Rubber-Band Ligation of Hemorrhoids 

Updated: Aug 23, 2019
Author: Pradeep Saxena, MBBS, MS; Chief Editor: Kurt E Roberts, MD 

Overview

Background

In rubber-band ligation, a rubber band is applied to the base of a hemorrhoid to hamper the blood supply to the hemorrhoidal mass. The hemorrhoid will then shrink and fall off within 2-7 days. For the majority of patients with hemorrhoids, outpatient treatment is feasible and sufficient,[1]  and rubber-band ligation is one of the most common outpatient treatments available for these patients.   

Rubber-band ligation is readily 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%.[2, 3, 4]

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.[2, 3, 4, 5, 6]  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.[3, 4]

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.[7]  Band ligation may also be considered for bleeding in severely anemic patients with fourth-degree hemorrhoids who are unfit for surgery. (See Technical Considerations.)

Contraindications

Rubber-band ligation is contraindicated for the following:

  • Patients using anticoagulants
  • Patients with a septic process in the anorectal region (eg, perianal abscess, proctitis, or colitis)
  • Patients with acutely thrombosed hemorrhoids
  • Patients with large grade IV hemorrhoids
  • Patients with hypertrophied anal papilla
  • Patients with chronic anal fissure (surgical treatment is more appropriate in such cases)
  • Cases in which insufficient tissue is availagble to be pulled inside the band ligator drum

A study by Hite et al found that the use of clopidogrel bisulfate did not increase bleeding complications in patients undergoing rubber-band ligation for symptomatic hemorrhoids.[8]

Technical Considerations

Best practices

Clinically, patients who have 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 prolapse outside anal canal but reduce spontaneously (see the image below)
  • Third degree - Hemorrhoids protrude outside anal canal and require manual reduction
  • Fourth degree - Hemorrhoids are irreducible and 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.[2, 3]

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 artery ligation (HAL).[9, 10, 11]  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[3] :

  • 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.[2]  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.[2]

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.

Outcomes

The multicenter HubBLe trial compared the outcomes of rubber-band ligation with those of HAL in 370 patients aged 18 years or older who presented with second- or third-degree hemorrhoids, including some who had previously undergone band ligation.[12] The primary outcome was recurrence at 1 year; the secondary outcomes were recurrence at 6 weeks; hemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness.

The 1-year recurrence rate was 30% for HAL and 49% for rubber-band ligation; however, when multiple band ligations were performed, the recurrence rate fell to 37.5%.[12]  Symptom scores, complication rates, EQ-5D-5L scores, and continence scores did not differ significantly between the two groups, and patients who underwent HAL were found to experience more pain in the early postoperative period. HAL was more expensive and was judged unlikely to be cost-effective.

 

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.[6]

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. Infiltration of local anesthetic has also been employed.[13]

The patient should be in the left lateral position with the buttocks projecting well over the operating table.

Monitoring & Follow-up

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

 

Technique

Rubber-Band Ligation

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.

A varant of rubber-band ligation is the approach referred to as endoscopic rubber-band ligation (ERBL), which combines the classical technique of elastic ligation with an endoscopic examination that provides better control and offers the possibility of photographic recording and sedation within a hospital environment.[14]

Complications

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

  • Pain (32%) [3]
  • Vasovagal symptoms (dizziness and fainting) [4]
  • Bleeding (1-5%)
  • External hemorrhoid thrombosis (2-3%)
  • Ulceration [15]
  • 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 with 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.[2]