Physiology The Haemorrhoidal plexus is a physiological structure of large vascular spaces and atero-venous shunts: so-called corpus cavernosum recti (CCR). The CCR is described as an atero-venous cavernous network without the interposition of a capillary system. Selzner et al. 1962; Staubesand et al. 1963; Thulesius et al 1973 Superior rectal artery
The superior rectal artery (SRA) contributes exclusively to the blood supply of the CCR and it is a functional blood supply that fills this cavernous network. Widmer 1955; Thomson 1975; Patricio et al 1988; Sun et al.1992; Shafik 1996; Aigner et al 2004 CCR Dentate line Physiology
Arteriovenous anastomoses within the submucosa are thought to contribute to the increase in volume of the anal cushions, sealing the anal canal. The cushions contribute approximately 15%20% of the resting anal pressure. Perhaps more importantly, they serve as a conformable plug to ensure complete closure of the anal canal. Stieve 1928; Widmer 1955, Selzner 1962; Thomson 1975; Gibbons et al. 1986, Lestar et al. 1989; Selzner 1992 The development of haemorrhoidal disease begins, from dilatation within the cavernous bodies of the anal cushions, caused by multifactorial mechanisms such as: Defects in regulation of arterovenous shunts Increased arterial blood flow Decreased venous drainage
Abnormal Normal SHUNT A/V SHUNT A/V Opened Closed Opened CAPILLARY Closed CAPILLARY
II DEGREE an external examination or palpation does not reveal anything except a slight swelling with occasional itching or secretion. The anal region is slightly painful. III DEGREE
the piles lose their retractility and have to be manually reinserted into the anus. Classification (Goligher) I DEGREE the piles protrude and then retract spontaneously
during bowel movement. This stage is characterised by strong itching, a burning feeling, mucous and bright red blood discharges. IV DEGREE the nodules and vascular masses become very painful and
cannot be reinserted. A considerable swelling prevents the blood from flowing back, a condition which could result in haemorrhoidial thrombosis, prolapse and ulcers. Aetiopathogenesis The pathogenesis of haemorrhoids is not yet finally elucidated
Holzheimer 2004 The pathogenesis of the enlarged, prolapsing cushions is unknown. American Gastroenterological Association Technical Review on the Diagnosis and Treatment of Haemorrhoids Gastroenterology 2004 Aetiology Genetic links Environmental factors Other Conditions
(association between haemorrhoids, hernia and genitourinary prolapse or varicose vein) (Selzner 1962, Burkitt 1975; Loder et al 1994) CONSTIPATION STRAINING (Stern 1964; Burkitt 1974; Hyams 1970; Thomson 1975, Haas et al. 1984) Low-fiber diet Obesity Sedentary lifestyle DETERIORATION OF CONNECTIVE SUPPORTIVE TISSUE (Gass-Adams 1955, Thomson 1975, Haas et al. 1980.
Loder et al.1994) Pregnancy Aetiopathogenesis Sphincter Hyper tone Hancok 1977; Teramoto et al. 1981; Lane 1982 Abnormally high anal pressure Anal cushions Hypertension Increased straining during defecation Venous drainage impairment increased cushions pressure Stress
on supporting connective mesh Increased congestion and slippage of the anal cushions Sun et al.1990 Deterioration of connective supportive tissue Gass-Adams 1955; Thomson 1975; Haas et al. 1980; Loder et al.1994 HISTORY From ancient Greece to the modern age Hippocrates (V B.C.):
Cauterisation; Excision; Ligature 'One may cut, resect, suture or burn hemorrhoids. These measures seem to be terrible but they don't cause any damage' Celsus (30 A.D.): Ligature; Excision (not more than 3 cushions at the same time) Galenus (138-201 A.D.): Ligature Ibn-Sina(981-1038 A.D.): Ligature Guglielmo da Saliceto (1210-1280): Excision + cauterisation Haemorrhoidal surgical techniques More invasive Traditional excisional surgery MM
Stapled anopexy (PPH) Minimally invasive Surgery Transanal Haemorrhoidal Dearterialization Less invasive Longo Stapled Hemorrhoidopexy or Tranversal Mucosectomy Advantages Highly effective in some conditions (mucosal prolapse) Immediate esthetical result Reduction of post-op pain Reduction of hospitalisation
Disadvantages Expensive disposable device Moderate complication rate Techniques associated with increased risks Associated risks LONGO Learning curve at least 50 Cases before safe results Realisation of the pursetring boursa is mandatorty and it is quite complicated to integrate all hemoroids in it when you have external protusion. Helicoidal pustring suturing to integrate only one side,quite difficult to have a correct vision of the procedure due to the introducer Evaluation of the distance from the dentate line Danger to integrate in the purstring some rectovaginal tissue
(see anatomy of the pelvic floor) Stapled versus conventional surgery for hemorrhoids. Jayaraman S, Colquhoun PH, Malthaner RA. Source University of Western Ontario, Department of Surgery, 339 Windermere Rd. Rm C8-114, London, Ontario, Canada. [email protected] Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also likely to be associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the "gold standard" in the
surgical treatment of internal hemorrhoids. A review of 1107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1107) complication rate. (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no
treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%)
Longo Technique without introducer Non Excisional Surgery Doppler-Guided Transanal Haemorrhoidal Dearterialization No Post-Op pain No Post-Op complications Resolutive No need for general anaesthesia No need for hospitalisation Can be Repeated Non Excisional Surgery
THD Surgical Approach Exact location of the terminal branches of the SRA. Precise needle rotation Exact needle penetration Selective ligature of the arteries SRA Ligation 2-3 cm Doppler signal to Dentate line
Doppler probe THD Surgical Approach After ligature, the arterial inflow to the piles decreases and the piles collapse . The decreased tension facilitates the shrinkage of haemorrhoids and reduction of the prolapse. The sutures create a mucosal fixation and lifting of the haemorrhoidal cushions. Localisation of the principal artery
branches Stich Technique Location of the terminal branches of the superior rectal artery in lithotomy position Technique: Modified technique for prolapsed piles RAR (Doppler Guided Recto Anal Repair Proctoplasty). AMI Gmbh HAL RAR Technique
The light source and the proctoscope is quite big and not easy to manipulate RAR (Doppler Guided Recto Anal Repair Proctoplasty). AMI Gmbh HAL RAR Technique Circular anchoring point in the proctoscope inducing instability of the needle holder Angiodin Procto Cannula
The horizontal diameter is slightly wider, allowing the needle to rotate freely inside the dearterializer, without any impediment, around a fixed point constituted by a slot where the tip of the needle holder is inserted. (Fig 1.) Rotational pattern of the needle Slot for the tip of the needle-holder_________ The slot is positioned in a slightly off central position at the tip of the cannula. This way, the results is ergonomically by far superior to the HAL; indeed in these the needle has to follow a groove to rotate and, frequently slips out of this groove making it very difficult to complete the rotation. The slit for the needle to perform the ligature of the Haemorrhoidal
Artery branches, is wider but shorter longitudinally (8 mm), such to constitute an impediment to the mucosal prolapse inside the proctoscope. (Fig.2) Slit for ligating the Superior Haemorrhoidal Artery branches All of the above, together with a thickness of the proctoscope wall much smaller than the HAL and the flat-top shape of our proctoscope allows for the needle to reach a depth, outside of the ligation slit by more than 6 mm, much more than the HAL (2,5 m). This guarantees that the arterial branch lies inside the needle rotation and is, therefore, ligated.
What is the real depth of the S.R.A? Do we realy match the right signal? 8 MHz 8 MHz Continio us Continio us 3to7mm 3to8mm
What is the real depth of the S.R.A? Do we realy match the right signal? With Angiodin Procto we can evaluate the exact depth of the Artery ,the size of it and we can safely evaluate the ligation of the artery due to the fact that some arteries are deeper than 8mm especially in the posterior wall of the anal canal What is the real depth of the S.R.A? Do we realy match the right signal? Discussion.... ANT Pos t
After 70 measurements during total anesthesia in Healthy voluntary patient undergoing cystoscopy we discovered that the depth of the posterior artery located at 5,7 where not running right under the mucosa measured depth was between 0,9cm to 1,6 cm We also discover that the relapse piles where mostly occuring posteriorly 5,7 PM Tips and Triks
Tips and Triks Do not allow heamatoma to occur in the proctoscope ! Tips and Triks Work with a curved needle holder to facilitate rotation and allows access with two instruments.. PROCEDURE OUTPATIENT TREATMENTS (PARASURGICAL PROCEDURES) HAEMORRHOIDAL
TISSUE EXCISION ( TRADITIONAL SURGICAL PROCEDURES) Advantage NO NEED OF HOSPITALIZATION CAN BE REPEATED LESS PAINFUL HIGHLY EFFECTIVE RARE RELAPSES HIGHLY EFFECTIVE IN SOME CONDITIONS STAPLED HAEMORRHOIDOPEXY (MUCOSAL PROLAPSE)
REDUCTION OF POST-OP PAIN REDUCTION OF HOSPITALISATION Disadvantage NOT ALWAYS INDICATED NOT ALWAYS EFFECTIVE USUALLY NOT RESOLUTIVE SEVERE POST.OP. PAIN NEED OF HOSPITALIZATION RARE BUT SEVERE COMPLICATIONS MODERATE COMPLICATIONS RAT TECHNIQUE ASSOCIATED RISKS (BLEEDING, PERFORATION,
SPHINCTER LESIONS) CAN BE EFFECTIVE IN GRADES 2 & 3 OF HAEMORRHOIDS NO POST-OP PAIN NO POST-OP COMPLICATION RESOLUTIVE Doppler Guided Haemorrhoidopexy NO NEED OF GENERAL ANESTHESIA NO NEED FOR HOSPITALISATION IMMEDIATE RETURN TO NORMAL ACTIVITY CAN BE REPEATED Preoperative Postoperative Preoperati
ve Postoperative 3 weeks later Preoperati ve Postoperative 3 weeks later Transanal Haemorrhoidal Dearterialization Aim: To assess the efficacy and safety of Doppler-guided THD for the
treatment of symptomatic haemorrhoids Patients 237 From Jan 2005 to With symptomatic haemorrhoids Sep 2009 All patients had failed conservative treatment and rubber
banding Sex Patients Mean age = 53 yrs (range 24-82) Female 48% Male 52% Goligher degree III
48% II 46% IV 6% Anaesthesia Surgical technique 40% 30% 35%
37% 28% 20% 10% 0% General Regional Local Number of ligation
96% 100% 80% 60% 40% 20% 0% 1% 1% 2% 3
4 5 6 After November 2000, always 6 ligatures Technique (location of terminal branches) The terminal branches of the superior rectal are generally located at 1 oclock, 3 oclock, 5 oclock,7 oclock, 9 oclock and 11 oclock, if observed in lithotomy position THD must be rotated until the pulsating Doppler signal, corresponding to the arterial pulsation, is audible.
When the artery is located it is possible to proceed to perform a ligature of it. Postoperative management No regular laxatives No antibiotics Analgesia Ketoralac 10mg orally as required Follow up 1 Week 1 Month 6 Months thereafter (post-op pain and any complications recorded Postoperative management
VAS - Postoperative pain 50% 45% 40% Mean = 1.35 30% 37% 20%
10% 5% 3% 10% 0% 0 <2 2-5 5-8
8-10 VAS Visual Analogue Scale 0 1 2 3 No pain mild pain 4 5 6 moderate pain
RELAPSE RATE RELATED TO GOLIGHER GRADE II: III: IV: 7 % (Bleeding) 4,8 % <2002 (6%) (before anupexis) >2002 (3,7%) (after anupexis) 26,6% <2002 (50%) (before anupexis) >2002 (11,1%) (after anupexis) Conclusions THD IS A SAFE AND EFFECTIVE TECHNIQUE FOR THE TREATMENT OF II AND III DEGREE
HAEMORRHOIDS. ITS ROLE FOR IV DEGREE HAEMORRHOIDS SHOULD BE FURTHER ASSESSED. NEGLIGIBLE TISSUE TRAUMA REDUCED POSTOP. PAIN NO MAJOR COMPLICATIONS DAY SURGERY IN LOCAL ANAESTHESIA WIDE INDICATIONS
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