared energy to the hemorrhoidal pedicle, which according to the physical properties of this element its deposit is made in the submucosa producing a submucosal necrosis and subsequent fixation. It works best in small hemorrhoids. The disadvantage of this element is the high cost compared to other much cheaper methods such as elastic bands with a very similar benefit.<\/p>\n\n\n\n
In spite of a new boom especially in our environment through commercial advertising campaigns, this method is completely revaluated in the scientific world, since through a frozen cylinder inserted in the anus, the hemorrhoidal tissue is burned, which produces a prolonged, bad smelling and painful tissue desquamation. But the main argument for which its use was abandoned is not being able to control the amount of tissue destruction, with the consequent fibrosis and anal stenosis. <\/p>\n\n\n\n
This energy source has demonstrated a shallower burn depth than the electrobisturi traditionally used in surgery, but the definitive functional results in terms of pain, scarring and incidence of stenosis have not shown any statistical difference. Thus, its use has not become popular due to the same argument for which infrared photocoagulation and bipolar forceps electrocoagulation have not become popular.<\/p>\n\n\n\n
<\/strong>This approach is designed for Grade III - IV hemorrhoids and although multiple techniques have been proposed such as the closed or Ferguson, open or Milligan-Morgan and circumferential or Whitehead, the latter completely re-evaluated and condemned for the high rate of residual strictures; all adhere to basic principles which are: decrease blood flow to the anorectal ring, resection of the redundant hemorrhoidal mucosa and fixation of the anoderm to the anoderm. <\/p>\n\n\n\n
<\/strong>Also called <\/strong>Stapler anoplasty, designed for Grade III and IV hemorrhoids with little external component. It was developed in 1998 by Antonio Longo in which he describes a method in which the prolapse of internal hemorrhoids can be surgically corrected in a transanal way with a circular stapler, avoiding the need for excision of the anoderm or the perianal skin which avoids the intense pain of traditional hemorrhoidectomy. This procedure consists in a simultaneous relocation and fixation of the internal hemorrhoids and the anoderm, since here there is no hemorrhoidectomy but a hemorrhoidopexy, which consists in sectioning a circumferential circle of 3 to 4 cms of the lower rectum and simultaneously ascending, stapling and fixing the hemorrhoidal folds, avoiding in a definitive way the continuation of the prolapse of the redundant mucosa of the hemorrhoids. Disruption of the superior hemorrhoidal arteries decreases blood flow, which in turn favors atrophy of the hemorrhoidal bundles and their external cutaneous component.<\/p>\n\n\n\n