Modern surgical management of haemorrhoids

Haemorrhoidal tissue is a normal component of the anal canal and is composed predominantly of vascular tissue, supported by smooth muscle and connective tissue. It’s function is to provide complete closure to the anus at rest and protection of the underlying muscle during defaecation.1 Haemorrhoidal disease is one of the most common anorectal conditions 2 although the exact incidence is difficult to determine because many people are reluctant to seek medical advice due to various personal, cultural and socioeconomic reasons.3 Estimates of the proportion of the UK population affected range from 4.4% to 24.5% 4 whilst more than 15 million people are believed to be affected annually within the United States.5 Internal haemorrhoids result from chronic engorgement of the three submucosal venous plexi of the anal canal and originate above the dentate line.6 With the weakening or fragmentation of the supportive connective tissue framework combined with the repeated passage of hard stool and straining producing a shearing force, these vascular cushions descend and prolapse.3 The degree of resultant prolapse is used to grade internal haemorrhoids using Goligher’s classification system: Grade I: haemorrhoids non prolapsing; Grade II: haemorrhoids prolapse on straining but reduce spontaneously; Grade III: haemorrhoids require manual reduction; Grade IV haemorrhoids are non-reducible.7 Symptoms resulting from internal haemorrhoids are commonly bright red bleeding per rectum, mucosal prolapse or protrusion, and puritus ani.6 Pain is not characteristic unless there has been thrombosis or strangulation of the haemorrhoid which possibly can lead to gangrene 8 and it should be noted that severity of symptoms do not necessarily correlate with the degree of haemorrhoidal prolapse.9 Conservative treatment has traditionally been recommended for the treatment of Grade I and II haemorrhoids including; changing bowel habit through dietary and lifestyle changes, increased oral hydration and the use of stool softeners and laxatives. Increased dietary fibre has been demonstrated to be consistently beneficial in relieving overall symptoms and bleeding.10 Non surgical interventions include rubber band ligation, injection sclerotherapy, cryotherapy, laser therapy, diathermy coagulation and infrared coagulation.9 These can be performed in an outpatient setting and are considered to be primary options in the treatment of grade I-III haemorrhoids.11 Meta analysis of outcomes from these interventions has demonstrated rubber band ligation to be the most effective in terms of response to treatment and reduced requirements for further intervention.11 Surgical intervention is usually the treatment of choice for grade III-IV haemorrhoids, prolapsed grade II haemorrhoids that have failed to respond to non surgical treatments, and circumferential grade II haemorrhoids.4 This is estimated to be approximately 10 % of all patients 12 and in 2004-5 of approximately 23,000 haemorrhoidal procedures carried out in England, 8,000 were surgical excisional interventions.4