Hemorrhoid surgery

The venous network of the anus is called the hemorrhoid: the internal hemorrhoidal plexus is located above the sphincter muscle, and the external hemorrhoidal plexus is located around the anus. If something hinders the veins to empty, dilatations form, which may remain constant. They will cause symptoms over time due to their size.

Why does the chronic dilatation of the hemorrhoid develop?

When the venous blood flow is permanently obstructed, the veins dilate. In case of internal hemorrhoids, four stages are distinguished based on the size of the dilatation (Figure 1).

• I) Symptoms are not present, but the dilatation is detectable during a proctological examination.
• II) A hemorrhoid lump is present, which slides out from the anus, but it goes back spontaneously.
• III) It has to be put back.
• IV) It cannot be put back.

Hemorrhoids in stage I (no symptoms), and stage II (foreign body sensation, the lump slides in and out) can be treated in outpatient care with band ligation. Surgery is necessary in stages III and IV.

In case of the dilatations of external hemorrhoids, the blood flow slows down, the blood is congested, then it coagulates (it is especially common during long travels in the summer heat), and the blood clot obstructs the vessel. Similar congestion and the formation of blood clots may also occur in case of advanced internal hemorrhoids.

Factors, which hinder blood flow and result in increased abdominal pressure:

• Pregnancy, delivery
• Constipation (low fiber diet, fatty foods, reduced fluid intake)
• Diarrhea (hot, spicy foods, alcohol, inflammatory bowel diseases, food intolerances)
• Lifting heavy weights
• Harmful lifestyle factors (lack of exercise, long term standing or sitting, overweight, obesity)

Symptoms of stage III and stage IV internal hemorrhoids

These are usually detected when they start to cause symptoms in stage II. The patient complains of foreign body sensation, and the lump sliding in and out. Additionally, painless, bright red bleeding may present, especially with harder stools. In stage III, the internal hemorrhoidal vein gets stuck outside of the anus, and if it is not put back, then it will become swollen and edematous, and it will start to bleed if the mucous membrane gets hurt. If this condition persists for a long period of time, the vein can get thrombosed or inflamed.

Making the diagnosis

It is necessary to perform a proctological investigation.

Treatment of internal hemorrhoids

When acute symptoms develop, conservative treatment should be used to reduce the symptoms and the inflammation. The recommended therapy for stage I and stage II hemorrhoids is the Barron’s ligation, the great advantage of which is that it can also be performed as an outpatient procedure, and it is almost painless (Figure 2).  The intervention has be performed in a surgical setting in stage III and stage IV. Multiple surgical options can be selected, and all of them are accompanied by the excision of the dilated vein. In case of concentrically dilated hemorrhoids, the surgery can also be performed with a stapler (Figure 3). The disadvantage of extended surgeries is that the recovery is slower, and the pain is more intense in the postoperative period.

Preventing the dilatation of internal hemorrhoids

High fiber diet, adequate hydration, a physically active lifestyle, and body weight control.