Removal of internal and external hemorrhoids and fissures

Hemorrhoids are one of the most common diseases today. It is thought that as many as 50% of people have a hemorrhoid challenge at least once in their lives. They occur in both sexes, more often with men in their middle age of life.

We need to distinguish the clinical picture of hemorrhoids from the hemorrhoidal pads, which we describe as a structure consisting of: smooth muscles, connective elastic tissue and arterial venous blood vessels (similar to the tissue of the penis). In the case of defecation, the pads are temporarily moved down and after the defecation of the muscle thread from the submucosal they are returned back. They close the rectum with the help of sphincter muscles.

Besides this division in determining the degree of disease, we can also use the division by Banov (1985) into four stages:
STAGE I – Hemorrhoids only protrude into the anal canal, they bleed often but there is no prolapse,
STAGE II – hemorrhoids prolapse outside the anus only during defecation, but then spontaneously return to the anal canal
STAGE III – Hemorrhoids prolapse spontaneously or during defecation outside the anus, but can be manually returned to the anal canal,
STAGE IV – Hemorrhoids are permanently prolapsed outside the anal canal and cannot be manually returned back. They are easily complicated by thrombosis or incarceration.

TREATMENT
Treatment is divided into symptomatic treatment (methods that regulate stool and local fats) and invasive techniques and surgical procedures.

SYMPTOMATIC TREATMENT:
Preparations – most often in the form of fats that have mild anesthetic and anti-inflammatory effects,
Proper nutrition – increase the intake of vegetables, fruits and cereals,
Reduce coffee and cigarette consumption – although coffee and cigarettes initially prod digestion, but if consumed in an increased amount they cause cramps and stool restraints,
Increase physical activity – in general, physical activity stimulates digestion.

INVASIVE METHODS:
Injection sclerotherapy – injection of a chemical substance (sclerosing agent) into the area of the hemorrhoids that causes narrowing of the blood vessels,
Hemorrhoid binding with a rubber ring known as Baron’s ligature. Elastic ribbons are placed on internal hemorrhoids, leading to an interruption of blood supply of the same. After few days, the mentioned ones dry out, and then during the normal discharge of the intestine they are removed,
Infrared photocoagulation of hemorrhoids. It is a specially designed device for this procedure. It gives excellent results in treatment of hemorrhoids of first and second stage. This non-surgical treatment is fast, well tolerated and without complications,
Diathermy,
Electrotherapy with DC voltage,
Laser hemorrhoid therapy.

SURGICAL PROCEDURES
Occasionally severe hemorrhoidal disease should be dealt with by a surgical route called hemorrhoidectomy. There are several successful surgical procedures that should be mentioned:
Milligan-Morgan Technique
Ferguson technique
Longo technique for rectum and hemorrhoid prolapse (PPH)

PPH is a technique that has been used since the early 90s. This method reduces the hemorrhoidal tissue prolapse by circular cutting of the anal mucosa using a circular stapler.

Korist PPH u odnosu na druge tehnike
manja bol u odnosu na klasični zahvat
brži povratak svakodnevnim aktivnostima

Risk of PPH technique:
If more muscle tissue is removed, the result may be a weakness in the rectal wall,
Injury of the internal sphincter, which may result in short-term or long-lasting dysfunction,
Very rarely the procedure can get complicated with sepsis,

Permanent pain in the anal canal can occur very rarely,
PPH may be unsuccessful for patients with large confluent hemorrhoids,
There is a very high risk of returning the prolapse after the procedure.

CAUSE
The exact cause that leads to the appearance of hemorrhoids is unknown, but there are many known factors that favor them:
Age,
Chronic constipation or diarrhea,
Pregnancy,
Long resting on the toilet (reading the newspaper),
Inheritance – is associated with family weakness of connective tissue and fragility of the blood vessels,
Abnormal enlargement of anal veins as well as AV fistula in the area of anal pads,
Increased pressure inside the abdominal cavity – thickness,
Lower shift of anal pads.

SYMPTOMS
Bleeding – bleeding is the most common symptom and mainly refers to internal hemorrhoids. The bleeding is light red and appears at the end of the stool. Sometimes it can be abundant and cause anemia,
Hemorrhoid bleeding during defecation,
Itching, burning, and swelling of the anus and anal region,
The pain.

COMPLICATIONS
Hemorrhoid thrombosis – occurs as a complication of hemorrhoids and is characterized by a painful, bluish limited swelling in a perianal area that is usually firm and painful to the touch.
Submucosal, perianal abscess.

DIAGNOSTICS
The diagnosis of hemorrhoids is simple and is possible by physical examination (external hemorrhoids), digital rectal examination and proctoscopy (internal hemorrhoids).

HAL
H.A.L. is the first system that offers treatment of sources of hemorrhoidal disease without surgical cutting of the mucous membrane and hemorrhoidal blood vessels. HAL it is performed with a modified proctoscope that has the addition of an ultrasound component. When the ultrasound determines hemorrhoidal blood vessel, the same one gets tied and it stops the bloodstream in the hemorrhoid.
This system offers two options: linking the hemorrhoidal artery without cutting the part of mucous membrane (Hemorrhoidal Artery Ligation)and raising the mucous membrane of the rectum with hemorrhoidal changes (Recto Anal Repair). This is a surgery from the group of aesthetic rectum surgeries (Proctoplastic).

ANAL FISSURE (fisura ani)
The causes are:
Onstipation,
Diarrhea,
Hemorrhoidal disease,
Rectal prolapse.
Anal fissure most commonly occurs between the age of 30 and 50, equally for the male and female population.

CLINICAL PICTURE
In clinical picture dominate pain, bleeding and increased tone of the sphincter. Pain, which occurs, when defecating, and after defecating it decreases, and then it soon reappears and then it is generally much stronger and lasts longer. This condition forces the patient to prolong their defecation for a few days, and the next stool that is firmer causes even more pain. Bleeding as one of the signs of this disease is usually minimal and manifests itself as a reddish-pink line along the hard, formed stool. The increased tone of the sphincter (a muscle that closes the anus) appears as a response to pain.

TREATMENT
Medical treatment is reflected in the local use of appropriate fats or certain baths and leads to a reduction of pain and loss of sphincter spasm. This therapy is applied in cases of acute fissures.
If such therapy is not effective, surgery is necessary.
One of the methods is lateral sphincterotomy, which can be performed in infirmary.

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Word of doctor

Doc. PhD. Jovan Ćulum

Abdominal surgery is a branch of medicine that deals with abdominal organs surgery, we provide great attention to preventive access and regular controls through endopic examination (gastroscopy and colonoscopy) within our clinic. Within the endoscopic ambulance there is also a dispensary equipped in accordance with the best medical practice and in line with world trends

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