Ot~ce Ligation Treatment of Hemorrhoids*

JAa~ES BARRON, M.D~** Detroit., Michigan

HEMORRHOIDS have afflicted man since the dawn of history. ~[t is among the first conditions described as contr ibuting to the discomfort of humans. T h e source of their discomfort could be viewed with ease be- cause of the accessibility of the parts. In our day, conditions are n o t different; al- though the frequency of hemorrhoids in the general populat ion is not known, it is likely that the incidence is higher than is gener- ally recognized. In 1960, Buie 4 reported an incidence of 52 per cent in a large series of patients examined proctoscopically at the Mayo Clinic.

T h e basic principles of it~e treatment of hemorrhoids have been remarkably con- sistent throughout history. Ligation, ex- cision and cautery were used by Hippoc- rates.6 Salmon, in 1888, according to Ailing- ham, is usually given Credit for introducing the modern operat ion of hemorrhoidec- tomy. I t consists of careful dissection and ligation of the hemorrhoidal mass with the patient under the inltuence of good anes- thesia7 ,s This method, in experienced hands, carries a low incidence of hemor- rhage and deformity and has been used in t reatment of bleeding and prolapsing in- ternal hemorrhoids. Despite claims that at tention to certain details of operative technic will eliminate or lessen pain, it is common knowledge that, in most cases, these operations usually are followed by pain. T h e medical profession and public ave acuteiv aware o~ this and ~hey ave not

Read at the meeting of the American Procto- logic Society, Miami Beach, Florida, April 30 to May 3, 1962.

** Surgeon-in-Charge of Division HL Department of General Surgery, Henry Ford Hospital.

completely satisfied with the progress that has been made to relieve pain. As a result, some patients wilt suffer many years with bleeding and prolapse before consulting a surgeon and, in all too many cases, this is responsible for serious delay in making a diagnosis of rectal carcinoma. YVithout question, if the pain could be decreased to a substantial degree, many patients would more willingly seek earlier at tention and more frequent d iagnos is of hemorrhoids and rectal cancer could be made. T h e pro- fusion of advertisements for salves and ointments is ample proof that patients seek other means o~ relief instead of consulting the physician. Another tactor responsible for the patient 's failure to consult the phy- sician is that he is reluctant to submit to expensive hospitalization and loss o1~ time from work. Rarely is there recurrence a~'ter the proper kind of hemorrhoidal opera- tion. z On the other hand, so-called recur- rence is ra ther common when appropr ia te surgical removal is not accomplished. When operat ing on large, prolapsing hemorrhoids, one will occasionally leave behind some hemorrhoidal tissue rather than risk com- plications due to undermining or removing too much of the anorectal tissues. The re are few patients who will not recoil from the thought of a second operat ion for hemorrhoids.

I t is generally agreed that the simple non- prolapsing type of internat hemorrhoid is most amenable to t reatment by injection. However, witi~ injection, there can be no well-controlled destruction o~" the internal hemorrhoid, tn all too many cases, the benefits are temporary and recurrence is evidenced by bleeding and prolapse.

109

110 BaRRON

Iqc. 1. T h e Blaisdelt ligator,

I first became interested in the nonsurgl- cal t reatment of hemorrhoids when Blais- dell 1 described an ingenious instrument for ligation of internal hemorrhoids in 1954 (Fig. l). This inst rument provided precise

control and with it, permanent destruction or" the hemorrhoids could be accomplished, a feature which is lacking when sclerosing solutions are injected.

Internal hemorrhoids are covered by rec- tal mucosa and are .practically dew~id of pain sense (Fig.~ 9). Basically, Blaisdell's idea comprised the standard ligature method of hemorrhoidectomy with the im- por tant difference that its applicat ion was limited to internal hemorrhoids, thus avoid- ing the extremely sensitive squamous and transitional epi thel ium of the anal canal. At first, he used silk as the ligature ma- terial. 2 T h e resuhs were satisfactory, but

Fro. 2. Stars indicate proper site for grasping the mucosa-covercd internal hemorrhoids devoid of pain sense.

F~c. 3. Modified glaisdell instrument and grasping forceps.

the incidence of delayed bleeding became a problem. In recent years this complica-. tion has been largely el iminated by the use ot2 rubber bands which provide a much longer period of hemostasis by compression which persists until s loughing of the hem- orrhoids is complete3, a

Since so many patients are reluctant to endure the discomfort, expense and loss of time from work atter the usual type of hemorrhoidectomy, I decided to employ Blaisdell's method instead of other meas- ures such as injection and puncture cau- terizat 'on with special small electrodes. A modification of Blaisdelt's ins t rument has been utilized (Fi. 3). T h e interchangeable handle permits rapid change of the ligature drums. T h e compression l 'ga ture principle has also been applied with excellent results in the destruction of polyps by introducing an instrument with a long shaft through a proctoscope. I have also used this instru- ment when removing hyper t rophied anal papillae. T h e loading feature of the Gray-

Fro. 4° Gravlee umbilical cord ligator.

OFFICE I J G A T I O N T R E A T M E N T OF H E M O R R H O I D S 1 1 ]

Fro. 5, Hemorrhoid be- ing drawn through ligat- ing drums. Note rubber band (arrows).

lee s umbil ical cord l igator has been utilized (Fig. 4). Sections of black rubber tub ing

are used for compression since they can be visualized more easily th rough the anoscope, Th i s is impor tan t because the band pro- duces tenesmus in a small percentage of cases and may have to be removed if it does not come away in the desired time. This modified ins t rument is easier to load and easier to man ipu la te because there are no movements necessary to pull the h e m o f

rhoid th rough the d r u m and then to squeeze the handle so that the bands are d ropped immedia te ly inu) the desired posi- tion (Fig. 5, 6). in actual practice the hemor rho id can be ligated more easily and ia less time than is requi red for injection of a sclerosing solution°

Al though I have per fo rmed l igation with this ins t rument in hundreds of patients, this presentat ion is l imited to a summary o[ resuhs in 150 consecutive cases done in

Fro. 6. Ligature in place (see arrows).

112 B A R R O N

1961. Early experience taught me to limit the ligation to one hemorrhoid at a time, especially when dealing with large hemor- rhoids in patients who had recurrence after previous injection or operation and when treating tense, nervous patients. I have also learned the importance of COrTecting constipation before at tempting treatment. It occurs in a large percentage of these pa- tients. In the beginning, only small internal hemorrhoids were treated, but ligation of large internat hemorrhoids, which previ- ously 1 thought would require surgery, are now being treated by ligation with excellent results. Th e enthusiasm of grateful patients has been most impressive and knowledge of this encourages other patients who have suffered for many years to seek treatment. I have also been impressed by the number of patients who have been operated upon or treated by injections and who have re- quested treatment b? ligation.

In 150 consecutive cases, the ages ranged from 24 to 78 years, hi all patients, bleeding or prolapse, or both, were the main indic> tions f'or treatment. Many patients had to wear protective pads because of the bloody and mucous discharge. One to four hemor- rhoids were treated in each patim~.t (aver- age 2.4).

All except seven patients were treated in the outpat ient department. These were treated as inpatients because of accompany- ing conditions. One hundred patients (66.6 per cent) required no sedatives to relieve pain during the course of the ligations. Thir ty-one (20.6 per cent) required only one or two sedatives (Empirin® compound No. 5, Darvon® compound or Demerol®, 50 nag.) with the first ligation and none were needed afterward. Twelve patients (8.0 per cent) took one ~o three sedatives

with each ]igation and seven @.6 per cent) required from five to II sedatives. In these instances, the patients were extremely nerv- ous individuals. During the past year, witli added experience, sedative requirements

have decreased. Another pleasing factor ,is that new patients are reassured by the good experiences and recommendations of their blends and relatives who have had liga- lions. In this series, 8.0 per cent had had previous surgery and 7.0 per cent had had injections. Thus a total of 15 per cent had previously had surgery or injection therapy. It is clear that hemorrhoids do recur and that a considerable nmnber of patients are unwilling to submit to a second operation but will accept ligation.

Four patients had bleeding after ligation. One had bleeding on the eighth day, which was easily controlled by coagulation with silver nitrate. Tw o patients had bleeding from hemorrhoids which had not been treated. In one of these, bleeding was easily controlled by ligation of the remaining hemorrhoids. In the latter instance, a fecal impaction had formed and straining was responsible for bleeding. No bleeding hom the ligated hemorrhoids required admit- tance to the hospital. When dealing with large vascular masses, hemorrhage is always possible, but thus far, bleeding from the ligated hemorrhoids has presented no seri-. ous problem. Th e tmligated hemorrhoids have presented the ,weater problem--consti- pation playing a significant part in these cases.

Of 150 patients, one lost two days be- cause of a thrombosed external hemorrhoid. In this case, l igat 'on was carried out at the conclusion of many gastro-intestinal x-rays, enemas and purgation. One patient lost two days because of nervous tension, one who was admitted with bleeding from un- ligated hemorrhoids lost four days, one pa- tient with a thrombosed external hemor- rhoid Iost two days, and one had a sma11 perbecta] abscess which was drained in the ou~patient depar tment and he tost two days. Another patient had tenesmus on the eighth day because the rubber band did not pass and had to be c u t He ]ost two days and another lost two days because he was

OFFICE L[GATION TREATMENT OF HEMORRHOIDS 113

tense and nervous (he requi red five Dolo- phine® tablets),

Usual ly external hemorrhoids are the re- sult of varicosity and thrombosis of external per ianal veins. Prolapse of in ternal hemor- rhoids has been encountered f requent ly in this series. In the great major i ty of pat ients with external hemorrhoids , there has been a gra t i fying reduc t ion in the size of the external hemor rho ids a few months after comple t ion of ligation, ~n only five pa- tients (3.3 per cent) have we found that removal of the external tags was necessary. W h e n required, this has been done in the ou tpa t i en t clinic where local anesthesia

was used.

Eight pat ients in this series have had serious heart disease and two had advanced Parkinson 's disease. Surgery had been denied one pat ient because of serious kid- ney disease. He had worn a belt with a rectal p lug to keep the hemorrho ids in their proper position. Many o[ the other patients were poor candidates t~or surgical t rea tment because of advanced age o) serious illness. One of the advantages o15 l igat ion t rea tment is that many people can be offered benefits equal to that of hemor- rhoid ablation. In addi t ion to the reduc- t ion in pain and the need for hospitaliza- tion, many patients in poor physical condi- t ion can he helped,

Experience has increased nay respect and enthusiasm for this procedure for internal hemorrhoids . Over 95 per cent of the pa- tients in this series required no medicat ion for relief of pain or, at most, only one to three sedatives.

I believe ti~at the BtaisdeH me thod o.~"

t igation is based on sound principles which p roduce accurate des t ruct ion of internal hemorrhoids with m i n i m u m discomfort . Modifications of the l igat ing ins t rument suggested provide certain advantages such as easy changing o[ l igat ing drums, sturdy const ruct ion and different length shafts that make it possible to use this ins t rument on rectal and colonic polyps, Add i t ion of the Gravlee load ing principle has simplified loading and the use of black rubber bands

is helpful.

We hope the growing list of grateful patients will encourage surgeons to seri- ously consider and utilize this method, i+ is our hope that p~:octologists, whose knowl- edge o~' a~latomy and physiology enables them to select cases suitable for this method, will give serious considera t ion to tryir~g it.

References

I. Btaisdell, Paul C.: Scientific Exhibit. American Medical Association, San Francisco. June 195:t.

2. Blaisdcll, Paul C.: Prevention of massive hem- orrhage secondary to hemorrhoidectomy. Surg.. Gyeec. k Obst. }06:-t85, 1958-.

3. Blaisdell, Paul C.: Pets(real commumcatior, to the author,

4. Buie, I.. A.: Practical Proctology. Ed. 2, Springfield, Charles C Thomas, 196g), 737 pp.

5. Gravlee, l_,. C. and ~g. N. jones: Automatic de- vice for tying the umbilical cord. Obst. ,.k Gynec. 15: t3, 1960.

6. Holley, C. J.: History of hemorrhoidal surgery. South. M. I. 39: 536, 19-t6.

7. Parks, A. G.: The surgical treatment of haem- orrhoids. Brit. J. Surg. 43: 337, 1956.

8. SmitE,, M.: Hemorrhoidectomy: Past and pres- ent. Dis. (]olo1~_ ~ Rcctme 4: 442. 1961.