Minimally Invasive
Procedure for Haemorrhoid (MIPH) Treatment
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 What
are haemorrhoids? |
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What
are the symptoms of piles? |
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How
is it diagnosed? |
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What
are the treatment options? |
| Conservative
Method |
| OPD/
Alternative procedures |
| Rubber
band ligation |
| Laser,
infrared, or bipolar coagulation |
| Sclerotherapy |
| Cryosurgery |
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Surgical
method |
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Conventional
or open method |
|
New
method or MIPH |
|
Benefits
and drawbacks |
|
Care
to be taken at home |
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|
What
are haemorrhoids? |
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|
 Haemorrhoids
are one of the most commonly occurring ailments, affecting
both men and women. One reason people do not talk about
haemorrhoid problems with their doctors is because they
anticipate a painful, traditional haemorrhoid surgery.
But the fact is that better understanding of the disease
process along with new technological improvements; have
enabled more procedures to be performed as day care
procedure.
Piles or Haemorrhoids can occur at any age. Many experts
believe that they are caused by continuous high pressure
in the veins of the body, which occurs because humans
stand upright. The causes of haemorrhoids include constipation
and excessive straining during bowel movements. Persistent diarrhoea and loose stool movements are also causes
of haemorrhoids, and some people inherit a family tendency
to develop piles. Women are more susceptible to haemorrhoids
during pregnancy, as pressure from the growing uterus
restricts blood flow in the pelvic area. Lifestyle factors
can also contribute to haemorrhoid development.
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| Haemorrhoids may be internal or external.
Both types of haemorrhoids can be present at the same
time. Internal haemorrhoids are classified further based
upon the degree to which they protrude from the anal canal.
This grading system is important since the grade in part
determines which type of treatment is best. But no widely
used grading system exists for external haemorrhoids.
According to this grading system: |
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Grade I haemorrhoids may bulge into the anal canal
but do not protrude through the anus. |
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Grade II haemorrhoids protrude through the anus
during straining and defecation, but return spontaneously.
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Grade III haemorrhoids protrude through the anus
with defecation or straining but do not return spontaneously,
requiring the patient to gently push it back into
its normal position with a finger. |
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Grade IV haemorrhoids cannot be manually returned
to their normal position. |
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What
are the symptoms of piles? |
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| The symptoms of piles can come and
go. There are five main symptoms: |
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Itching and irritation
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Aching pain and discomfort
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Bleeding
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A lump, which may be tender
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Soiling of pants or knickers with slime or faeces
('skid marks'). |
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| Itching and irritation probably occur
because the lumpy piles stop acting as soft pads to keep
the mucus in; instead, a little mucus leaks out and irritates
the area around the anus. Pain and discomfort comes from
swelling around the pile, and from scratching of the lining
of the anal canal by faeces as they pass over the lumpy
area. The scratching also causes bleeding, which is a
fresh bright red colour and may be seen on faeces or toilet
paper or dripping in the pan. A pile that has been pushed
down (a second- or third-degree pile) may be felt as a
lump at the anus. Internal haemorrhoids cannot cause cutaneous
pain, but they can bleed and prolapse. Prolapse of internal
haemorrhoids can cause perianal pain by causing a spasm
of the sphincter complex. This spasm results in discomfort
while the prolapsed haemorrhoids are exposed. The discomfort
is relieved with reduction. Internal haemorrhoids can
also cause acute pain when incarcerated and strangulated.
Again, the pain is related to the sphincter complex spasm.
See the table given below to know the symptoms of specific
types of haemorrhoids: |
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Bulge of Internal Piles
Bleeding of Internal Piles
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How
is it diagnosed? |
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| Haemorrhoids are diagnosed based upon
a history, physical examination and visual inspection
of the anal canal and rectum. When the patient reports
to the physician with the symptoms of piles, the physician
takes detailed case history. |
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| To confirm presence of haemorrhoids,
the doctor will do a rectal examination. The doctor will
place a gloved and lubricated finger into the rectum to
feel for abnormalities. External haemorrhoids can be diagnosed
by a visual and/or rectal examination. To diagnose internal
haemorrhoids, the doctor will insert a thin tube-like
instrument (called an anoscope) into the lower few inches
of the rectum. The anoscope has a light at the end and
an eyepiece at the front for viewing into the anal canal.
The procedure is painless but uncomfortable and lasts
about 1 minute and is done in the OPD. Despite the fact
that bleeding is common in patients with haemorrhoids,
other potential causes of bleeding are excluded. To test
for blood that may not be visible, the clinician obtains
a small stool sample on a gloved finger. The stool is
smeared onto a chemically coated paper and drops of another
chemical are added. If blood is present, the colour of
the paper will change to blue. |
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| A more detailed look can be done by
a procedure called sigmoidoscopy that is done under sedation
or anaesthesia and a look upto 25 cm can be done to rule
out any sinister disease that may be associated. Occasionally,
a barium examination or colonoscopic examination of the
large intestine may be required if other diseases are
suspected. |
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What
are the treatment options? |
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| Several options are available for
the treatment of haemorrhoids. For many, conservative
or minimally invasive measures are effective in relieving
symptoms. But in many cases, the physician may ask the
patient to undergo the surgery. |
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Conservative
Method |
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| Increasing fibre in the diet is one
of the best ways to soften and bulk the stool, which can
help to reduce bleeding from haemorrhoids. The physician
may also prescribe fibre supplementation. These products
work by absorbing water and increasing stool bulk, which
increases the frequency of bowel movement and softens
stool. For grade II piles, Sitz bath will be recommended.
The rectal area is immersed in warm water for 10 to 15
minutes two to three times daily. Pain-relieving creams
and suppositories are also given to give temporary relief. |
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OPD / Alternate Procedure |
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| Patients who have bothersome haemorrhoid
symptoms, despite trying conservative measures, may consider
a minimally invasive procedure. Most procedures are performed
as a day surgery, allowing a patient to go home in the
afternoon or evening. The following procedures are intended
for treatment of internal haemorrhoids: |
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| Rubber band ligation - Rubber
band ligation is the most widely used procedure, and is
best suited for grade I, grade II, and certain grade III
internal haemorrhoids. Rubber bands or rings are placed
around the base of an internal haemorrhoid. As the blood
supply is restricted, the haemorrhoid shrinks and degenerates
over several days. Many patients report a sense of "tightness"
after the procedure, which may improve with warm sitz
baths. |
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| Laser, infrared, or bipolar coagulation
- These methods involve the destruction of internal haemorrhoids
with laser or infrared light or heat. Coagulation causes
the haemorrhoidal tissue to harden and degenerate, and
to form scar tissue as the area heals. Coagulation is
generally effective for grade I and grade II internal
haemorrhoids. In a technique called Haemorrhoidolysis,
therapeutic galvanic waves are applied directly to the
haemorrhoid, to shrink and dissolve the tissue. |
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| Sclerotherapy - During sclerotherapy,
a chemical solution is injected into haemorrhoidal tissue,
causing inflammation, degeneration, and scar formation. |
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| Cryosurgery- This freezes the
pile to destroy it. It is not used much, because it causes
a watery discharge afterwards. |
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Surgical
Method |
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| Patients who continue to experience
symptoms despite conservative or minimally invasive therapies
typically require surgical removal of haemorrhoids (haemorrhoidectomy).
Surgery is the treatment of choice for patients with symptomatic
grade IV internal haemorrhoids or strangulated internal
haemorrhoids. Now under this, there are again two ways
for doing it: |
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Conventional
or open method
New method or MIPH method |
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Conventional method |
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| Surgery to remove haemorrhoids is
called haemorrhoidectomy. During this, the doctor makes
incisions around the anus to cut away the haemorrhoids.
It involves the surgical removal of excess haemorrhoidal
tissue and anal canal lining. Most anal surgeries are
being done under general or regional anaesthesia. Most
patients experience some degree of pain following the
surgery. It is painful for 7-10 days afterwards. |
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| While surgery usually relieves the
pain, swelling, bleeding, and itching caused by haemorrhoids,
a drawback to this procedure is that the incisions are
made in a highly sensitive area and might require stitches,
which can cause the area to be tender and painful. In
addition, patients might have some trouble urinating because
the pain following surgery makes it difficult to relax
and allow urine to flow. |
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New Method or stapler haemorrhoidectomy |
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| In the past, open surgery was the
only option available to surgeons when they needed to
see inside a patient's body or remove or repair and organ.
But today, minimally invasive technology is completely
changing the way doctors approach patient care. While
conventional surgical haemorrhoidectomy is a safe and
reliable procedure, it is often associated with significant
postoperative pain. A new procedure for removing large
haemorrhoids, the stapler haemorrhoidectomy, is less painful
and allows patients to return to work and other normal
activities much earlier than with the conventional procedure.
Stapled Piles Surgery is also known as PPH (procedure
for prolapse and haemorrhoids) or MIPH (Minimally invasive
procedure for haemorrhoids). The PPH procedure was first
introduced in Italy in 1997 and in the last four years
has become very popular all over the world. |
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This technique uses a stapling device and takes advantage
of the fact that pain-sensing nerve fibres are absent
higher in the anal canal. In this procedure, the mucosa
above the dentate line, which contains part of the pile
mass, is excised and stapled with the stapler gun, thus
taking care of bleeding and prolapse - the two major
components of piles. The pile masses are compressed
into a cup like cavity inside the stapler. When fired,
the titanium staples cut and seal simultaneously, thus
causing minimal bleeding and as the cut line is above
the nerves, there is reduction in post operative pain.
Additionally there is no incision on the perianal skin
or lower part of anal canal and the wound in the anal
mucosa is also primarily closed with a stapler, thus,
there is no need to do any post operative dressing.
It can be done as an outpatient, using local anaesthesia
with intravenous (IV) sedation. Routine preoperative
workup for these techniques is required. Simple distal
rectal evacuation is required for a clean operative
field. Distal rectal evacuation is best achieved by
small-volume saline enemas. But it should be done by
a surgeon who is especially trained in doing stapler
surgery. This is because there are few risks associated
with the unskilled hands. The risks include: damage
to the rectal wall, overstretching of sphincter muscles.
etc.
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Benefits
and drawbacks |
|
 Studies
suggest that Stapled Piles Surgery (also known as PPH
- procedure for prolapse and haemorrhoids or MIPH - Minimally
invasive procedure for haemorrhoids) is an effective treatment.
This technique potentially provides a tool for reducing
some of the problems associated with conventional surgery.
It considerably reduces operative bleeding, postoperative
pain, the length of hospital stay, and encourages a rapid
return to normal activities when compared with conventional
piles surgery. So the clear advantages of the modern methods
for outpatient treatment of internal piles are that they
are quick and relatively painless. Patients lose little
if any time from work, the complications are minor, and
the cure rates are high. So to summarise, given below
are the advantages of MIPH in points: |
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Smaller
incisions resulting in reduced pain and discomfort
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Minimal
scarring |
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Greater
surgical precision |
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Fewer
complications |
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Less
blood loss and a decreased need for blood transfusions
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Reduced
risk of infection |
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Shorter
hospital stays |
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Faster
recoveries |
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Care
to be taken at home |
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| While no strategy completely removes
the risk of haemorrhoids occurring again, following these
suggestions can lower the risk: |
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Avoid
straining during bowel movements. |
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Avoid
constipation |
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Drink
enough liquid for proper hydration. |
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Eat
a diet high in fibre. |
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Exercise
regularly. |
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