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Hemorrhoid Ligation

  • Author: Pradeep Saxena, MBBS, MS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Sep 02, 2015
 

Overview

Background

Hemorrhoid ligation is one of the most common outpatient treatments available for patients with hemorrhoids. In this procedure, a rubber band is applied to the base of the hemorrhoid to hamper the blood supply to the hemorrhoidal mass. The hemorrhoid will then shrink and fall off within 2-7 days. Rubber band ligation can be performed in an ambulatory setting. The procedure causes less pain and has a shorter recovery period than surgical hemorrhoidectomy. Its success rate is between 60% and 80%.[1, 2, 3]

Outpatient treatment is feasible and sufficient for the majority of patients with hemorrhoids. A number of prospective studies have found rubber band ligation to be a simple, safe, and effective method for treating symptomatic first-, second-, and third-degree hemorrhoids as an outpatient procedure with significant improvement in quality of life.[1, 2, 3, 4, 5] Hemorrhoid ligation has a limited morbidity, good results, long-term effectiveness, and good patient acceptance. It has been found to be safe even for patients with cirrhosis and portal hypertension and for patients on anticoagulation threrapy.[2, 3]

Indications

Hemorrhoid ligation is performed for first-degree, second-degree, and some cases of third-degree hemorrhoids when the patient complains of bleeding or prolapse of hemorrhoids.[6] Band ligation may also be considered for bleeding in severely anemic patients with fourth-degree hemorrhoids who are unfit for surgery.

Contraindications

Hemorrhoid ligation is contraindicated for the following:

  • Patients using anticoagulants
  • Any septic process in the anorectal region (eg, perianal abscess, proctitis, or colitis)
  • Acute thrombosis of hemorrhoids.
  • In presence of large grade IV hemorrhoids
  • Hypertrophied anal papilla
  • Chronic anal fissure (surgical treatment is more appropriate)
  • Band ligation should not be done if there is insufficient tissue to be pulled inside the band ligator drum

Technical considerations

Best practices

Clinically, hemorrhoids usually present with bleeding, prolapse, pain (with thrombosis or ulceration), perianal mucous discharge, or pruritus. The complications of hemorrhoids are thrombosis, infection with inflammation, ulceration, and anemia.

Internal hemorrhoids are classified into four grades, as follows:

  • First degree - Veins of anal canal increase in number and size, and they bleed on defecation
  • Second degree - Hemorrhoids prolapsed outside anal canal but reduce spontaneously (see the image below)
  • Third degree - Hemorrhoids protrude outside anal canal and require manual reduction
  • Fourth degree - Irreducible hemorrhoids that remain constantly prolapsed
Second-degree hemorrhoids. Second-degree hemorrhoids.

The initial treatment for symptomatic first- and second-degree hemorrhoids with a short history of bleeding, prolapse, or itching and pain is directed toward controlling constipation with dietary measures such as a high-fiber diet, sitz bath, stool softeners, laxatives, and various topical creams.[1, 2]

When medical treatment fails, ambulatory treatment is advised. Ambulatory treatments for hemorrhoids include injection sclerotherapy, rubber band ligation, cryosurgery, infrared coagulation, and ultrasonic Doppler-guided transanal hemorrhoidal ligation.[7, 8, 9] Surgical treatment includes open or closed hemorrhoidectomy and stapled hemorrhoidopexy.

Procedural planning

A proctosigmoidoscopy or anoscopy is always performed before any treatment for hemorrhoids is considered. In patients older than 40 years, polyps and other colonic pathology may be present; therefore, colonoscopy is advised in these patients before they are treated for hemorrhoids. A colonoscopy or barium enema should be always performed before any treatment for hemorrhoids is considered in the following cases[2] :

  • If there is suspicion of colonic disease based on patient’s symptoms and clinical evaluation
  • When hemorrhoids do not appear to be the cause of bleeding
  • When bleeding is continuous even after hemorrhoid ligation

It is now widely accepted that piles are nothing more than a sliding downwards of part of the anal canal lining.[1] It is therefore obvious that treatment measures have to address reduction of the prolapse as well as reduction of blood flow to the hemorrhoid mass. The principle of outpatient treatment is to fix the mucosa above the prolapsing hemorrhoid. Preceding lateral internal sphincterotomy under local anesthesia may be done simultaneously for patients with high sphincter tone associated with first-degree hemorrhoids.

Complication prevention

Because of the risk of hemorrhage, rubber band ligation is absolutely contraindicated in patients on anticoagulant therapy. Patients taking aspirin should stop the medication at least 14 days before the procedure.[1]

The rubber rings must be applied on an insensitive area well above the dentate line to avoid postprocedural pain.

The clinician should carefully examine the patient for anorectal complains before embarking on rubber band ligation. Failure to recognize a septic process in this region may lead to fatal sepsis with extensive cellulitis and gangrene after the procedure.

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Periprocedural Care

Patient education and consent

Formal consent should always be obtained before placement of rubber bands to treat hemorrhoids because complications have been reported in randomized controlled trials.[5]

Patients should be advised that there is a recurrence rate of about 20-25% in 5 years.

Stool softeners and bulk agents should be prescribed, and the patient should avoid straining for bowel movements. The patient should be warned about the possibility of bleeding after the procedure and after 1-2 weeks when the rubber rings are dislodged. If the patient thinks that bleeding is severe or persistent, he or she should contact the surgeon.

In cases of pain or fever, the patient should come back for consultation. A sitz bath may be advised to keep the anal area clean and hygienic to prevent infections and reduce pain. The patient should be advised to avoid heavy lifting or strenuous activities for 3-4 days.

Equipment

Equipment for hemorrhoid ligation includes the following:

  • Barron hemorrhoidal ligator with rubber rings/bands (see the image below)
  • Hemorrhoid-grasping forceps
  • Proctoscope/anoscope
  • Light source (torch)
  • Gauge piece
  • Artery forceps
Barron hemorrhoidal ligator with loading cone and Barron hemorrhoidal ligator with loading cone and grasping forceps.

Patient preparation

A proctoclysis enema is given just before the procedure. For lubrication and local anesthesia, 5% lidocaine jelly is applied locally in the anal canal. The patient should be in the left lateral position with buttocks projecting well over the operating table.

Monitoring and follow-up

A single treatment can achieve satisfactory results. If the symptoms of bleeding and prolapse due to hemorrhoids are not relieved, further band ligation or other conservative treatment may be tried. If the symptoms are not controlled after three sessions, hemorrhoidectomy may be considered.

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Technique

Procedure

Usually, one or two hemorrhoids are ligated at a time. Any remaining hemorrhoids may be ligated after a period of 4-6 weeks.

A Barron hemorrhoidal ligator with a hemorrhoid-grasping forceps is used. The ligator has a drum at one end over which rubber bands are loaded. It is connected with a 30-cm shaft to the handle, which has a trigger to release the bands.

A loading cone is screwed over the drum of the Barron hemorrhoidal ligator. Two rubber rings/bands are slipped to load the ligator (see the first image below). The hemorrhoid-grasping forceps is then passed through the drum of the ligator and is now ready to grasp the hemorrhoid (see the second image below).

Loaded rubber rings on drum of Barron hemorrhoidal Loaded rubber rings on drum of Barron hemorrhoidal ligator.
Loaded band ligator ready for use. Loaded band ligator ready for use.

A proctoscope/anoscope is inserted into the anal opening. The hemorrhoids are visualized, and the most prominent hemorrhoid is addressed first. The assistant holds and maintains the position of the anoscope, while the operator holds the preloaded Barron band ligator with the grasping forceps. The internal hemorrhoid is grasped with the forceps about 1 cm proximal to the dentate line and maneuvered into the drum of the ligator (see the image below). If the patient complains of pain, a more proximal point should be selected for band ligation.

Grasping forceps holding the hemorrhoid. Grasping forceps holding the hemorrhoid.

The hemorrhoid is pulled taut through the drum of the ligator (see the first image below). The ligator is then pushed up against the base of the hemorrhoid, and the trigger is released to apply two rubber rings/bands to the base of the hemorrhoid (see the second image below). The process is repeated for other hemorrhoids.

Hemorrhoid held taut, with drum of ligator pushed Hemorrhoid held taut, with drum of ligator pushed against base of hemorrhoid and trigger released.
Rubber bands applied on hemorrhoid. Rubber bands applied on hemorrhoid.

Alternatively, a suction hemorrhoid ligator may be used. This instrument draws the hemorrhoidal mass into the drum through suction; therefore, the grasping forceps is not required. After the pile mass has been adequately drawn into the drum by means of suction, the trigger is released to apply the rings to the base of the hemorrhoid.

Multiple pile masses may be ligated, but more than one banding session spaced over 3-4 weeks may be required.

The procedure is shown in the video below.

Barron band ligation for hemorrhoids.

Complications

Most complications of the procedure are minor and self-limiting; they can be managed on an outpatient basis. Complications of hemorrhoid ligation include the following:

  • Pain (32%) [2]
  • Vasovagal symptoms (dizziness and fainting) [3]
  • Bleeding (1-5%)
  • External hemorrhoid thrombosis (2-3%)
  • Ulceration [10]
  • Fulminant sepsis

Some discomfort in the anal region may be felt for a few days and is usually relieved by sitz baths and analgesics. In case of severe pain, removal of the rings is necessary. The rubber ring may be removed by conventional stitch-cutting scissors.

Late bleeding (1-2 weeks after the procedure) may be significant, and patients should be advised to keep a watch on the amount of blood loss. If bleeding is reported, anoscopic examination should be done under adequate visualization and anesthesia. If the bleeding site is identified, suture ligation should be done. If the patient is pale, hypotensive, and tachycardic, hospitalization and blood transfusion may be required.

If thrombosis of the corresponding external hemorrhoid occurs after internal hemorrhoid ligation, excision of the thrombosed external hemorrhoid may be required.

Sepsis has been reported in a few cases after band ligation. Young males are at increased risk. The septic patient presents with fever, anorectal pain, perineal pain, scrotal swelling, difficulty in micturition, cellulitis, and sometimes frank gangrene. The clinician should carefully examine the patient for anorectal complains before embarking on rubber band ligation. Failure to recognize a septic process in this region may lead to fatal sepsis with extensive cellulitis and gangrene after the procedure. Treatment is with extensive debridement, wound toilet, and parenteral antibiotics. Colostomy may sometimes be required.[1]

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Contributor Information and Disclosures
Author

Pradeep Saxena, MBBS, MS Associate Professor, Department of Surgery, Gandhi Medical College, India

Pradeep Saxena, MBBS, MS is a member of the following medical societies: Association of Surgeons of India, Association of Colon and Rectal Surgeons of India

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The author gratefully acknowledges the contributions of Dr. Ashish Kumar Dwivedi, Resident Surgical Officer, Dr. Sandeep Prajapati, Resident Surgical Officer, and Dr. Narayan Das Kewalani, Department of Surgery, Gandhi Medical College and Hamidia Hospital, for their help with the development and writing of this article.

References
  1. Corman ML. Hemorrhoids. Brown B, McMullan E, LaPlante MM. Colon and Rectal Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2004. 1: 177-244/8.

  2. Bernal JC, Enguix M, López García J, García Romero J, Trullenque Peris R. Rubber-band ligation for hemorrhoids in a colorectal unit. A prospective study. Rev Esp Enferm Dig. 2005 Jan. 97 (1):38-45. [Medline]. [Full Text].

  3. El Nakeeb AM, Fikry AA, Omar WH, Fouda EM, El Metwally TA, Ghazy HE, et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008 Nov 14. 14 (42):6525-30. [Medline]. [Full Text].

  4. Forlini A, Manzelli A, Quaresima S, Forlini M. Long-term result after rubber band ligation for haemorrhoids. Int J Colorectal Dis. 2009 Sep. 24(9):1007-10. [Medline].

  5. Reese GE, von Roon AC, Tekkis PP. Haemorrhoids. BMJ Clin Evid. 2009 Jan 29. 2009:0415. [Medline]. [Full Text].

  6. Lu LY, Zhu Y, Sun Q. A retrospective analysis of short and long term efficacy of RBL for hemorrhoids. Eur Rev Med Pharmacol Sci. 2013 Oct. 17 (20):2827-30. [Medline].

  7. Wallis de Vries BM, van der Beek ES, de Wijkerslooth LR, et al. Treatment of grade 2 and 3 hemorrhoids with Doppler-guided hemorrhoidal artery ligation. Dig Surg. 2007. 24(6):436-40. [Medline].

  8. Roka S, Gold D, Walega P, et al. DG-RAR for the treatment of symptomatic grade III and grade IV haemorrhoids: a 12-month multi-centre, prospective observational study. Eur Surg. 2013 Feb. 45(1):26-30. [Medline]. [Full Text].

  9. Scheyer M, Antonietti E, Rollinger G, Lancee S, Pokorny H. Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center. Tech Coloproctol. 2015 Jan. 19 (1):5-9. [Medline].

  10. Patel S, Shahzad G, Rizvon K, Subramani K, Viswanathan P, Mustacchia P. Rectal ulcers and massive bleeding after hemorrhoidal band ligation while on aspirin. World J Clin Cases. 2014 Apr 16. 2 (4):86-9. [Medline].

 
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Second-degree hemorrhoids.
Barron hemorrhoidal ligator with loading cone and grasping forceps.
Loaded rubber rings on drum of Barron hemorrhoidal ligator.
Loaded band ligator ready for use.
Barron band ligation for hemorrhoids.
Grasping forceps holding the hemorrhoid.
Hemorrhoid held taut, with drum of ligator pushed against base of hemorrhoid and trigger released.
Rubber bands applied on hemorrhoid.
 
 
 
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