Hemorrhoids, also known as piles, are protrusions of varicose veins and connective tissue around the anal canal extending to inside the rectum. Symptoms are itching, pain, bleeding, and swelling. The number one cause is genetics (an absence of valves within the hemorrhoidal veins), followed by irregular bowel habits (constipation or diarrhea), and any activity that causes increased intra-abdominal pressure (prolonged straining, lifting, etc.)
Hemorrhoids are classified as external or internal, and can be staged or graded 1 to 4. Click on the Classification of Hemorrhoids page and or watch the Hemorrhoid Surgery Video [3:00] to see and hear the differences in the Goligher hemorrhoid classification system, and to learn the basics of Hemorrhoid surgery.
Fissures are cracks or tears in the anal skin that typically cause pain and bleeding with bowel movements. They can occur alone, or in the presence of hemorrhoids. Both are caused by by constipation and or excessive straining at the stool. Treatment can be with topical cream, laser fissurectomy which is less painful, controlled-intermittent anal dilatation, or with surgery (e.g. lateral internal sphincterotomy and or anoplasty).
Laser*: Except for traditional surgery, laser is the only instrument that can be used on both internal and external hemorrhoids. Laser is used to vaporizes and remove anal & rectal tissue with pinpoint accuracy, one cell layer at a time, until the entire hemorrhoid is removed in puffs of carbonized steam. With laser, there is less pain, less bleeding, and a faster recovery. Animation of laser surgery (with comparison of hemorrhoid grades 1 to 4 on a live patient) [2:00]. Laser can be used painlessly to perform an infrared coagulation of internal hemorrhoids (see below).
Infrared Coagulation: A CO2 laser's invisible infrared light can be used to effect heat-driven coagulation to a specific spot on tissue. By spot welding hemorrhoidal tissue into place, Laser welded hyper-attachments can prevent the hemorrhoids from sagging downward and protruding outside the rectum. A specialized instrument called an Infra-Red Coagulator (IRC), is also used for this purpose. IRC Educational Animation [9:15] IRC Medical 3-D Animation 
Rubber band Ligation: A grasping forceps is used to pull an internal hemorrhoid into a small one-inch tube. A rubber band is pushed off the top of the tube onto the hemorrhoid, gripping and strangulating the base of the hemorrhoid, choking off its blood supply. As a result, the hemorrhoid shrivels up and dies, and falls off during a normal bowel movement in about ten days. Rubber Band Hemorrhoid Ligation Animation [0:30]
Anoscopy and the CRH O’Regan System: A disposable anoscope and suction band ligator is used to pull/suck the hemorrhoid into a syringe where it is captured. Then a band is deployed around the base of the hemorrhoid choking off its blood supply (a variation of the ligation procedure, above). Diagnostic anoscopy and the CRH O’Regan procedure animation [4:15]
Sclerotherapy: A sclerosing agent, typically 5% phenol in oil, is injected into an internal hemorrhoid. The substance injected leads to an inflammatory response, the blood flow into the hemorrhoid is partially blocked, secondary fibrosis is facilitated, shrinking and hardening the hemorrhoid. Animation illustrating where the sclerosant is injected [0:25]. Live video showing a hemorrhoid being sclerosed [0:12].
Radiofrequency Coagulation: Bipolar electrotherapy is applied for a directed coagulation effect of the mucous membrane near the hemorrhoid. A specialized Bipolar Circumactive Probe (BICAP) or a bipolar direct probe (e.g., EVRF®) is effective for the treatment of bleeding internal hemorrhoids. Bipolar electrotherapy is applied for a directed coagulation/ablation effect of the mucous membrane near the hemorrhoid. Caution is taken to assure that a thick eschar doesn't develop, for fear of subsequent sloughing and delayed bleeding. Animation of EVRF Hemorrhoid Treatment [3:12]. Live video of EVRF treatment [1:47]. For more information about how electric modalities are used in the treatment of hemorrhoids, view the Electric Treatment Of Hemorrhoids.pdf
Henorrhoidolysis: Utilizing a specialized device (e.g., Ultroid®) a low voltage negative galvanic current is applied to an internal hemorrhoid pierced by a needle-tipped electrode. A chemical reaction occurs around the electrode, a white foam appears (hydrogen gas) and the electrode tip becomes loose due to the liquefying action of sodium hydroxide on the proteins around the electrode. The partially liquified part of the hemorrhoid is then reabsorbed into the body's lymphactic system. Ultroid® Physician Training Video [5:04]. For more information about how electric modalities are used in the treatment of hemorrhoids, view the Electric Treatment Of Hemorrhoids.pdf
Hemorrhoidal Arterial Ligation (H.A.L.) and Transanal Hemorrhoidal Dearterialization (THD) is performed using a modified proctoscope in conjunction with a Doppler ultrasound flowmeter for identification of each hemorrhoid's arterial blood supply, which is subsequently ligated. A needle and thread is passed beneath the artery, and a knot is externally tied, to stop the blood flow to the hemorrhoid. Because less tissue is excised, there is less pain experienced than with traditional hemorrhoid surgery. H.A.L. animation video [2:22]. For more information about HAL and RAR for the treatment of prolapse and hemorrhoids, view the HAL-RAR.pdf
Mucosal Prolapse Recto Anal Repair(R.A.R.) mucopexy is most often associated with the H.A.L. procedure for reducing severe prolapsing hemorrhoids, resulting from mucosal prolapse of the deep rectum. Prolapsed mucosa is gathered up through an obliterative locking-suture technique, creating tissue scars that integrates “seamlessly” back into the anal tissue, which has the effect of lifting up the hemorrhoids and mucosa and putting them back where they belong. Patients report minimal discomfort or pain associated with this procedure. | R.A.R. animation [2:22]. R.A.R. & THD live video [2:22]. For more information about HAL and RAR for the treatment of prolapse and hemorrhoids, view the HAL-RAR.pdf
Hemorrhoid Surgery includes: Traditional Surgery.pdf, Stapled hemorrhoidopexy (PPH Procedure.pdf), Harmonic Scalpel.pdf, Laser Surgery.pdf for hemorrhoids, Atomizing Hemorrhoids.pdf are discussed further, with pictures. Watch this video to understand the basics of hemorrhoid surgery [3:00].
IMPORTANT: Know What to Ask Your Surgeon.pdf, and and Know About the Complications of Hemorrhoid Surgery.pdf.
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